Study setting and participants

Following the discussion with our main collaborators, the Department of Public Health Engineering of Cox’s Bazar district and UNICEF (donor), we identified the key institutions and the officials for the assessment considering their involvement in Upazila Water and Sanitation (WATSAN) Committee. A convenient sampling method was used to identify potential participants from those institutions. Participants were contacted by directly visiting or through emails, letters, and phone calls. Efforts were made to engage all relevant institutions considering their organizational hierarchy, distinct principles, and accountability. Upazila-level officials from the respective institutions were invited to participate along with the district-level officials.

Data collection

A team of anthropologists that included one assistant scientist, a senior research officer and 6 research assistants who have qualitative research experiences performed the qualitative assessment. The assistant scientist led to implementing the overall assessment and all were involved in data collection, analysis and interpretation. Having a team of researchers would minimize the possibility of biasness, and such a team would also be able to handle the high volume of data better.

Workshops.

Then, we conducted seven capacity assessment workshops during August- September 2019, with personnel from other government, non-government and private organizations engaged in WASH-related activities in Cox’s Bazar (Table 1). The government organizations included DPHE, DPE, DSHE (Directorate of Secondary and Higher Education), DGHS, DGFP (Directorate General of Family Planning), LGIs such as Upazila Parishad and Union Parishad. The non-government organizations included were BRAC, Dushtha Shasthya Kendra (DSK), the Village Education Resource Center (VERC), iDE, formerly known as International Development Enterprises) and private organizations included were RFL, Gazi Tanks, National Polymer and Bengal Plastic. We ensured participation of all designated officials and stakeholders from each Upazila. Nominated alternatives were present in case of the absence of any participants.

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Table 1. Participants of the capacity assessment workshops and KII.

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The workshops were led by an experienced moderator with knowledge of the local language. A guideline was prepared in Bengali to support facilitation and later translated into English for documentation. The guideline was generated to identify institutional capacity factors, such as: i) knowledge of policy, organizational strategy, guidelines, and framework, ii) institutional arrangements for service delivery such as planning, implementation, coordination, monitoring, and reporting, and iii) availability and management of human, financial and infrastructural resources.

Each workshop consisted of only participants from one institution. This allowed the participants to speak freely and avoid conflicting opinions about their collaborative work. The sessions were audio-recorded with verbal consent from the participants to avoid missing or misinterpretation of data. Moreover, two team members took detailed notes and listed major points on flipcharts. The duration of each workshop was approximately 2–3 hours.

Data analysis

The team prepared transcripts by summarizing the data from notes and audio recordings shortly after each interview and workshop. A coding framework was developed using the key components of institutional capacity assessment as broad themes and underlying questions as sub-themes which was discussed and agreed upon with the wider study team before analysis. Elements of these broad themes and sub-themes were then extracted from the data by two team members trained in qualitative research methodology. The method of thematic analysis was employed, which helped to identify, analyze, and interpret the patterns of meaning within the qualitative data. Fig 1 shows the institutional capacity assessment data collection and analysis process.

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Fig 1. Flow chart of institutional capacity assessment through workshops.

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Local institutions and programs related to WASH service delivery in Cox’s Bazar

DPHE is the national agency for water sanitation and hygiene initiatives and provides services in both urban (except in the four areas where Water Supply and Sewerage Authority supports) and rural areas. DPHE provided WASH infrastructure and services at the district level, such as Cox’s Bazar. DPHE also coordinates with DGHS, DGFP, DPE, DSHE, and LGIs) such as Upazila Parishad and Union Parishad, to support the WATSAN Committees. WATSAN Committees are established by the Government of Bangladesh at all administrative levels—district, sub-district, unions, and wards to ensure safe water supply, sanitation, and development of personal health care for the community people. These committees comprise the respective district, sub-district, union and ward-level officials and representatives from DGHS, DGFP, DPE, DSHE, and other LGIs, as illustrated in Fig 2.

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Fig 2. Structure of Upazila WATSAN committee.

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The Union WATSAN committee includes respective frontline workers from DGHS and DGFP, the Headmaster or any teacher of Primary and Secondary Schools, all Union Parishad Members, the Union Parishad Secretary, Tubewell Mechanic of DPHE, a religious leader and an NGO representative (if available). The Union Parishad Chairman acts as the Chairman of that Union WATSAN committee. The Upazila WATSAN Committee and other respective WATSAN Committees coordinate to ensure improved WASH facilities and promotion activities in their jurisdiction. Upazilas or Union Parishads are referred to as a body of people elected to manage the affairs of an Upazila or union level.

Other than the WATSAN committees at different administrative levels, other committees coordinated or managed institutional activities in many ways. Standing and School Management Committees (SMC) are important to mention among them. Standing committees were formed to support the Union Parishad in planning and implementing services on different issues such as education, health, family planning, social welfare and disaster management, agriculture etc., with transparency, accountability, and people’s participation. The SMCs engage local people to monitor school management to ensure the development activities of the school. Upazila-level officials from DPE and DSHE guide headteachers and SMCs to ensure safe drinking water for the students. DPHE allocates budget and constructs WASH blocks in Primary Schools under the Primary Education development program-4 (The government’s flagship initiative in the education sector for FY2019–FY2023) [14]. WASH blocks are gender-segregated, safely-managed sanitation facilities or latrines with running water sources. In addition, the School Learning Improvement Plan (SLIP) initiative provides modest funds to schools to manage and implement activities according to their own identified needs to improve the quality of education at the school level. DPHE also constructs WASH blocks in cyclone shelters. A cyclone shelter is an elevated building providing security from disasters such as cyclones and associated storm surges. Most cyclone shelters in Bangladesh are elementary schools [15].

In Bangladesh, community clinics and family welfare centers (under DGHS and DGFP, respectively) in rural areas provide primary-level healthcare and family planning services to the community. Although constructing WASH facilities in community clinics and family welfare centers is not linked with DPHE or WATSAN committees, DPHE’s responsibility for water supply indirectly affects the construction works at the community clinics and family welfare centers.

NGOs have their priorities and goals of service delivery as per donor requirements, which are time- and area-limited and may differ from the Government Institutions’ responsibilities; however, NGOs usually offer their services by co-coordinating and collaborating with LGIs. Private sector representatives, dealers and entrepreneurs manufacture and sell sanitation products based on the choice, customers’ budget, or economic status. In some cases, they work jointly with Union Parishad and NGOs, maintaining a private-public partnership to work towards hygiene promotion as a part of their marketing policy. Some NGOs (e.g., BRAC) provide loans to dealers to manufacture specific sanitation products and to sell those products in the open market. The institutional responsibilities of the active organizations in the context of Cox’s Bazar are provided in Table 2.

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Table 2. Institutional responsibilities on drinking water supply, sanitation and hygiene.

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WASH conditions in the context of Cox’s Bazar

Participants reported inadequate WASH practices in public areas, marketplaces and community clinics. For example, a few participants expressed that people are less aware of personal hygiene, and some do not use soap for regular handwashing due to poor economic conditions. For instance, in one union, participants from the LGI reported that half of the population used soap after using latrines, and some did not practice handwashing at five critical times during the day. About fecal sludge management, DGFP participants mentioned that many latrines overflow during floods and people practice manual emptying and open disposal of fecal sludge, which causes an unhealthy environment for all. Participants from both DPHE and DGFP reported that unclean toilets and the lack of gender-segregated toilets in cyclone shelters prevented many people from using them. This maintenance problem is also revealed in one of the Bangladesh Government projects (Ashrayan Prokolpo), where disadvantaged poor people from different places take shelter. Mentioning the situation from a particular Upazila, one key informant stated that each Ashrayan project accommodates about 120 families, with two toilets for every six families and separate bathing facilities. However, the users struggle with proper maintenance and cleaning of the toilets. As a result, the toilets become unusable quickly. Lack of proper coordination and appropriate budgeting for maintenance, inadequate design provisions against disaster (e.g., placing the WASH facility below flood level), lack of consideration for water quantity and quality (e.g., unavailability of running water, absence of Iron Removal Plant) and poor construction materials have rendered most of the WASH blocks damaged or unusable, as reported by the Primary School Officials.

Participants from DGHS and DGFP mentioned that they face problems in maintaining and renovating WASH facilities at the many community clinics and family welfare centers because they do not have a running water supply and electricity. DGFP participants mentioned that about 20% of their family welfare centers have no running water supply. Also, there is no maintenance plan for WASH facilities at the family welfare centers and due to the lack of proper cleaning and maintenance, DGFP own study findings showed that nearly 40–50% of facilities are unhygienic. DGHS participants mentioned that approximately 90% of tubewells at the community clinics are not functional. They added that they do not get water from the tubewells in the hilly areas since the groundwater levels have declined.

DPE participants mentioned that many WASH blocks in Pekua, Kutubdia and Chakaria Upazila constructed during 2013–2015 were not functional due to the unavailability of electricity and running water supply. High concentration of iron in the water also leaves a stain in the sanitary ware, damaging the WASH blocks. They also mentioned that consideration of the flood level for constructing WASH blocks is important and should ensure good quality construction materials for WASH blocks for the longevity of those facilities. Lack of menstrual hygiene management (MHM) facilities at school toilets may have been a reason behind the absence of female students during menstruation, as attributed by DSHE participants.

Private sector participants mentioned that there is inadequate availability of need-based sanitary ware or products that are appropriate for different geographical contexts. Also, people are unaware of quality or sustainable products; for example, plastic slabs are less durable than ceramic slabs, but considering cost, people buy less sustainable products. Therefore, local entrepreneurs and private sectors may collaborate to ensure quality products at a low cost.

Knowledge of policy, organizational strategy, guidelines, and framework

Bangladesh has several national policies, plans and strategies related to water supply, sanitation, and hygiene. Our findings revealed that most participants had not heard about those policies and were unaware of their roles and responsibilities. For instance, one participant explained the policy in the following manner

’Policies include ensuring clean water, managing advanced sanitation system, plant for removing arsenic and iron from water.’

Another participant explained that they identify poor and unprivileged people through locally elected members and then provide latrines or tube wells. However, he remained unsure about any clear guidelines regarding this. Representatives from other government institutions (DGHS, DGFP, DPE, DSHE and LGIs) also could not mention the institutional policy, strategy, organizational mandates, and regulatory framework that support delivering WASH services at their level. However, they all acknowledged the necessity of training in this regard.

Although private sector participants mentioned receiving ’hygienic latrine’ training from NGOs, most of them never received any training or guidelines from the government on other WASH issues such as iron and other pollutant-free safe drinkable water and sustainable and environment-friendly sanitation products.

Inadequate consideration of bottom-up feedback

DPHE local teams implement programs after consultation with Upazila Executive Officer and local government institutions as per their allocation received from the DPHE Head Office. Every year Union Parishad chairmen collect information through their respective Union Parishad Members at the ward-level WATSAN committee. Similarly, the Upazila WATSAN committee collects information from all Union Parishad Chairmen, informs the district WATSAN committee, and later gives the compiled demand to DPHE, but when DPHE allocates, it does not match the bottom-up recommendation. Besides, the allocation procedure deprives marginalized people of becoming beneficiaries of the intervention. A key informant mentioned:

’We usually receive the allocation for construction of tubewells in this Upazila 3 times a year from the ’Polly Onchole Pani Sorboraho Prokolpo’ (Village Water Supply Project) and is distributed through the Upazila WATSAN committee. 50% of this allocation is received by the Upazila Chairman and 50% by the local Member of Parliament (MP).’

The participant mentioned that the budgeting system must be changed, adding that:

’Around 40% should be decided by the MPs, 40% by the WATSAN committee members, and the rest 20% should be kept preserved for the demand from the institutions itself, to decide’.

Also, this type of top-down approach suggested for the budgeting system is not always context-specific. For example, different areas have different requirements. In certain areas of the district, decreasing groundwater levels and high concentrations of iron and salinity in surface and groundwater were reported as key challenges. Another key informant mentioned that there are some areas with a high concentration of iron, stating that:

’If an iron treatment plant or water plant can be set up in different union parishads and piped networking system can be ensured for water supply, that will be an effective step. Also, purified surface water should be used, and constant running water sources should be closed to stop wasting natural sources and avoid water scarcity in the future.’

Insufficient coordination between organizations

There is absence of effective coordination among DPHE and other members of the WATSAN committee. Meetings are not arranged regularly. Although Upazila WATSAN committee meetings are supposed to be organized once every two months, they are arranged only in cases of emergencies and priority issues. One key informant mentioned that yearly only one or two meetings of the WATSAN committees are organized. Since the members of this committee are regularly connected for work purposes, he thinks the work is usually done properly even if there is a lack of regular meetings held by the WATSAN committee.

We found inadequate coordination between the Upazila and Union WATSAN Committees or Union Standing Committee. In a workshop, a few participants reported that,

’Lack of coordination between WATSAN and standing committees hamper taking effective measures for WASH facilities. To make it more effective at the Upazila and union levels, a few members could form a new committee that is only responsible for monitoring WASH services. Since the WATSAN committee is mainly responsible for WASH, this committee should be activated to make it more accountable and effective in carrying out coordination meetings. Monthly meetings need to be arranged at both Upazila and union levels.’

Participants mentioned that the lack of inspection for waste management in marketplaces, such as fish markets and slaughterhouses, makes these places unclean and unhygienic. Participants also reported that the lack of coordination between the Upazila WATSAN committee and SMC has affected the implementation of WASH activities at secondary education institutes.

The local Government has no separate or specific WASH reporting and monitoring system for Union Parishad. Despite the fact that Union Parishad and DPHE work collaboratively, there are no operations or monitoring systems that are systematically designed to ensure the sustainability of infrastructure.

Since there are no systematic arrangements for quality assessment from the government or NGOs, some local traders or entrepreneurs profit from selling low-quality sanitary ware or products (e.g., toilets and basins). The entrepreneurs recommended training, provision of loans with low-interest rates, and quality assurance mechanisms for attaining quality WASH products in the market.

Inadequate resources (human resources, financial resources and infrastructural resources) hampered WASH service delivery

DPHE has representation at the national and sub-national levels to ensure WASH services. However, DPHE participants mentioned that due to the high influx of Rohingya refugees in Cox’s Bazar, there is a shortage of manpower to work in the host community of Ukhiya and Teknaf Upazila. In the district, optimal service delivery is hampered due to less skilled human resources and inadequate financial resources. One participant mentioned that to increase the skills of the mechanics, they need to be trained on issues such as appropriate places for tube wells to be installed, the water level, suitable technologies etc. Inadequate financial resources for transport costs and technical logistics supply are other constraints for optimal WASH service delivery. DPHE receives the same amount of allocation for transport allowance of their staff for all Upazilas. This amount is often inadequate for larger Upazilas, such as Chakaria having 18 unions.

DPHE mentioned lack of transport support sometimes hampered their regular activities and made them unable to render the services at remote unions on time. They mentioned that they can make a specific number of limited visits in a year to a remote area due to a limited budget, and for these visits, they do not get any vehicle support. One key informant mentioned,

’vehicles’ should be arranged for the mechanics of this office (Upazila DPHE). There is an allowance of BDT 5,000 for such travel, which is divided among four mechanics. This allocation is insufficient, so often these mechanics must go to different places at their own expense, making it impossible for them to work well’.

Another key informant revealed that in some remote areas, such as in Ramu Upazilla, deep-layer digging is required for deep tubewells. However, the DPHE cannot provide the appropriate technology, such as submersible pumps or drilling equipment, to install such tubewells due to the absence of electricity in areas such as Gorjonia. Sometimes they can manage the electricity through generators, which results in high costs. In addition, some areas of Teknaf and Ukhia Upazila of Cox’s Bazar have an excessive rocky layer where installing tubewells is inappropriate, and alternative ways, such as pipelined water supply system, need huge investments and bigger plans. DPHE participants also mentioned that rocky layers make it difficult to install deep tube wells, and there is not enough budget for cutting or drilling through those layers. One participant from DPHE mentioned that the budget allocation should be increased for the hilly areas according to the rate of hilly areas. Regarding implementation challenges by the private contractors and mechanics, one key informant mentioned that,

’Contractors and mechanics are not government staff but are rather ’private’ workers. They often do not want to go to work in some ’hard-to-reach’ areas like Gorjonia and Kocchopia. To hire them, they need to pay some extra ’tips’, which also raise the overall cost of the installation’.

In general, budgets are prepared using a top-down approach. Local officials do not have any role or engagement in budget preparation and planning. In the workshops, participants could not inform anything about the budget allocation of the current fiscal year. Participants also reported not having a specific budget allocation to implement WASH-specific activities (e.g., for providing inclusive wash blocks in secondary education institutes).

Both DPE and DSHE have an adequate workforce at the Upazila level, and they visit the schools following their monitoring protocols. DPE participants mentioned they have an adequate workforce to perform WASH activities. Upazila Education Officers regularly visit the schools and inform the principal regarding the maintenance and usage of toilets. Besides, they sent a proposal for the new construction of required WASH blocks in the school with the help of DPHE.

In addition, participants from the DGHS mentioned having a separate workforce to ensure the quality of WASH activities/services and maintenance of WASH facilities in the healthcare centers. But there is no exclusive staff for WASH service delivery. Frontline workers/community health workers do activities related to issues around WASH service and practices at the community level (e. g. courtyard session, one-to-one session etc).

Similarly, frontline workers of DGFP perform some awareness-raising works related to hand washing and personal hygiene. Participants from DGFP mentioned having an allocation of only TK 700 per year to maintain the cleanliness of each Family Welfare Centre.

Excess workload

WASH counseling activities are often compromised due to the existing workload of the frontline workers of DGHS caused by the large population of FDMNs in the area. The health centers, such as community clinics, lack functional WASH facilities and maintenance capacity, resulting in inadequate WASH practices by both health service providers and patients or caregivers. However, one key informant mentioned that Upazila Health Complex (Upazila level health facility) arranges different programs in schools, such as "National Worm Control Week (krimisoptaho)" and "Jatiyo Sastho Seba Soptaho" (National Health Service Week), where the Health Assistants spread awareness among the students regarding hygiene practices. Handwashing campaigns are also organized in the "Little Doctors (Khude Doctor)" program, where the students are instructed to demonstrate handwashing properly. This creates an opportunity for the Upazila Health Complex to raise awareness among people about WASH.

Recommendations from DPHE

DPHE participants recommended including disabled or physically challenged people while planning or budgeting for any WASH facility construction. They also recommend biofil-toilet technology to ensure safely managed sanitation facilities at the cyclone shelters. Biofil toilets have an environmentally friendly digester system, which treats organic waste through aerobic decomposition. The arrangement of separate toilets for the disabled and physically challenged people at the cyclone shelters was also another recommendation. They mentioned that the Union WATSAN and SMC meetings should be regularized, and the committee should inform the decisions to the Upazila DPHE. Moreover, the WATSAN committee should prepare monthly reports.

DPE participants recommended determining water extraction techniques and installation design based on local realities. They also recommended using surface water to ensure a pipeline water supply network to each school or group of schools. They mentioned the requirement of a concise and integrated policy and strategic guideline for conducting WASH activities at the local level that will include health, education, and WASH together.

DPE and DSHE participants recommended that MHM be considered during the construction of WASH blocks in schools and for cyclone shelters. Emergency sanitary napkins can be promoted with the support of the SLIP fund, as recommended by one DPE participant. Teachers, SMC, and scout groups could be trained to raise awareness of the WASH needs and requirements of the students.

Recommendations from the private sectors

Private sector participants recommended building awareness among the community people about sustainable WASH products at the household level for market promotion and collaborating with local NGOs and Union Parishad. They also mentioned that relevant institutions might collaboratively develop and share the context-specific plan with the private sector. The private sector or entrepreneurs can follow that plan within their capacity.

Implications for research and policy

Capacity assessment helps to improve the capabilities of individuals and organizations to function efficiently to attain sustainable results [30]. Our findings can help service providers or implementers to get evidence of strengths and weaknesses and the private sector to focus on demand-based production and marketing of contextually appropriate WASH products/technologies. In combination, these findings will help all to improve the current condition in WASH service delivery in a particular area by improving the existing capacities of the institutes and coordination among the relevant stakeholders. Strengthening institutional capacity collaboratively will improve several areas of service delivery [31–33]. The assessment of institutional capacity shows the gaps in delivering WASH services and opportunities to improve the WASH sector at the district level. Engaging the private sector and researchers in the WASH sector networks is a prerequisite for continuous improvement. Further studies and periodic monitoring and review of the WASH situation should be done to evaluate the effectiveness of interventions in achieving the SDG targets.