Report. KAP Baseline Survey on Water, Sanitation, and Hygiene. in Eight Regions of Ethiopia

Transcription

1 Report On in Eight Regions of Ethiopia Submitted to: UNICEF Ethiopia Submitted by: DAB Development Research and Training PLC August 2017 Addis Ababa i

2 ACKNOWLEDGMENTS This baseline survey wouldn t have been successful without the invaluable support we got from others. Firstly, DAB-DRT wants to acknowledge the continuous support from UNICEF staff, including Dr. Jane Bevan, Mrs. Netsanet Kassa, Mr. Getachew H/Michael, and Mrs. Kalkidan Gugsa for guiding us from the beginning up to the end of the survey. The supervision of UNICEF local staffs in regions covered by the survey is also appreciated. We would also like to forward our gratitude for government offices in different levels for providing us support letters and continuous supervisions for the security of our field staffs in line with the ongoing emergency plan. Moreover, DAB-DRT would like to appreciate the efforts of our hardworking consulting team members and our administrative staffs for their commitment beyond office hours for the successful accomplishment of the WASH KAP survey. It is a pleasure to work with you all and we appreciate your commitment. We would also like to thank our field supervisors and both qualitative and quantitative data collectors. Finally, we are grateful for household members, FGD participants and our key informants in different positions for sharing us the information we need and for devoting their scare time. ii

3 TABLE OF CONTENTS Acknowledgments... ii Table of contents... iii List of tables... vi List of figures... viii Acronyms... x Executive summary... xi 1. Introduction Objectives and thematic areas of the survey Objectives of the Survey Thematic Areas of the Survey Methodology Study Design Study Area Data Collection Methods Household Survey Key Informant Interviews (KIIs) Focus Group Discussions (FGD) Direct Observation Data Collection Tools Data Collection Process Data management and quality control Data Management and Analysis Quality Control Ethical considerations Operational definition of terms Challenges Limitations of the study Baseline findings Response Rates and Characteristics of Respondents Response Rates Respondents Characteristics Household Characteristics and Possessions Household Characteristics Household Possessions Household Water Supply iii

4 Access to Safe and Adequate Water Safe Water Management Practices Willingness to Pay for Water Services Challenges related to water supply among marginalized groups Status of Water Points Household sanitation facilities Household Toilet Facilities Defecation Practices and Disposal of Child Faeces Household Hand Washing Facilities Willingness to Pay for Improved Sanitation Services Knowledge and Perception about Toilets Demand for Sanitation Supply for Sanitation Factors Associated With Installing Household Toilet Facility Hygiene Practices Hand Washing Practices Personal Hygiene Practices Baby WASH Child Washing Practices Feeding Practices Waste Management and Cleanliness of Child Playing Ground Diarrhea Prevalence and Care for Sick Child Food Hygiene Knowledge Related to Food Hygiene Food Preparation and Storage Practices Multi-media Channels Access to Information on Hygiene and Sanitation and Community Networks Trustworthy and Preferred Information Sources Menstrual Hygiene Management Access to Information about Menstrual Hygiene Knowledge and Practice Related to Menstrual Hygiene Challenges Related to Menstrual Hygiene Management Menstrual Hygiene Management at Schools Effect of Menstruation on Girls Education Conclusions and Recommendations Annex iv

5 Annex 1: list of selected Kebeles and EAs Annex 2: The survey team v

6 LIST OF TABLES Table 1: Baseline values for key indicators, December xiv Table 2: Number of study woredas by region, December Table 3: Distribution of sample woredas, EAs and households across regions for each strata, December Table 4: List of key informants interviewed for the survey, December Table 5: Number of FGDs conducted for the survey by type of group, December Table 6: Number of observed WASH facilities by type, December Table 7: Background characteristics of respondents, December Table 8: Religious affiliation and educational status of women and men respondents, December Table 9: Average number of people living per household by residence and region, December Table 10: Percentage of households possessing various household effects and means of transportation by residence and region, December Table 11: Average number of animals owned by a household according to residence, December Table 12: Percent distribution of households by source of drinking water according to residence, December Table 13: Percent distribution of households by water collection time according to residence, by region and WASH emergency hotspot classification, December Table 14: Percent distribution of households by water treatment practice according to residence, by region and WASH emergency hotspot classification, December Table 15: Household drinking water storage practices according to residence and by region, December Table 16: Knowledge of women on occasions in which drinking water could be contaminated by disease causing organisms according to residence, December Table 17: Percent distribution of households by type of toilet/latrine facilities according to residence, December Table 18: Structural and hygiene condition of observed communal, public, and school toilet facilities, December Table 19: Percentage of women and men reported washing their hands at critical moments in the 24 hours period preceding the survey by residence, December Table 20: Percent distribution of women by knowledge on critical moments for hand washing with soap or substitute by residence, December Table 21: Percent distribution of men by knowledge on critical moments for hand washing with soap or substitute by residence, December Table 22: Practice related to frequency of bathing (body washing) among women and men according to residence, December Table 23: Number of times women and men respondents wash their face (eyes and nose) in the day preceding the survey according to residence, December Table 24: Knowledge of women respondents related to face (eyes and nose) hygiene according to residence by residence, December Table 25: Number of times mothers/caregivers wash the hands of their child under 3 years of age in the day preceding the survey according to residence, December Table 26: Number of times mothers/caregivers wash the face (eyes and nose) of their child under 3 years of age in the day preceding the survey according to residence, December Table 27: Practices of mothers/caregivers related to bathing (body washing) of their child under 3 years of age according to residence, December Table 28: Percent distribution of households by principal solid waste disposal methods according to residence, December Table 29: Percent distribution of households by principal liquid waste disposal methods according to residence, December Table 30: Practice of mothers/caregivers in giving drinks (including breast milk) and foods for a child sick of diarrhea according to residence, December Table 31: Knowledge of women and men about ways to make food safe for consumption according to residence, December Table 32: Practice in covering food storage containers according to residence, December vi

7 Table 33: Percentage of respondents who ever received information/advice on water, sanitation, and hygiene in the past 3 months by type of source, according to residence, December Table 34: Percentage of respondents who read newspaper or magazine, listen to radio and watch television according to residence, December Table 35: Type of information sources considered giving trustworthy/credible and useful information about water, sanitation according to residence, December Table 36: Access to information about menstrual hygiene among adolescent girls according to residence, December Table 37: Knowledge of women and adolescent girls about menstruation according to residence, December Table 38: Types of material women and adolescent girls usually use to manage menstruation according to residence, December Table 39: Type of absorbent materials considered as ideal to manage menstruation according to residence, December Table 40: Frequency of changing sanitary pad or homemade cloth in a day (24 hours) during the first three days of menstrual flow according to residence, December Table 41: Place of drying reusable sanitary pad or homemade cloth and underwear according to residence, December Table 42: Disposal methods of used menstrual materials according to residence, December Table 43: Frequency in cleaning external Genitals during menstruation according to residence, December Table 44: Frequency in taking bath during menstruation among adolescent girls according to residence, December Table 45: Challenges related to menstruation adolescent girls usually encounter according to residence, December Table 46: Availability of water and soap for menstrual hygiene at school according to residence, December Table 47: Place for changing and disposing sanitary pads at school according to residence, December vii

8 LIST OF FIGURES Figure 1: Current marital status of respondents, December Figure 2: Current employment status of women and men respondents, December Figure 3: Percent distribution of households by type of material of the main living house s floor, roof and wall, December Figure 4: Percent distribution of households by source of drinking water according to residence, by region and WASH emergency hotspot classification, December Figure 5: Reasons for using drinking water from non-protected source, December Figure 6: Reasons for unavailability of adequate quantity of water from the main source in the past 2 weeks according to residence, December Figure 7: Person responsible for water collection, December Figure 8: Percentage of women who wash their hand and drinking cups with soap before withdrawing water according to residence, December Figure 9: Frequency in washing drinking water containers, December Figure 10: Methods used for washing drinking water containers, December Figure 11: Percentage of households with access to improved water sources currently paying water fee by region, December Figure 12: Percentage of households that are willing to pay for water services in the future, December Figure 13: Percentage of households that use improved not shared toilet facilities according to residence and by WASH emergency hotspot classification, December Figure 14: Percentage of men using toilet facilities while at home and away from home by region, December Figure 15: Percentage of households with indiscriminately disposed human faeces in the compounds by region, December Figure 16: Place the child s faeces disposed the last time the child passed stool according to residence, December Figure 17: Advantages of owning a toilet facility reported by women, December Figure 18: Frequency in cleaning toilet facilities, December Figure 19: Reasons for satisfaction with the current toilet facility among adopters, December Figure 20: Willingness to improve/replace the current toilet facilities among current adopters according to residence, December Figure 21: Willingness to build toilet facilities (change the current place of defecation) among current non-adopters according to residence, December Figure 22: Motivators/reasons for installing household toilet facilities among current adopters according to residence, December Figure 23: Motivators Reasons for desire to build household toilet facilities among current non-adopters according to residence, December Figure 24: Reasons related to preference on types of toilet facilities by respondents among current non-adopters according to residence, December Figure 25: Reasons for not wanting to improve/replace the current toilet/latrine facilities among current adopters according to residence, December Figure 26: Reasons for not having a household toilet/latrine facility among current non-adopters according to residence, December Figure 27: Challenges related to construction household toilet facilities among current non-adopters according to residence, December Figure 28: Percentage of women and men who wash their hand with soap at all 3 critical moments in the previous day by residence, December Figure 29: Percentage of women with children under the age of five years reported washing their hands with soap or ash before breastfeeding/feeding a child and after cleaning a child s bottom in the previous day by residence, December Figure 30: Percentage of women and men who knew washing hands with water only is not sufficient to prevent diarrhea by residence, December Figure 31: Percentage of women reported washing their face with soap at least two times in the previous day according to residence, December Figure 32: Percentage of women and men who use soap the last time they wash their face (eyes and nose) by region, December Figure 33: Percentage of caretakers of children of age under 3 years reported washing their child s hand with soap or substitute the last time s/he passed stool by residence, December Figure 34: Percentage of caretakers of children of age under 3 years reported washing their child s hand with soap at least two times in the previous day by residence, December viii

9 Figure 35: Percentage of caretakers of children of age under 3 years reported washing their child s face with soap at least two times in the previous day by residence, December Figure 36: Practices of mothers/caregivers related to drying the face (eyes and nose) of their child under 3 years of age according to residence, December Figure 37: Findings from observation on face and hand of children under 3 years of age according to residence, December Figure 38: Method of washing child-feeding utensils by residence, December Figure 39: Frequency of washing child-feeding utensils by residence, December Figure 40: Practice of lactating women in washing hands before breastfeeding by residence, December Figure 41: Percentage of households that use safe waste disposal method by residence, December Figure 42: Percentage of children aged 6-59 months had received deworming pills in the past six months, December Figure 43: Prevalence of diarrhea in the two weeks period prior to the survey among children under the age of 5 years by region, December Figure 44: Practice related to frequency of washing food preparation utensils among women according to residence, December Figure 45: Practice in washing food preparation utensils used for handling of raw foods among women according to residence, December Figure 46: Practice in eating food immediately after it is cooked according to residence, December Figure 47: Practices related to reheating/recooking of leftover food according to residence, December Figure 48: Percentage of women who wash their hand before preparing/handling food the last time they handled/prepared food according to residence, December Figure 49: Percentage of households having separate room used as a kitchen and type of stove used by households according to residence, December Figure 50: Reasons given by women respondents for not talking freely about menstruation with their youngest daughter according to residence, December Figure 51: Practice in freely talking/discussing about menstruation among adolescent girls according to residence, December Figure 52: Reasons for not freely talking/ discussing about menstruation among adolescent girls according to residence, December Figure 53: Percentage of women and girls who knew menstruation is a sign of maturity, according to residence, December Figure 54: Percentage of women and girls who knew unmarried girl could also menstruate, according to residence, December Figure 55: Percentage of women and adolescent girls washing reusable sanitary pad or homemade cloth with soap according to residence, December Figure 56: Percent of adult women and adolescent girls who are able to afford to buy sanitary pad according to residence, December Figure 57: Percent of adult women and adolescent girls who are willing to pay for sanitary pad what they afford according to residence, December Figure 58: Reasons for not willing to pay for sanitary pad what they afford according to residence, December Figure 59: Access to education on menstrual hygiene management at school among adolescent girls according to residence, December Figure 60: Percentage of adolescent girls who said they feel confident to manage menses at school according to residence, December ix

10 ACRONYMS CLTS CSA CSPro EDHS E.C FGDs GoE GTP HEW HH KAP KII MDG MHM NGO ODF ORS OWNP PSU SPSS SSUs VIPL WASH WASHCO WIF Community-Led Total Sanitation Central Statistics Agency Census and Survey Processing System Ethiopia Demographic and Health Survey Ethiopian Calendar Focus Group Discussions Government of Ethiopia Growth and Transformation Plan Health Extension Worker Household Knowledge Attitude and Practice Key Informant Interviews Millennium Development Goal Menstrual Hygiene Management Non-Governmental Organization Open Defecation Free Oral Rehydration Salt One WASH National Program Primary Sampling Unit Statistical Package for Social Sciences Secondary Sampling Unit Ventilated Improved Pit Latrine Water, Sanitation and Hygiene Water, Sanitation and Hygiene Committee WaSH Implementation Framework x

11 EXECUTIVE SUMMARY Background The overall objective of the survey was to establish baseline data for the UNICEF Ethiopia new country program ( ) through KAP survey on the identified behavioral indicators to guide strategic approaches for social and behavior change communication. The survey measured the baseline status (quantitative and qualitative parameters) of knowledge, attitude, and practices specific to water, hygiene and sanitation indicators and set clear benchmarks for measuring impact. The survey was conducted in Amhara, Oromia, Tigray, SNNP, Afar, Somali, Benishangul Gumuz and Gambella regions of Ethiopia. It covered urban (small and medium towns), rural (both pastoralist and non-pastoralist) areas. Methods This baseline survey employed a community-based cross-sectional study design with both qualitative and quantitative data collection methods. Data collection was undertaken by Android based tablets, using the Census and Survey Processing System (CSPro) version App. The survey used a mix of data collection methods. Through household survey, face-to-face interviews were conducted with 2702 adult women, 1370 adult men, and 641 adolescent girls aged years. Qualitative data was collected through 122 Key Informant Interviews (KIIs) with experts and officials at federal, regional, woreda, and Kebele level, and 70 focus Group Discussions (FGDs) with various community members. Direct observation was done on existing WASH facilities including 23 hand-dug wells, 34 springs, 23 boreholes and 74 communal and school toilet facilities. Findings Access to safe water and household water management Sixty-three percent of households have access to an improved source of drinking water. There is extreme disparity in access to improved sources of drinking water among urban and rural areas, 93% in urban areas as compared with 31% in rural pastoralist and 64% in rural non-pastoralist areas. Comparing access to improved water sources based on WASH emergency hotspot classification, 59% of households in emergency woredas use drinking water from improved sources while the figure is 65% in non-emergency woredas. The average daily per capita water consumption is 14.2 liters (21.4 for urban, 15.8 for rural pastoralist, and 11.3 for rural non-pastoralist). The average water collection time is 46.5 minutes and it took less than 30 minutes to collect water (including two-way travel and queuing time) for 48% of households. The percentage of households having access to water supply within 30 minutes of walking distance (including queuing time) is 16% in rural pastoralists, 85% in urban areas and 48% in rural non-pastoralist areas. The majority of households (81%) do not treat drinking water at household level. Eighty-six percent of households use narrowmouthed containers for storing drinking water. During observation, 97% of respondents used safe methods while withdrawing drinking water from the storage containers. However, only 6% of women wash their hands and 5% wash the drinking cup with soap before withdrawing drinking water. Household sanitation facilities Ten percent of households use improved toilet facilities that are not shared with other households, with the highest in urban areas (24%) as compared with 5% and 7% for rural pastoralist and non-pastoralist households respectively. There is no difference in the percentage of households using improved not shared toilet facilities across emergency and non-emergency woredas (both 10%). Overall, more than a third (37%) of households do not have access to toilet facilities. Availability of hand washing facility is very low (8%), of which 53% of the facilities have soap or ash. Two-third (67%) of the hand washing facilities have signs indicating recent use. The practice of keeping toilet facilities hygienically is very low with only 11% of respondents reported cleaning the toilet every day while 34% of them said they never clean it. Findings from this survey showed rampant open defecation practice in which indiscriminately disposed human faeces seen in 41% of the surveyed households. The faeces of 49% of children is disposed in a safe way (by putting in a toilet or by burring) the last time the child defecated. Respondents from current sanitation adopters (households having toilet facility) were asked about the attributes of the toilet facility currently being used, that they like most and 51% of them said because it is located nearby. Other preferred attributes include; not being shared with other households (30%), the facility provides privacy (27%), and has minimal smell xi

12 (27%). Disease prevention (71%), preventing environmental contamination (45%), getting a defecation place that ensure privacy (41%), and prestige (18%) are the main motivators for installing household toilet facility among current adopters. Those respondents who are not willing to upgrade the current toilet facility were asked the reasons and the majority (67%) of them said they are happy with the current facilities. Lack of money is the second major reason for not willing to upgrade toilet facility (32%), followed by unavailability of land (7%). Lack of manpower (21%) and lack of construction materials (20%) are the main factors for not having household toilet facility among current non-adaptors (households without toilet facility). Other major reported factors for not having a household toilet facility include; unable to afford the cost (17%), difficulty of the land to dig (13%), and lack of plot of land (11%). One respondent in every ten (8%) said that they have other priorities. Willingness to pay Sixty-two percent of households having access to improved water sources pay water fees. When asked if they are willing to pay for water services in the future, 57% of respondents replied yes. More than half (63%) of those respondents who are willing to improve/upgrade the current toilet facility said they are willing to cover the cost. Among current non-adopters, 65% of households are willing to build a new private toilet facility. Of which, 30% of them are willing to cover the cost. Sanitation-marketing program is at infancy stage and the participation of the private sector in sanitation marketing is very low. Hygiene practices Only 23% of women and 13% of men reported that they wash their hands with soap or ash at all the 3 critical moments (before eating, after defecation /using a toilet and before handling/preparing food) in the past 24 hours. Among women having a child under the age of 5 years, 13% wash their hands before breastfeeding/feeding a child and 14% after cleaning a child s bottom in the 24 hours prior to the survey. Forty-five percent of women and forty-seven percent of men usually take bath at least once per week and 38% of women and 36 men at least twice per week. Forty-nine percent of women knew proper face hygiene is important to prevent trachoma. Less than half (43%) of women wash their face with soap at least two times in the previous day. Baby WASH As part of the survey, observations were conducted on the hygiene of children under 3 years of age and the findings revealed poor hygiene status among a considerable proportion of them. Flies were seen on the faces of 46% of children and 40% of them have visible exudate on the eyes. Dirt materials on hands and under fingernails was seen in more than half (62%) of children. Only 50% of mothers/caretakers of children under the age of 3 years reported that they wash their child s hand with soap or substitute the last time s/he passed stool and 39% wash their child s hand with soap twice or more times in the previous day. The percentage of mothers/caretakers who wash their child s face with soap twice or more times in the previous day is 42%. A-third (36%) of mothers/caregivers of children under 3 years of age usually wash their child s body on daily basis. Only 2% of lactating mothers have a practice of washing their hands every time before breastfeeding while 26% of mothers do not wash at all. When it comes to frequency of washing child-feeding utensils, only 22% of mothers/caretakers have the practice of washing the utensils every time they use it to feed the child. During observation, spoons/bottles/cups were found to be clean in only 48% of households. Among those mothers/caretakers of children under 3 years of age who reported their child has toys or playing tools, 44% of said they wash the toys or playing tools. Fifty-two percent of observed child playing places were found clean. One child under the age of 5 years in every ten (11.7%) had diarrhea and 2.4% had diarrhea with blood in the two weeks before the survey. The majority of mothers/caregivers gave less than usual fluid, including breast milk (24% much less than usual and 43% somewhat less than usual), and food (27% much less than usual and 47% somewhat less than usual) to their child the last time s/he had diarrhea. While only 10% of mothers/caregivers gave more than usual fluid to drink and 5% food during diarrheal illness. xii

13 Food hygiene Only 7% of women reported that that they always wash food preparation surfaces/utensils with clean and soapy water while 34% of them do not wash at all. The percentage of women who always wash food preparation utensils used for handling of raw foods before using it for handling other food items is 39%, and 59% of women always store raw and cooked foods separately. When asked how often their family members eat food immediately after it is cooked, 22% of women replied always and 38% of them said often. Only 14% of women said that they always thoroughly reheat/recook leftover foods before eating. Multi-media channels Health extension workers are the common source of information on hygiene and sanitation, followed by health workers (nurses, environmental health workers, health officers etc ). Two respondent in every ten (22% women and 20% men) received information about hygiene and sanitation from health extension workers in the 3 months period prior to the survey. Health workers are mentioned as a source of information about hygiene and sanitation by 14% of women. Health extension workers are also the most trustworthy information sources mentioned by half of respondents, followed by health workers. Thirty-one percent of women and 52% of men attended either formal or informal education, of which 9% of women and 16% of men said they read newspaper or magazine at least once a week. Twenty percent of men read newspaper or magazine less than once a week and the figure is 13% for women. Fifty percent of men listen to a radio (26% at least once a week and 24% less than once a week) while only 14% of women listen a radio at least once a week and 15% once a week. The percentage of women who watch television at least once a week is 12% while the figure is 16% among men. Only 8% of women watch television less than once a week as compared with 13% among men. Menstrual hygiene management Half (52%) of adolescent girls never received information about menstrual hygiene. Only two women in every ten (22%) said that they talked with their daughter about menstruation before she started menstruating. The use of disposable sanitary pads is common among adolescent girls as compared with adult women (50% girls Vs. 24% women). Half (49%) of adult women and 30% of adolescent girls usually use reusable pieces of cloth to manage menstruation. A few (13% adult women and 12% adolescent girls) use disposable pieces of cloth. The frequency in changing menstrual hygiene materials in a day (24 hours) during the first three days of menstrual flow is 3-4 times for 28% of adult women and 35% of adolescent girls. Three in every ten (32% adult women and 30% adolescent girls) reported that they change menstrual hygiene materials as needed/required. Half (48%) of girls and a third (33%) of adult women usually dispose of used menstrual hygiene materials in toilets. Sixty-four percent of adolescent girls are currently enrolled at school. Among those adolescent girls currently enrolled at school, only 19% of them said emergency sanitary pads are available at their school, of which 78% said the materials are provided free of charge. More than half (56%) and 80% of adolescent girls reported that water and soap is never available at school respectively. Two girls in every ten (21%) reported availability of a separate room for changing menstrual hygiene materials at schools. School toilets/latrines are common places for changing sanitary pads at schools (47%) while 34% of girls said that they did not change menstrual hygiene materials at schools. Schoolgirls were asked if they feel confident to properly manage their menstrual hygiene while at school and 61% of them replied yes. Eleven percent of schoolgirls reported that they had ever missed school due to menstruation related problem and, on average, a girl missed 3 school days the last time absent from school due to menstruation. xiii

14 Table 1: Baseline values for key indicators, December 2016 Indicators Urban Rural Rural nonpastoralist pastoralist Rural total Urban + Rural Access to improved drinking water sources and safe water management practices % of households using protected water sources as main source of drinking 93.2% 31.1% 63.9% 55.6% 62.9% water Average time to fetch water (in minutes) Per capita daily water consumption in liters There is no protected water source in the 71.4% 94.5% 87.8% 87.6% 89.7% Reasons for using drinking area water from non-improved Protected water source is far 11.4% 21.1% 26.9% 24.6% 24.2% 8.6% 6.3% 12.1% 9.8% 9.8% Protected water source has bad taste/odor 0% 0.3% 1.7% 1.1% 1.1% % of households treating drinking water at household level using appropriate water treatment methods (boiling, bleaching, filtering and solar 11.3% 19.8% 14.8% 16.1% 15.1% disinfection) sources (challenges in getting Expensive water fee at protected water safe drinking water) source % of households storing drinking water with narrow-mouthed containers 84.0% 93.2% 83.3% 85.8% 85.5% % of women respondents withdrawing drinking water from storage containers using safe methods (by pouring method or a cup exclusively used for this purpose) 96.5% 95.8% 96.7% 96.5% 96.5% % of women with knowledge on routes of water contamination Identified potential areas of water contamination in the water supply system At source 43.1% 53.1% 51.4% 51.9% 50.1% At home during storage 51.3% 41.1% 38.3% 39.0% 41.4% While withdrawing from storage containers 26.8% 21.1% 19.8% 20.1% 21.4% During transportation from source to home 15.5% 18.7% 13.1% 14.6% 14.7% % of observed water points without a functioning drainage canal % of observed water points where pollution sources such as animal and human excreta and rubbish were seen within 10 meters of the facilities 73.1% 82.4% 64.0% 67.2% 74.1% 34.6% 58.8% 16.0% 23.6% 38.8% Access to improved toilet facilities and child faeces disposal practice % of households with access to improved, not shared toilet facility 24.3% 4.9% 6.7% 6.2% 9.8% % of households with access to hand washing facility near toilets (among households with a toilet facility) % of women with knowledge on health risks from unsafe disposal of child faeces % of households that disposed the youngest child s faeces safely (in to latrine or by burying) the last time the child passed stool Face washing practices (eyes & nose) with focus on children and women % of women reported washing their face with soap at least two times in the previous day (24 hour recall) % of caretakers of children of age under 3 years reported washing their child s face with soap at least two times in the previous day (24 hour recall) % of women who knew the benefit of face hygiene for prevention of Trachoma Hand washing with soap or substitute at critical moments % of women reported washing their hand with soap or substitute before eating in the previous day (24 hour recall) % of women reported washing their hand with soap or substitute after using the toilet in the previous day (24 hour recall) % of women reported washing their hand with soap or substitute before handling food in the previous day (24 hour recall) % of caretakers of children of age under 3 years reported washing their hand with soap or substitute after cleaning a child s bottom in the previous day (24 hour recall) % of caretakers of children of age under 3 years reported washing their hand with soap or substitute before breastfeeding/feeding a child in the previous day (24 hour recall) % of women reported washing their hand with soap at all 3 critical moments (before eating, before handling food and after using the toilet) in the previous day (24 hour recall) 11.2% 6.8% 6.0% 6.2% 7.5% 54.2% 38.7% 50.4% 47.5% 48.8% 80.2% 23.4% 46.3% 41.3% 50.0% 61.9% 36.7% 38.5% 38.5% 42.7% 72.8% 24.5% 38.4% 34.7% 41.5% 64.4% 30.2% 49.6% 44.7% 48.5% 75.3% 67.1% 62.6% 63.8% 66.0% 60.5% 24.2% 34.2% 31.7% 37.2% 62.5% 54.5% 52.9% 53.3% 55.1% 18.8% 6.8% 15.0% 12.8% 13.7% 13.4% 12.7% 13.6% 13.4% 13.4% 37.7% 19.1% 19.7% 19.5% 23.1% xiv

15 Indicators Urban Rural Rural nonpastoralist pastoralist Rural total Urban + Rural % of caretakers of children of age under 3 years reported washing child s hand with soap or substitute the last time the child passed stool 75.9% 32.6% 49.1% 44.8% 50.3% % of women who knew at least 3 critical moments for hand washing 53.8% 46.5% 37.9% 40.1% 42.7% % of women who knew hand washing with water only is not adequate to prevent diarrheal diseases 80.3% 47.6% 66.2% 61.5% 65.1% % of households with all essential hand-washing supplies readily available (water, soap/substitute and washing device allowing for unassisted hand washing) 5.9% 0.5% 1.0% 0.9% 1.9% Food hygiene (with specific focus for babies under 3 years of age) % of women who knew at least 2 safe food handling methods 79.9% 61.6% 73.1% 70.2% 72.1% % of households with separate kitchen or smokeless stove 75.1% 34.4% 59.0% 52.8% 57.1% % of households with shelves for kitchenware 48.3% 13.3% 29.9% 26.0% 30.3% % of households with all food storage containers covered during observation 50.8% 30.5% 33.0% 32.4% 36.0% % of households always storing raw and cooked foods separately 71.5% 52.2% 57.9% 56.5% 59.4% % of women reported washing food preparation surfaces/utensils with clean soapy water (always or often) 38.1% 10.9% 20.9% 22.2% % of women reported their family members always eat food immediately after cooked 24.9% 31.1% 17.7% 21.1% 21.8% % of women reported their family members always eat leftover food after it is thoroughly reheated/recooked 19.9% 1.5% 15.6% 12.0% 13.5% % of women reported always washing food preparation utensils used for handling of raw foods before using it for handling other food item 58.6% 26.2% 37.2% 34.4% 39.1% % of women reported washing hand with soap before handling food the last time they handled food 64.0% 28.0% 36.6% 34.4% 40.1% % of caretakers of children of age under 3 years with knowledge about the risk of diarrheal disease from bottle feeding 41.9% 13.3% 20.9% 18.9% 23.0% % of caretakers of children of age under 3 years reported they do not bottle-feed their youngest child 93.2% 91% 94.5% 93.6% 93.5% % of caretakers of children of age under 3 years who reported they wash the spoon or bottle with detergent or warm water every time before feeding 33.3% 6.0% 12.7% 10.9% 16.8% % of caretakers of children of age under 3 years who reported they used spoon for child feeding 36.6% 18.0% 16.8% 17.1% 20.6% Baby WASH (regular washing of babies and safe environment for babies under 3 years of age) % of caretakers of children of age under 3 years reported washing their child s body on a daily basis 57.6% 22.7% 34.3% 31.2% 35.9% % of lactating mothers reported taking bath at least once a week 97.7% 100.0% 92.2% 93.8% 94.6% % of lactating mothers reported washing hands every time before breastfeeding 3.1% 0% 2.0% 1.6% 1.9% % of households disposing solid waste safely 70.5% 34.7% 57.9% 52.0% 55.7% % of households disposing liquid waste safely 27.0% 6.7% 16.3% 13.9% 16.4% % of households with separate animal house 62.1% 84.0% 64.2% 69.6% 68.9% % of households with a living room having adequate ventilation 77.4% 25.3% 48.5% 42.6% 49.3% % of households with clean living room 48.5% 20.5% 21.8% 21.5% 26.7% % of household compounds that are open defecation free 79.3% 46.2% 57.7% 54.8% 59.5% % of household compounds that are free from indiscriminately disposed 41.2% 28.4% 22.1% 23.7% 27.1% solid waste % of household compounds that are free from indiscriminately disposed liquid waste 46.9% 36.9% 35.3% 35.7% 37.9% Menstrual hygiene management focusing on adolescent girls % of adolescent girls who knew menstruation is normal natural process 75.5% 75.8% 65.7% 68.3% 69.9% % of adolescent girls who knew clean absorbent reusable or disposable materials are safe materials for menstrual hygiene management % of adolescent girls who knew menstrual materials (sanitary pads or homemade cloth) should be changed three to four times over 24 hours % of adolescent girls who knew homemade menstrual cloth and reusable pads including underwear needs to be washed with water and soap % of adolescent girls who knew homemade menstrual cloth and reusable pads including underwear needs to be dried in open sun 91.6% 84.4% 65.9% 69.3% 75.3% 31.5% 18.7% 22.4% 21.4% 23.7% 40.6% 45.3% 41.6% 42.6% 42.1% 30.8% 43.8% 36.5% 38.4% 36.7% xv

16 Indicators Urban Rural Rural nonpastoralist pastoralist Rural total Urban + Rural % of adolescent girls who knew reusable sanitary materials should not be shared with other individuals 76.2% 67.2% 57.6% 60.0% 63.7% % of adolescent girls who knew the need to wash the skin outside and around their vagina at least once in a day during menstruation 76.9% 75% 71.1% 72.1% 73.2% % of adolescent girls who knew used menstrual materials should be disposed in a closed temporary collection and buried or burned 34.3% 45.3% 29.5% 33.5% 33.7% % of adolescent girls reported changing menstrual Adolescent girls 41.2% 22.4% 36.9% 32.0% 34.5% pads 3-4 times over 24 hours Adult women 42.8% 24.3% 24.5% 24.4% 27.5% % of adolescent girls and women reported washing Adolescent girls 83.3% 59.0% 86.2% 76.0% 76.7% reusable menstrual cloth with water and soap Adult women 91.3% 54.0% 86.9% 76.5% 77.7% % of adolescent girls and women reported drying Adolescent girls 58.3% 87.2% 78.5% 81.7% 79.3% menstrual cloth and reusable pads in open sun Adult women 50.0% 84.8% 64.0% 70.6% 68.9% % of adolescent girls and women reported properly Adolescent girls 89.4% 63.2% 67.8% 66.2% 72.6% disposing absorbent materials (sanitary pads or menstrual cloth) Adult women 73.6% 31.4% 48.7% 43.3% 48.6% % of adolescent girls and women who prefer Adolescent girls 89.4% 19.7% 57.7% 44.9% 57.1% disposable sanitary pad as ideal absorbent Adult women 71.8% 13.0% 24.5% 20.9% 29.6% % of adolescent girls and women who prefer reusable Adolescent girls 3.5% 7.9% 2.0% 4.0% 3.9% sanitary pad as ideal absorbent Adult women 3.9% 1.1% 2.5% 2.1% 2.4% % of adolescent girls and women reported they are Adolescent girls 87.1% 13.2% 60.4% 44.4% 56.1% able to afford to pay for sanitary pad Adult women 76.9% 11.1% 36.3% 28.5% 36.7% % of adolescent girls and women willing to pay for Adolescent girls 98.6% 100% 92.2% 93.0% 95.4% sanitary pad what they afford Adult women 100% 96.2% 91.2% 91.8% 94.7% % of adolescent girls reported they do not ever get teased by their friends related to menstruation 98.8% 89.5% 92.6% 91.6% 93.5% % of adolescent girls reported ever discuss freely about menstruation and do not feel ashamed revealing their menstrual status 53.8% 28.1% 32.7% 31.5% 37.0% Shame 66.7% 78.3% % 69.1% Reasons for not freely discussing about Due to culture and beliefs of the society 12.1% %% 16.5% 15.8% menstruation among I don t feel free to discuss 22.7% 25.0% 13.0% 16.2% 17.3% adolescent girls Due to taboos 10.6% 10.9% 10.9% 10.9% 10.9% Due to religion 0% 1.1% 1.6% 1.5% 1.2% % of adolescent school girls reported sanitary pads for emergency menstrual hygiene management are available in their school % of adolescent school girls reported water for menstrual hygiene is always available in their school % of adolescent school girls reported soap for menstrual hygiene is always available in their school % of adolescent school girls reported feeling confident to manage menses at school 1 % of adolescent school girls reported not missing any school due to menstruation related problems % of adolescent school girls reported never interrupted school class due to menstruation related problems People s perception about menstruation (social taboos, curse, sin and related isolations) [Qualitative indicator] Perception of adolescent girls and other community members on leaks, stains, and odors related to menses [Qualitative indicator] 28.2% 19.2% 10.5% 12.4% 18.6% 20.5% 11.5% 13.7% 13.2% 16.1% 12.8% 0% 6.3% 5.0% 8.0% 74.4% 30.8% 58.9% 52.9% 61.3% 91% 84.6% 89.5% 88.4% 89.4% 96.2% 96.2% 90.5% 91.7% 93.5% People consider menstruation as a normal natural process and a sign of maturity for girls Yet, some individuals associate menstruation with sexual intercourse and abortion when they see menstrual bloodstain on a girl s cloth In some areas, a woman is not allowed to prepare and serve food, fetch water, and participate in social gatherings during menstruation For most girls, the main psychological effect of menstruation is fear of accidental bloodstain on cloth and teasing associated with it Adolescent girls are also concerned about odor thinking, if they sit close to other people, others may smell odor from their menses There are few male students who are not willing to sit on the place where a girl who is menstruating once sat on Willingness to pay for improved water and sanitation services % of households willing to pay for water services in the future 85.1% 48.4% 51.1% 50.4% 57.1% 1 Confidence to effectively manage personal hygiene during menses as defined by the respondent xvi

17 Indicators % of households willing to pay for installing new toilet facility on their own (among current non-adopters 2 that want to build new toilet) % of households willing to pay for improving/upgrading toilet facility by their own (among current adopters 3 that want to improve/upgrade the existing toilet) List of identified factors affecting willingness to pay for sanitation [Qualitative indicator] Lack of awareness about sanitation Communities choice on sanitation technology options (among current non-adopters) Urban Rural Rural nonpastoralist pastoralist Giving low priority for sanitation among other household issues Limited economic capacity of households Rural total Urban + Rural 48.0% 17.0% 37.2% 28.6% 29.6% 73.1% 46.3% 61.0% 59.3% 62.8% Pit latrine with slab 64.0% 55.3% 72.3% 65.4% 65.1% Ventilated improved Pit latrine (VIP) 14.0% 16.3% 12.6% 14.1% 14.2% Flush toilet 10.0% 9.8% 7.7% 8.5% 8.6% Composting toilet 4.0% 0.8% 2.7% 1.9% 2.0% No manpower to construct 8.0% 22.8% 21.6% 22.1% 21.4% Reasons for not installing household Do not have adequate construction 10.0% 31.8% 11.9% 19.9% 19.8% toilet facilities among current nonadopters Expensive construction cost 14.0% 27.0% 9.5% 16.6% 16.8% materials The area land is difficult to dig a pit 16.0% 10.3% 14.1% 12.6% 12.7% Ultimate decision maker for installing the toilet facility Men/Husband 58.7% 76.0% 73.0% 73.4% 69.3% households currently using (among current adopters) Women/Wife 19.9% 14.0% 13.1% 13.2% 15.1% Appropriate multi- media channels % of households having Radio 42.5% 13.3% 26.5% 23.2% 26.9% % of households having Television 49.2% 2.5% 4.2% 3.8% 12.5% % of respondents reading a newspaper or magazine at least once a week % of respondents listening to the radio at least once a week % of respondents watching television at least once a week Information sources considered by women to give trustworthy/useful information about sanitation and latrines Information sources considered by men to give trustworthy/useful information about sanitation and latrines Level of trustworthiness/credibility of available information sources among the communities [Qualitative indicator] Women 14.9% 4.2% 5.2% 5.1% 8.7% Men 25.5% 10.0% 12.5% 12.2% 15.9% Women 23.4% 8.2% 13.6% 12.2% 14.4% Men 46.4% 18.0% 22.4% 21.4% 25.8% Women 44.1% 2.7% 4.2% 3.9% 11.6% Men 56.9% 5.6% 8.0% 7.4% 16.1% Health extension workers 45.4% 45.5% 54.7% 52.4% 51.0% Health workers 39.5% 43.3% 36.2% 38.0% 38.3% Family members 19.7% 12.0% 19.4% 17.5% 18.0% Health Development Army/CHW 18.4% 15.6% 17.9% 17.3% 17.5% Electronic media (TV and Radio) 22.2% 8.5% 6.9% 7.3% 10.2% Health extension workers 45.2% 45.1% 52.8% 51.0% 50.0% Health workers 38.1% 42.9% 37.1% 38.5% 38.4% Family members 20.5% 20.7% 20.3% 20.4% 20.4% Health Development Army/CHW 17.2% 15.8% 19.4% 18.6% 18.3% Electronic media (TV and Radio) 30.5% 14.7% 11.0% 11.9% 15.1% People trust information from those who live with the community, especially health extension workers and health development armies Information from health centers, Kebele meetings, newspapers, religious leaders, and government officials are considered as credible Radios, especially those broadcasting in local languages, are also believed to provide credible information Religious places and gatherings Coffee ceremonies Available local formal and Market places informal networks and interpersonal communication Weeding ceremonies medias in the community Funeral gatherings [Qualitative indicator] Debo (a traditional work group in rural areas) Idir (community self-help groups during funerals) Iquib (community based saving groups) The private sector role in improving the hygiene and sanitation situations particularly in sanitation marketing Extent of participation of the private sector in hygiene and sanitation [Qualitative indicator] The private sector participates in selling construction materials, and working as contractors and consultants in building institutional sanitation facilities However, the participation of private sector in sanitation marketing is almost none 2 Households currently without toilet facility 3 Households currently having toilet facility xvii

18 Indicators Potential and opportunities for involvement of the private sector in hygiene and sanitation [Qualitative indicator] % of households that can afford to pay for private toilet builders Identified challenges hindering the participation of the private sector in hygiene and sanitation [Qualitative indicator] Urban Rural Rural nonpastoralist pastoralist Rural total Urban + Rural There are experiences in engaging youths and women in slab production by organizing them in micro and small scale groups which could be scaled up. Current adopters 86.3% 66.7% 82.0% 80.1% 82.4% Current non-adopters 60.0% 40.0% 68.2% 56.8% 63.6% WASH programs give little attention for participation of the private sector Unavailability of credit service to enhance participation of the private sector in WASH services Limited interest of the private sector to engage in WASH services Low demand for sanitation Lack of information about the business potential of the WASH sector xvii i

19 1. INTRODUCTION There is a considerable socio-economic and health burden attributed to inadequate water, sanitation and hygiene (WASH) facilities and practices, particularly in low-income countries. 4 Every year, millions of people worldwide die from diseases attributable to lack of access to safe drinking water and basic sanitation, 1.6 million of them dying from diarrheal diseases in particular million people are also at risk of trachoma, 146 million of them threatened by blindness due to the disease and 133 million suffering from high intensity intestinal helminthes infections. 6 Children, especially those in developing countries, are the most affected groups from diseases resulting from unsafe and inadequate drinking water, and poor sanitation and hygiene. Ninety percent of annual deaths from diarrheal diseases are among children under five years of age. 7 In Ethiopia, particularly in the rural areas where majority of the population lives, lack of adequate potable water and poor hygiene and sanitation practices are the main causes of illness. Diarrheal diseases cause twenty three percent of all deaths under the age of five in the country. 8 Childhood illnesses such as diarrheal diseases have also significantly contributed to the high chronic malnutrition rates among under 5 children in Ethiopia with a 44 percent stunting prevalence. 9 Lack of safe drinking water and access to basic sanitation facilities and poor hygiene practices are the major causes of childhood diarrhea. Analysis of the 2011 Ethiopia Demographic and Health Survey (EDHS) data on determinants of childhood diarrhea among under 5 children in Benishangul Gumuz Regional State identified absence of toilet facility and improper child stool disposal as the major risk factors for childhood diarrhea. 10 Over the last decade, Ethiopia has made a promising progress in improving access to improved drinking water sources. The country has met the MDG target by increasing the percent of population with access to improved drinking water sources from 13 percent in 1990 to 57 percent in Despite this remarkable success, however, access to safe drinking water supply in Ethiopia remains among the lowest in the world and even lower than the sub-saharan average of 68 percent for safe water coverage. The difference in the status of coverage between urban and rural areas also remains significant; in 2015, 93% of the urban population in the country use improved drinking water sources while only 49 percent of the rural population have access to improved drinking water sources. 12 According to the 2015 WHO/UNICEF JMP updates and MDG assessment, the proportion of people practicing open defecation in Ethiopia has decreased from 92 percent during the MDG baseline year to 29 percent in However, Ethiopia did not met the MDG target for sanitation with only 6 percent of households in 2016 use improved and not shared toilet/latrine facility (urban 16 percent and rural 4%). 13 Findings from the 2016 demographic and health (DHS) survey also showed that still a third (32 percent) of households do not have access to a toilet facility, with the highest in rural areas (39 percent) as compared with 7 percent in urban areas. Proper attention has not been given to the issue of menstrual hygiene management (MHM) in general and MHM among adolescents in particular. 14 The UN defines the term adolescence as a period of life between years. 15 Significant physical, emotional, and social changes characterizes the period of adolescence. 16 The median age at first marriage among Ethiopian women aged is 16.5 years 17, indicating the period of adolescence for Ethiopian females is also a transition from childhood to adulthood and bearing family responsibilities. In females, the period of adolescence is a period when the onset of menstruation starts. 18 During the first onset of menstruation, adolescent girls usually face challenges related to the management of menstrual hygiene. Social, economic and cultural factors including lack of access to sanitary pads, water and 4Cairncross, S., J. Bartram, et al (2010). "Hygiene, sanitation, and water: what needs to be done?" PLoS Med7 (11): e Ibid 7 Ibid 8 UNICEF Sanitation Priority Country Fact Sheet 2014: Ethiopia. 9 Ibid 10 Sinmegn Mihrete et al. (2014). Determinants of childhood diarrhea among under five children in Benishangul Gumuz Regional State, North West Ethiopia. BMC Pediatrics, 14:102: 11 WHO/UNICEF (2015): 25 Years Progress On Sanitation and Drinking Water 2015 Update and MDG assessment. 12 Ibid 13 EDHS 2016 key indicators report 14 Water Aid (2009). Menstrual hygiene and management an issue for adolescent school girls. Available from: 15 WHO (2001). The second decade: improving adolescent health and development. Geneva: National adolescent health information center, University of California (2004). Improving the health of adolescents & young adults. Available: ucsf.edu/wpcontent/uploads/2011/11/complete2010 Guide.pdf. 17 EDHS Loughborough University (2012). Developing knowledge and capacity in water and sanitation; Menstruation hygiene management for schoolgirls in low-income countries. Available: MHM_A4_Pages.pdf. 1

20 latrine facilities, and limited awareness about menstrual hygiene puts adolescents at risk of emotional and health problems during menstruation. 19 In Ethiopia, adolescents have limited access to information on MHM and the practice of discussing about menstruation and providing support to adolescents among family members and peers is low. The findings of a study conducted on Menstrual Hygiene Management among adolescent school girls in Amhara regional state showed that mothers are the main source of information about menstrual hygiene for only 23 percent of adolescents and 61.6 percent of adolescents reported that they had never discussed with their friends about menstrual hygiene. 20 Findings from another assessment on knowledge and practice of menstrual hygiene among high school girls in Western Ethiopia also showed similar findings in which mothers are the main source of information on MHM for 35 percent of schoolgirls. 21 The same study also revealed that knowledge and practice of menstrual hygiene among school is girls is low in which 60.9 percent of respondents had good knowledge on menstrual hygiene while less than half (39.9 percent) of them had good practice. 22 The government of Ethiopia (GoE) recognizes WASH as a priority and is committed to improve access to safe and sustainable water supply and improved sanitation facilities for its citizens. In view of its commitment, the second Growth and Transformation Plan (GTP-2) of the government targets to reach 83 percent water supply access (85 percent for rural and 75 percent for urban areas) with minimum service level as per GTP-2 standard with improved water supply schemes by the end of the plan period (2019/2020). The GTP-2 standards for water supply are: l/c/day within a distance of 1 km from the water delivery point for rural water supply 100 l/c/day for category-1 towns/cities 80 l/c/day for category-2 towns/cities 60 l/c/day for category-3 towns/cities 50 l/c/day for category-4 towns/cities up to the premises 40 l/c/day for category-5 towns/cities within a distance of 250m with piped system For the sanitation sub-sector, the targets are to increase the proportion of households with access to improved latrines and hand washing facilities to 82 percent and with proper solid waste collection and disposal service to 40 percent by the end of the GTP-2 period. The plan also targets to reach 35 percent for proportion of households using household water treatment and safe storage practice. 24 To operationalize its plan, the government of Ethiopia has devised various strategies and developed a number of strategy documents, among them the One WASH National Program (OWNP) which is developed based on a sector wide approach (SWAp). The Ministry of Water, Irrigation and Electricity, The Ministry of Health and The Ministry of Education share the responsibility for achieving the targets of OWNP, while Ministry of Finance & Economic Development plays an important role in the sector on financial issues. The program has the following four components: rural and pastoral WASH, urban WASH, institutional WASH, and program management and capacity building. The national WASH Implementation Framework (WIF), developed in 2011, sets out the WASH structure from community to national level, defines the role and responsibilities of various actors and elaborates the implementation modality of WASH programs in urban, rural (agrarian and pastoralist) context. In line with the Government of Ethiopia s country programmes, UN agencies, NGOs and other development partners have been working in the WASH sector for decades. As the main partner in the WASH sector, UNICEF Ethiopia has launched a new country program for the next five years ( ). As part of the program, UNICEF Ethiopia in collaboration with DAB-Development Research & Training PLC undertook this WASH baseline survey for the program. This report presents findings from the baseline survey conducted in Amhara, Tigray, Oromia, SNNP, Benishangul Gumuz, Afar, Somali, and Gambella regional states of Ethiopia. 19 Ibid 20 Gultie T, Hailu D, Workineh Y (2014). Age of Menarche and Knowledge about Menstrual Hygiene Management among Adolescent School Girls in Amhara Province, Ethiopia: Implication to Health Care Workers & School Teachers. 21 Upashe et al. (2015). Assessment of knowledge and practice of menstrual hygiene among high school girls in Western Ethiopia. BMC Women's Health 15:84 22 Ibid 23 Ministry of Water, Irrigation and Electric (2015). Second Growth and Transformation National Plan for the Water Supply and Sanitation Sub-sector (2015/ /20). 24 Federal Ministry of Health (2015). Health Sector Transformation Plan (2015/ /20). 2

21 2. OBJECTIVES AND THEMATIC AREAS OF THE SURVEY 2.1. Objectives of the Survey The overall objective of the survey was to establish baseline data for the UNICEF Ethiopia new country program ( ) through KAP survey on the identified behavioral indicators in order to guide strategic approaches for social and behavior change communication in Amhara, Oromia, Tigray, SNNP, Afar, Somali, Benishangul Gumuz and Gambella regions. Specifically, the survey measured the baseline status (quantitative and qualitative parameters) of knowledge, attitude, and practices specific to water, hygiene and sanitation indicators and set clear benchmarks for measuring impact on the following areas: Risk behaviors and barriers for adopting the desired behavior Key factors that positively influence adoption of desired behaviors and appropriate multi-media channels to convey messages Household s ability and willingness to build basic and improved sanitation and hygiene facilities and pay for available water services The extent of the private sector role in the targeted regions in improving the hygiene and sanitation situation particularly in sanitation marketing Most trusted sources of information and potential C4D platforms 2.2. Thematic Areas of the Survey The thematic focus of the survey dwells on knowledge, attitude, and practices related to various aspects of water, hygiene and sanitation behaviors including: Safe Water Management (SWM) from the source to uptake (consumption) Hand Washing (HW) with soap or substitute at critical time Menstrual hygiene management (MHM) focusing on adolescents Improved toilet usage, including safe disposal of child feces Face washing practices (eyes and nose) with particular focus on children and mothers Baby WASH (safe environment for babies under three and regular washing of babies) Food hygiene (with specific focus for babies under three) Affordability to pay for water and sanitation services 3. METHODOLOGY 3.1. Study Design This baseline survey employed a community-based cross-sectional study design with both qualitative and quantitative data collection methods. Data collection was undertaken by Android based tablets, using the Census and Survey Processing System (CSPro) version App Study Area This baseline survey covered eight regional states of Ethiopia, namely: Amhara, Oromia, Tigray, SNNP, Afar, Somali, Benishangul Gumuz, and Gambella regions. Forty-four woredas selected from urban (small and medium towns), rural (both pastoralist and non-pastoralist) areas were included in the survey. The Table below presents the number of woredas included in the survey in the eight regional states. Table 2: Number of study woredas by region, December 2016 Type of woreda Tigray Amhara Afar Oromia Gambella SNNP Benishangul Gumuz Somali Total Urban Rural pastoralist Rural non-pastoralist Total

22 3.3. Data Collection Methods The survey used a mix of data collection methods, including face-to-face interviews using a structured questionnaire (household KAP survey), Key Informant Interviews (KIIs), Focus Group Discussions (FGDs), and direct observation of WASH facilities. The sections below present the details on data collection methods employed in the survey Household Survey Sample size of the household KAP survey The sample size of this KAP baseline survey was determined using the following formula 25 by taking into account the following assumptions. Where, n = za{deft 2 [( p )/e2 ]/[ R i x R h x d]} P is estimated prevalence rate (proportion) P of 50% [50% yields the maximum sample size] Deft is estimated design effect of 2.5 [Since we use a multi-stage cluster sampling design] D is the number of target individuals per household of 0.69 [Average number of under five children per household to determine diarrheal disease prevalence from the 2007 census] R i is individual response rate of 93% [Overall women response rate from EDHS 2011] R h is household gross response rate of 98% [Household response rate from EDHS 2011] e is relative Margin of Error of 0.12 za is z- score value at 95% confidence level 2 Thus, taking the above parameters of interest, the total calculated sample was 2,760 households. Sampling Procedure Selection of the study subjects was done using a multi-stage cluster sampling method. The Central Statistical Agency s (CSA) Enumeration Areas (EA) created for the 2007 census and households residing in the enumeration areas were used as primary sampling units (PSUs) and secondary sampling units (SSUs) respectively. Homogeneity among the households within an EA, relative sampling cost per EA and per household, and experience from EDHS surveys were considered while deciding the number of households to be included per EA. Accordingly, it was decided to include 20 households in each EA yielding a total number of 138 EAs for the survey (2,760/20=138). Stratification was used to get representative samples for rural, urban, pastoralist and non-pastoralist areas and for each of the eight regions. Accordingly, 20 percent of the sample allocated for pastoralist and 80 percent for non-pastoralist areas. The sample of non-pastoralist areas were further allocated to urban and rural areas using the power allocation technique. That is, between the proportional allocation (based on the proportion of EAs in urban and rural areas) and the equal size allocation. The distribution of EAs across regions was also done using the power allocation scheme by considering probability proportional to the EA size and with independent selection in each sampling stratum (rural pastoralist, rural non-pastoralist and urban areas). Based on these, (28 EAs, 560 households) were allocated for rural pastoralist, (27 EAs, 540 households) for urban areas and (83 EAs, 1,660 households) for rural non-pastoralist areas. Nationally, the survey covered 44 woredas across the eight regions. The number of woredas included in the survey for each region was decided in line with the number of EAs and households found in the regions. Systematic random sampling was used to select sample woredas from each region. First, using CSA s complete list of woredas, a separate list of woredas was prepared for each region. Except for Somali region, all woredas in the seven regions were included in the list. For Somali region, cartographic maps of EAs are available only for Shinile, Jijiga and Liben Warder Zones. Hence, the list for Somali 25 Adopted from USAID (2012). Sampling and Household Listing Manual; DHS Methodology 4

23 region only consists of woredas found in these three zones. Then, the sampling interval (K) was determined by dividing the total number of woredas in the list for each region to the number of allocated sample woredas for the region. The first woreda (J) was selected by randomly choosing between number 1 and K. Subsequent woredas were selected by adding the sampling interval (K) to the serial number of previously selected woreda. Simple random sampling method was used to select EAs (clusters) within each selected woreda. First, list all EAs found in the woreda was prepared separately for each stratum (urban, rural pastoralist and rural non-pastoralist). Then, the required number of EAs (clusters) for the woreda, for each stratum, was selected through a simple random sampling technique using a random number generator App installed on tablets. Households in each EA were selected using simple random sampling method. Upon arrival to a selected EA, enumerators prepared a list of all households found within the boundary of the EA. From the serial list, 20 households were selected randomly using a random number generator App installed on tablets. In each selected household, face-to-face interviews were conducted with one adult woman aged 18 years and above living permanently in the household. Interviews were also conducted with adult man aged 18 years and above and adolescent girls of age between years old living permanently in the household. Revisits were conducted when the target respondent was absent during the time of a visit. In cases when the respondent was not found after two revisits, it was recorded as absent. Replacements were not done for absent households or respondents Table 3 below shows the selected sample woredas together with the number of allocated EAs and households by region and strata. See Annex 1 for list of the EAs included in the survey. Table 3: Distribution of sample woredas, EAs and households across regions for each strata, December 2016 Urban Rural pastoralist Rural non-pastoralist Total Region No. of No. of No. of No. of No. of No. of No. of No. of No. of No. of No. of No. of woredas EAs HHs woredas EAs HHs woredas EAs HHs woredas EAs HHs Tigray Amhara Afar Oromia Gambella SNNP Benishangul Gumuz Somali Total , , Key Informant Interviews (KIIs) Key Informant Interviews (KIIs) were conducted with relevant experts and officials at federal, regional, woreda, municipal/urban and Kebele level. The aim was to collect qualitative information about the WASH situation in target regions, woredas as well as at country level and triangulate with quantitative findings from the household survey. Informants were selected considering representativeness from rural, urban, pastoralist and non-pastoralist areas across the eight regions. Qualified interviewers, possessing an academic background in health and social sciences and with ample experience in qualitative data collection on WASH facilitated the interviews. Interview guides with open-ended questions were prepared and used for this purpose. Separate interview guides were prepared and used for informants at various levels and sectors. For this survey, 122 KIIs were conducted at federal, regional, woreda, municipal/urban and Kebele levels (Table 4). 5

24 Table 4: List of key informants interviewed for the survey, December 2016 Type of informant Number Experts from federal level 4 Experts from regional level 18 Experts from woreda water Office 16 Experts from woreda health Office 24 Experts from woreda education Office 15 Experts from woreda finance and Economy Office 7 Experts from woreda youth and women Affairs Office 7 Experts from woreda Micro and Small Scale Enterprises Office 6 Experts from woreda Municipality Office 5 Rural Health Extension Workers (HEWs) 12 Urban Health Extension Workers 8 Total Focus Group Discussions (FGD) For this survey, focus group discussions (FGDs) were conducted with various community groups to collect qualitative data related to services and practices. A group of 8-12 people with similar backgrounds participated per FGD. Participants were identified with the help of village leaders and health extension workers. Experienced modulators who are fluent in local languages facilitated the FGDs. Discussion guides, with open-ended questions, were used to facilitate FGDs. Separate guides were prepared for various target groups depending on the type of information needed. As presented in Table 5 below, 70 FGDs were conducted with five types of community groups drawn from urban and rural (both pastoralist and non-pastoralist areas). Table 5: Number of FGDs conducted for the survey by type of group, December 2016 Type of group Number Remark Adult women 18 Adult men 23 Adolescent girls 15 Adolescent boys 7 Marginalized community groups 5 People with disability, elderly and socially marginalized groups Kebele WASH Teams (KWT) 2 Total Direct Observation Existing WASH facilities found in the survey Kebeles were observed as part of this baseline survey. Using a checklist, the quality, functionality and utilization of the facilities, including community water supply systems, communal/public toilet facilities, WASH facilities at schools and health facilities were assessed. As part of the observation, semi-structured interviews were also conducted with management bodies and caretakers of WASH facilities. The aim of the interviews was to assess the management, institutionalization, maintenance and repair of the facilities and identify issues (factors) related to the sustainable functioning and utilization of the WASH facilities. Table 6 presents the number of observed WASH facilities by type across the eight regions. Table 6: Number of observed WASH facilities by type, December 2016 Region Community School Health facility Other Total Hand-dug well Spring Borehole Communal/school Toilet facility

25 3.4. Data Collection Tools Most of the questions in the household survey are adopted from questionnaires used in EDHS survey, Knowledge, Practices and Coverage (KPC) Survey and other similar studies. Additional questions were also developed in line with the survey objectives and indicators. The household questionnaire has the following four major components; woman s questionnaire, man s questionnaire, adolescent girl s questionnaire, and checklist for observation of household sanitation facilities. For KIIs and FGDs, guides were prepared with open-ended questions. Separate guides were prepared for various key informants and FGD participants to collect relevant qualitative data based on the survey objectives, and identified indicators. The data collection tools for observation of WASH facilities includes checklist for direct observation and semi-structured interview guides with management bodies and operators of the facilities. UNICEF Ethiopia and other stakeholders reviewed the draft tools. The tools were then revised based on the comments provided and translated to Amharic and Afan-Oromo languages. Pre-testing of the translated tools was conducted before the actual survey. The final versions of the household questionnaire and WASH facility observation tools are programed using the CSPro data collection application and uploaded on Android based tables Data Collection Process Ten teams, each team consisting of team leaders, enumerators (for the household survey), and modulators/note takers (for qualitative data) collected the primary data. The recruitment of data collectors was done by considering their educational level, their communication skills in English and local languages, interest and commitment to work at field, physical ability to work in difficult settings, their team work skill and previous track records in collection of quality data. Training was given for the data collection teams before deployment to the field. The training was provided using a training guide prepared for this purpose. The training guide was developed in a user-friendly, flexible format using adult learning principles and provides a step-by-step guide for facilitating every sessions. The training was conducted for 5 days and included both theoretical and practical sessions. Theoretically, the training included a briefing on the objectives of the survey, sampling methods, basic concepts of the quantitative and qualitative data collection methods, use of tablets for data collection, terminologies, and ethical principles. It includes briefing on the data collection tools (on each question) to data collectors so as to enable them comprehend the type of data to be collected and understand each question clearly. The practical part of the training was held at the community level. The core survey team from DAB-DRT with support from UNICEF Ethiopia staffs provided the training. Data collectors were provided with a detailed written interviewers manual for use as a quick reference. The manual was prepared in simple and clear language the typical interviewer can understand and provided guidelines on all aspects of the survey including; sampling procedure for selection of household and respondents, basic interviewing rules, study ethics, operational definition of terms, and use and troubleshooting tablets. The interviewers manual also provides detailed explanation on every questions of the household questionnaire. A dedicated field manager coordinated the overall field logistics arrangements of the survey. The survey teams were equipped with Android based tablets (with uploaded translated version of the questionnaire in CSPro App), reserve batteries, recharging cables, power banks, voice recorders (for recording of KIIs and FGDs) and paper-version of the questionnaires as a backup. 4. DATA MANAGEMENT AND QUALITY CONTROL 4.1. Data Management and Analysis Tablets with CSPro applications were used to collect data from the household KAP survey and observation of WASH facilities. To create backups and prevent data loss, the study team transferred data from tablets to hard drives on a regular basis. Each administered questionnaire was reviewed by team leaders on daily basis for completeness and consistency. After the whole field data collection was finalized, the data from tablets was exported to SPSS version 22 for Windows. Then, the data was cleaned for missing values, inconsistencies and out of range figures, and open-ended questions ( other options) were coded. 7

26 SPSS version 22 for Windows was used for quantitative data analysis. Descriptive statistics including frequencies, proportions and means were computed and findings are presented in tables and graphs. Separate analysis was conducted for urban, rural, pastoralist and non-pastoralist areas. Findings on key indicators are presented disaggregated for regions and based on WASH emergency priority hotspot classification. All key informant interviews and focus group discussions were audio recorded. Recordings of qualitative data from KIIs and FGDs were transcribed, and then translated to English. NVivo software, version 7 for Windows, was used for qualitative data management. A code book was prepared to compile qualitative information from KIIs and FGDs for selected themes as per the objectives of the survey. Using the prepared code book, transcriptions of the qualitative data were coded to NVivo 7 and analyzed using thematic analysis technique Quality Control The quality of this survey was maintained by introducing strategic monitoring measures at all stages including at planning, data collection, data management, interpretation, and write-up. The data collection tools (including structured questionnaires, KII and FGD guides, and checklists) were developed carefully in consultation with UNICEF Ethiopia. As much as possible, the tools especially the household questionnaires were adopted from standard questionnaires such as EDHS survey, and Knowledge, Practices and Coverage (KPC) Survey tools. UNICEF Ethiopia and other partners reviewed the tools and the revised versions were pilot-tested before the actual data collection. The data was collected using the local language translated version (Amharic and Afan Oromo languages) of the tools. Well-qualified and experienced team leader/principal investigator led the survey team and full-time dedicated survey managers coordinated the day-to-day data collection process. Qualified individuals, with minimum educational status of college diploma, having ample experience in data collection of similar surveys and versed in local languages collected the data. The data collection teams had received a 5-day comprehensive training and provided with interviewers manual for use as a quick reference at field level. Team leaders, who were assigned for each data collection team closely followed the field level data collection and undertook random spot-checks to ascertain proper sampling procedures were followed in selecting households and study participants and to ensure data quality was maintained. On a daily basis, team leaders reviewed and checked each filled questionnaire for completeness and consistency of data. Team leaders also checked sample recordings of discussions and interviews to ascertain relevant information is gathered. The use of digital data collection method significantly improved the quality of data as the CSPro template was programed to prevent missing values, and entry of out of range and inconsistent data. This prevented human errors as enumerators may not properly follow SKIP patterns and other instructions while administering using paper based questionnaire. An experienced statistician coded, edited, and cleaned the data prior to analysis. The team leader and experienced statistician undertook the data analysis using IBM SPSS version 22 for windows. Sample translations of KIIs and FGDs were checked with transcriptions and recordings for accuracy. Qualitative data from KIIs and FGDs were analyzed using thematic analysis technique using NVivo 7 software. 5. ETHICAL CONSIDERATIONS Ethical clearance and official support letter for the survey was obtained from federal ministry of health and respective regional health bureaus. The data collection team informed relevant woreda sector offices and Kebele leaders about the purpose of the survey before data collection. Study participants were informed about the purpose of the survey and how the results will be used. They were clearly informed about their right to refuse to take part, terminate the interview/discussion at any point or not answering any question. By reading the consent form, enumerators received verbal consent from each study participant before interview/discussion. Interviews and discussions were conducted in settings that ensure privacy. Maximum care was taken to ensure identity of individual respondents should not be disclosed and the privacy of study subjects is maintained while undertaking data analysis and presentation of findings. 8

27 DAB-DRT strictly followed UNICEF s rules on data privacy, not sharing any information from the survey to third parties and kept all information gathered by the survey in strictly secured and confidential way. 6. OPERATIONAL DEFINITION OF TERMS Knowledge refers to information stored in memory. Remembering the fact or condition of something learned through experience or education. Attitude is a feeling or way of thinking about someone or something. Practice is an action that has specific purpose, duration, and frequency and could be done consciously or unconsciously. It refers to doing something regularly or constantly as an ordinary part of life. Menstrual Hygiene Management (MHM): Women and adolescent girls use a clean material to absorb or collect menstrual blood, and this material can be changed in privacy as often as necessary for the duration of menstruation. MHM also includes using soap and water for washing the body as required, and having access to facilities to wash or dispose of used menstrual management materials. Improved toilet facility is defined as a toilet or improved latrine that ensure excreta are disposed of safely and is not shared with other households. These includes; flush toilet (to piped sewer system, septic tank, or pit latrine), ventilated improved Pit latrine (VIP), pit latrine with slab, and composting toilet. Current-adopters: Households currently having a toilet facility for use by their family members. Current-non-adopters: Households currently without a toilet facility. 7. CHALLENGES In conducting field works like the current WASH KAP survey challenges are rationally expected. Having this in mind, we were ready for mitigation measures for both expected and unexpected challenges, in advance, before deploying staffs in the field. Practically, we had the following challenges: Instrumentally, the FGD guide is found to be a little bit long which makes some of the participants bored. But, our trained field staffs reported that they mitigated these challenges by pursuing participants about the benefits of the information they got from them for the community they live in. Our team in Tigray faced incompatibility of the application installed on the CAPI, specifically for Hintalo Wejerat, and it was mitigated by using paper questionnaire of the HH survey which was our plan B. Widespread problems related with infrastructure affected daily schedules of almost all teams. The lack of road infrastructure to reach sample Kebeles and villages which resulted in the investigators having to walk long distance on foot. In this case, DAB-DRT have been forced to recruit second round teams with members having the physical capability to walk longer hours, in some cases more than a day long. All some EAs in Seru Woreda of Oromia region, two EAs in Afdem Woreda of Somalia region, two EAs in Amaro Woreda of SNNP region and one EA in Kunoba Woreda of Afar region are surveyed by the second round teams which cost DAB-DRT additional costs beyond planned at the beginning. Apart from the monetary costs we incurred, the remoteness of some sample EAs made delay from our planned field schedule and it had implications on the final report submission too. Bureaucracies at woreda and Kebele levels are reported to be other challenges that delayed our fieldwork schedule, mainly due to the ongoing emergency plan which asked any field team to get approval from a joint of three government offices, i.e. Health Bureau, woreda Administration and Police, before starting the actual work. Since the CSA cartographic map that we have used in this survey is outdated as it was prepared in 2007 and was demarcated before 10 years makes delineation difficult, especially, for enumeration areas located in towns. Though it cost us additional time and money, the out-datedness of the cartographic map didn t have any implication on the quality of the data as our field staff executed the survey depending on the cartography with all its challenges. 9

28 Linguistic Barriers in Gambela, Benishangul Gumuz and SNNP regions were observable as some of the sample respondents didn t speak and listen to Amharic and it was difficult for DAB-DRT to recruit local staffs. We mitigated these barriers by spending extra costs by hiring local translators. 8. LIMITATIONS OF THE STUDY Twenty percent of the sample households were purposively allocated for pastoralist areas. Although this was done to get sufficient sample size from pastoralist areas, it could lead to sampling bias. Calculations for the percentage of men washing hands before preparing/handling food do not exclude those respondents who are not involved in food preparation activities. Data about methods used for cleaning drinking water containers was based on respondents response (not observation) and may not precisely show the actual practices. Amount of water used for livestock was not considered (taken out) while calculating daily per capita water consumption. 9. BASELINE FINDINGS 9.1. Response Rates and Characteristics of Respondents Response Rates A total of 2702 women were interviewed with a response rate of 97.9%. From 2,724 eligible men found in the surveyed households, 1370 were successfully interviewed yielding a response rate of 50.3%. Eight hundred thirty adolescent girls aged years were found in the surveyed households and 641 (77.2%) were interviewed. Table 7: Background characteristics of respondents, December 2016 Background characteristics Women Men Adolescent girls Eligible Interviewed % Eligible Interviewed % Eligible Interviewed % Residence Urban % % % Rural pastoralist % % % Rural non-pastoralist 1, % % % Region Tigray % % % Afar % % % Amhara % % % Oromia % % % Somali % % % Benishangul Gumuz % % % SNNP % % % Gambella % % % Total 2, % % % 10

29 Respondents Characteristics Figure 1 presents current marital status of women and men respondents. The majority of respondents (85% women and 99% men) are currently married. Orthodox Christians 99.1% constitute for 39% of women, 36% of men and Women 85.2% 38% of adolescent girls. A-third (33% women, Men 32% men and 31% adolescent girls are Muslims. Regarding educational status of respondents, 69% of women and 48% of men respondents never attended formal or informal education. Two women in every ten (19%) and three men in every ten have attended primary school. Among adolescent girls, two-third (66%) has attended primary education, while 17% of them never attended formal or informal education. 8.9% 5.0% 0.5% 0.2% 0.9% 0.2% Married Widowed Divorced Separated Figure 1: Current marital status of respondents, December 2016 Table 8: Religious affiliation and educational status of women and men respondents, December 2016 Characteristics Women Men Adolescent girls Count Percent Count Percent Count Percent Religion Orthodox Catholic Protestant Muslim Traditional Other Education status Primary Secondary Technical/vocational Higher Informal school Never attended formal or informal education Two women in every five (40.9%) are currently unemployed and 36.2% of women are engaged in farming. Six men in every ten (62%) are farmers and a few (6%) of are traders [Figure 2]. 11

30 House wife/unemployed Farmer Business/trader Petty trading Pastoralist Government employee Student Daily laborer Private organization employee Other 61.6% Women Men 40.9% 36.2% 0.0% 5.7% 6.3% 5.4% 5.3% 3.6% 0.0% 13.5% 9.1% 4.7% 2.8% 1.4% 1.3% 0.0% 0.4% 1.2% 0.7% Figure 2: Current employment status of women and men respondents, December Household Characteristics and Possessions Household Characteristics Table 9 shows the average household size, average number of children under the age of 5 and 3 years, and adolescent girls of age years currently living per household by residence. As shown in the table, the average household size is 5.2, ranging from 4.7 in Amhara region to 5.7 in Somali. On average 0.7 children under the age of five years lives per household and one household in every two has adolescent girl age between years of age. Table 9: Average number of people living per household by residence and region, December 2016 Background characteristics Total number of people in HH Children under the age of 5 years Children under the age of 3 years Adolescent girls (age years) Residence Urban Rural pastoralist Rural non-pastoralist Region Tigray Afar Amhara Oromia Somali Benishangul Gumuz SNNP Gambella Total

31 A quarter (27%) of households have electricity. As expected, the proportion of households having electricity is higher in urban areas (81%), while only 5% of households in rural pastoralist areas have electricity. The percentage of households having electricity is 17% for rural non-pastoralist areas. The main living house for eight households in every ten (82%) have earth or sand floors. The floor of the main living house for a few (8%) of households is made from cement. Half (53%) of households live in a house made from corrugated iron/metal roof and 31% of the houses have a roof made of thatch, leaf or mud. Fifty-four percent of houses have walls made of bamboo or wood with mud. Earth/sand Flooring material Other Dung Cement 3.1% 6.4% 8.1% 82.4 % Main material of the roof No roof Other Rustic mat/plastic sheets Thatch/leaf/mud Corrugated iron /metal 1.7% 6.2% 9.1% 30.5% 52.5% Main material of the exterior walls Other Bricks No walls Uncovered adobe Dirt Cane/trunks/bambo o/reed Bamboo/wood with mud 6.0% 2.4% 2.7% 6.3% 8.3% 19.9% 54.4% Figure 3: Percent distribution of households by type of material of the main living house s floor, roof and wall, December Household Possessions Table 10 presents the percentage of households possessing various household effects and means of transportation. A quarter (27%) of households have radios and only 13% of them possess televisions. More proportion of households in urban areas possesses radios (43%) and televisions (49%) while only 13% and 3% of households in rural pastoralist areas own these goods respectively. More than half (57%) of households have mobile telephones while only 2% of them have non-mobile phones. Three percent of households have refrigerators, most of them in urban areas (12%). Only a small percentage of households (2%) own means of transportations such as bicycle, motorcycle/scooter and animal-drawn cart. Table 10: Percentage of households possessing various household effects and means of transportation by residence and region, December 2016 Background Mobile Non-Mobile Motorcycle/ Animaldrawn number Sample Radio Television Refrigerator Bicycle characteristics Telephone Telephone scooter Residence Urban Rural pastoralist Rural non-pastoralist Region Tigray Afar Amhara Oromia Somali Benishangul Gumuz SNNP Gambella Total

32 Two-third (67%) of households own agricultural land. Ownership of agricultural land is highest in rural non-pastoralist areas (84%) as compared with 45% among rural pastoralists and 35% in urban areas. Seventy-seven percent of households own animals. Nearly all (94%) households in rural pastoralist areas own animals followed by rural non-pastoralist areas (84%). Four urban households in every ten (40%) own animals. As shown in Table 11 below, on average, a household owns 3.5 cows, bulls or oxen, 4.7% goats, 3 sheep and 0.7 camels. Ownership of animals is relatively highest among rural pastoralists. For instance, 5% of households in rural pastoralist areas own cows, bulls or oxen and 15% own goats as compared with 3% and 1% among non-pastoralists respectively. Among those households owning animals, 70% have a separate house for animals (urban 62%, rural pastoralist 84% and rural non-pastoralist 64%). Table 11: Average number of animals owned by a household according to residence, December 2016 Background characteristics Cows/bulls/oxen Horses/donkeys/mules Camels Goats Sheep Chickens Beehives Urban Rural pastoralist Rural non-pastoralist Total Household Water Supply Access to Safe and Adequate Water Sixty-three percent of households have access to an improved source of drinking water, with a substantial variation among urban and rural areas. Nearly all (93%) of households in urban areas have access to improved source of drinking water as compared with 31% in rural pastoralist households and 64% in rural non-pastoralists. Comparing access to improved water sources according to WASH emergency hotspot classification, 59% of households in emergency woredas use drinking water from improved sources while the figure is 65% in non-emergency woredas. Overall, more than a-third of households uses drinking water from non-improved sources [Figure 4]. Improved source Non-improved source 6.8% 68.9% 36.1% 4.1% 55.4% 11.7% 33.5% 32.0% 23.3% 34.8% 44.2% 40.6% 37.1% 50.8% 93.2% 31.1% 63.9% 95.9% 44.6% 66.5% 55.8% 49.2% 88.3% 68.0% 76.7% 65.2% 59.4% 62.9% Figure 4: Percent distribution of households by source of drinking water according to residence, by region and WASH emergency hotspot classification, December

33 Table 12 presents source of drinking water by type of facility in urban and rural areas. As shown in the table, public taps/standpipes are the major types of improved water sources used by 23% of households, followed by protected wells (13%) and protected springs (11%). Across areas, four urban households in every ten (38%) get water from water piped into yard/plot and 23% of households in rural non-pastoralist areas from public taps/standpipes. Unprotected wells serve as the main source of water for 30% of households in rural pastoralist areas. Table 12: Percent distribution of households by source of drinking water according to residence, December 2016 Type of water source Urban Rural pastoralist Rural non-pastoralist Total Improved source Piped into dwelling Piped to yard/plot Public tap/standpipe Borehole Protected well Protected spring Rainwater Bottled water Non-improved source Unprotected well Unprotected spring Tanker truck/cart with small tank Surface water Other source Sample number Respondents from households using drinking water from non-improved sources were asked the reasons and nearly all (90%) of them said they did not have access to improved sources. A-quarter of respondents mentioned distance as a reason for not using drinking water from improved sources and 10% of them complained the water fee at improved sources is expensive and they are not able to afford the payment [Figure 5]. Other Not important to use from protected source Protected water source has bad test/odor Expensive water fee at protected water source 4.2% 0.3% 1.1% 9.8% Protected water source is far 24.2% There is no protected water source in the area 89.7% Figure 5: Reasons for using drinking water from non-protected source, December 2016 As shown above, although more than half of households have access to improved source of drinking water they didn t always get sufficient quantity of water from the sources. Respondents were asked if they usually get sufficient quantity of water from their main source and 57% of them replied yes while 43% said sufficient quantity of water is usually unavailable from the main source. The proportion of respondents who reported that sufficient quantity of water is usually unavailable from the main source is the highest among rural pastoralists (62%) as compared with 39% in urban areas and 38% in rural nonpastoralist areas. Moreover, a third (33%) of respondents reported that there was a time when sufficient quantity of water was unavailable from the main source for one day or longer in the 2 weeks period preceding the survey, with the highest in urban areas (54%), followed by 36% in rural pastoralists and 26% among rural non-pastoralists. Unavailability of sufficient water at sources is the main reason for not getting adequate water. Those respondents who reported unavailability of sufficient quantity of water from the main source in the past 2 weeks were asked the reasons and 15

34 the majority (73%) of them said it was because the water sources do not have adequate water. A quarter (27%) of them mentioned non-functionality of water points. Distance is another factor in which 16% of respondents said they did not get adequate water because the water source is located too far. No adequate water at Source is not functioning No manpower to collect WASHCO limits amount Source is too far source at all-time enough Urban 66.0% 38.7% 1.4% 3.9% 1.1% Rural pastoralist 84.2% 12.0% 0.0% 34.2% 3.3% Rural non-pastoralist 73.0% 25.3% 5.3% 15.1% 8.8% Total 73.1% 26.8% 3.0% 15.5% 5.2% Figure 6: Reasons for unavailability of adequate quantity of water from the main source in the past 2 weeks according to residence, December 2016 Findings from the qualitative study also showed similar finding in which community members participated in FGDs mentioned insufficient water supply as a major challenge. Mismatch between the water yield capacities of water sources with the number of users is the main reason for water scarcity, according to FGD participants and key informants. A woman in Moretina Jiru Woreda of Amhara region described the challenge in getting adequate water supply as: We use spring water for drinking, cooking and hygiene purpose. The spring water we have in the village is not adequate for all the community. So, to solve the problem, we have to travel for 1-2 hours to fetch water. Another woman in Gursum Woreda of Somali region also added: The main problem of this community is shortage of water; we don't even have adequate drinking water let alone water for washing and other purposes. Increase for water demand resulting from population growth aggravates water shortage, given the limited capacity of existing water sources. Informants from woreda water offices and community members participated in FGDs stressed that the water supply is not matching the demand as the population is increasing overtime while the supply remains the same, if not reduced. Woman FGD participant in Gambella Zuria Woreda of Gambella region said: The numbers of hand-pumps installed are limited in number as compared to the demand. As a result, we need to go to the water points early in the morning and need to wait a long queue [to fetch water]. One expert at a woreda water office in Oromia region also elaborated the impact of population growth on water supply as: The demand is not equal with the water supply because of the number of population is increasing from time to time when the [water] resource is limited. The problem in getting adequate water supply becomes even worse during the dry seasons as water yield significantly declines during such times. During the dry season, improved water sources become dry and people have no choice but use drinking water from unprotected sources. An expert from woreda water office in Benishangul Gumuz region said: The situation of access to safe and adequate water supply in the woreda is limited because hand pumps and ground water sources get dry during winter seasons and the community face water supply problem. Reduction of water yield is further aggravated by recurrent droughts further affecting access to adequate water supply among communities. The drought that occurred during 2016 affected the water yield at many of the existing water sources 16

35 resulting in water shortage among the affected communities. A male community member in Amaro Woreda of SNNP region described the effect of drought on water supply as: In the drought-affected areas, water from the main springs was dry, people were severely affected by water scarcity, and the community uses water from unprotected sources. One interviewed health extension worker in rural Kebele of Dalifagie Woreda, Afar region also explained the effect of the drought as: The community use water from unprotected sources, which is susceptible diseases like diarrhea as a result of water shortage from the drought. Shortage of water caused by the drought affected the community in many ways. Households are subject to increased expense to buy water, and women and children have to travel long distances to fetch water for the family, according to community members participated in FGDs. During the drought we used to pay 10 Birr for one Jerry can (20 litre container) and this was only possible if the men go to fetch water, said a woman FGD participant in Shinelle Woreda of Somali region. Women and children were the most affected segment of the community. Another woman in Alamata Woreda of Tigray region also explained the effect of the drought on water shortage and consequently the increased work burden on women as; When the boreholes were dried [due to the drought, women were the ones that traveled long distance to fetch water. The average daily per capita water consumption is 14.2 liters (21.4 for urban, 15.8 for rural pastoralist, and 11.3 for rural non-pastoralist). Lack of adequate water supply could be considered as a reason for the low per capita water consumption, though other reasons such as the practice of using water for personal hygiene could also contribute for this. It took less than 30 minutes to collect water (including two-way travel and queuing time) for 48% of households, of which 16% in dwelling/yard. Only 16% of households in rural pastoralist areas have access to water supply within 30 minutes of walking distance (including queuing time) as compared with 85% in urban areas and 48% of rural non-pastoralist areas [Table 13]. The average time of water collection is 46.5 minutes (93.9 for rural pastoralists, 42.3 for rural non-pastoralists and 11.2 for urban areas). The average water collection time is relatively higher in WASH emergency hotspot woredas (52.3 minutes) as compared to 42.8 minutes in non-emergency woredas. Table 13: Percent distribution of households by water collection time according to residence, by region and WASH emergency hotspot classification, December 2016 Background characteristics In dwelling/yard Less than 30 minutes 30 minutes or more Residence Urban Rural pastoralist Rural non-pastoralist Region Tigray Afar Amhara Oromia Somali Benishangul Gumuz SNNP Gambella WASH hotspot classification Non-emergency Emergency Total

36 Overall, it took 30 minutes or more to collect water for slightly more than half (52%) of households. This has its own implication on work burden among women and girls, as they are mostly responsible for collecting water for the household. Findings from this survey revealed that adult women are responsible for water collection in 80% of households (urban 86%, rural pastoralist 89% and rural non-pastoralist 76%). Female children under 15 years old take the responsibility for water collection in 10% Male child under 15 years old Female child under 3% 15 years old 10% Other 2% of households, with the highest in rural non-pastoralist areas (11%) followed by 4% in both urban and rural pastoralist areas. According to community members Adult man 5% participated in FGDs, traditionally people considers water collection as a women s job. In the community I am living, I haven t seen a man collecting water for the household, said one man who participated in an FGD in Gawo Adult woman 80% Kebe Woreda of Oromia region. In rare cases, boys participate in collection and there are men who Figure 7: Person responsible for water collection, December 2016 collect water when their wife becomes sick or pregnant. A woman in Alamata Woreda of TIgray region said; Boys fetch water if they don t have a sister or if they are asked by their mother to do so Safe Water Management Practices Four respondents in every five (81%) said that they did not treat drinking water at household level, with the highest in urban areas (87%) followed by 81% in rural non-pastoralist and 78% in rural pastoralist areas. Chlorination is the main water treatment method used by 12% of households. Across regions, households in Somali have better household water treatment practice in which 40% of respondents said they treat drinking water by chlorination. More proportion of households in emergency woredas treats water with chlorination (17%) as compared with 9% in non-emergency woredas. Table 14: Percent distribution of households by water treatment practice according to residence, by region and WASH emergency hotspot classification, December 2016 Background characteristics Boiling Chlorination Strain through a cloth Filtration Solar disinfection Let it stand and settle Other Don't know No treatment Residence Urban Rural pastoralist Rural non-pastoralist Region Tigray Afar Amhara Oromia Somali Benishangul Gumuz SNNP Gambella WASH hotspot classification Non-emergency Emergency Total In an effort to assess safe water management practices at household level, enumerators asked women respondents to give them a cup of drinking water by pretending as being thirsty. Then, observation was made on the type of drinking water 18

37 storage container, storage condition of the containers, the method used by respondents to withdraw water from the containers, and their hand and cup washing practice. The findings showed that the majority (86%) of households used narrow-mouthed containers for storing drinking water and a few (5%) of them use containers with tap or spigot. drinking water storage containers were found covered in 81% of households. However, the practice of storing drinking water at safe places is found to be very limited. Only 43% of drinking water storage containers are inaccessible to children and 55% of them were inaccessible to animals. Table 15: Household drinking water storage practices according to residence and by region, December 2016 Background characteristics Narrow-mouthed containers Containers covered Containers inaccessible to animals Containers inaccessible to children Residence Urban Rural pastoralist Rural non-pastoralist Region Tigray Afar Amhara Oromia Somali Benishangul Gumuz SNNP Gambella Total Nearly all (97%) of respondents used safe methods while withdrawing drinking water from the storage containers, either by tilting and pouring method or by dipping using a cup exclusively used for withdrawing water. The percentage of women who used safe water withdrawing techniques is similar across areas (urban 97%, rural pastoralist 96% and rural non-pastoralist 97%). Although this indicates good practice in water handling, the practice of washing hands and drinking cup is almost nonexistent. During observation, only 6% and 5% of women wash their hands and drinking cup with soap before withdrawing drinking water respectively. 12.1% 9.8% 4.2% 4.5% 2.6% 4.1% 5.9% 4.9% Washed hands with soap Washed cup with soap Urban Rural pastoralist Rural non-pastoralist Total Figure 8: Percentage of women who wash their hand and drinking cups with soap before withdrawing water according to residence, December 2016 Women respondents were asked how often they wash drinking water storage containers and 31% of them said they wash the containers every time they collect water. A few (6%) of women reported that they wash the containers once a day while 4% of them said they never wash the water containers at all. Regarding water container washing methods, slightly lower than half (45%) of women reported they wash the containers by rubbing with cereals, gravel or sand. Twenty-three percent of women said they usually wash drinking water containers using soap or detergent while 26% of them wash using plain water only. 19

38 Never wash at all More than 7 4% days 17% Other 2% Always when collecting water 31% Other 6% With water only 26% Every 4 days to once per week 20% Every 2 to 3 days 20% Once per day 6% Figure 9: Frequency in washing drinking water containers, December 2016 Rubbing with cereals/ gravel/ sand 45% Using soap/ detergent 23% Figure 10: Methods used for washing drinking water containers, December 2016 Except for storing drinking water in a covered, narrow-mouthed containers and the use safe method to withdraw water from containers, the above findings showed gaps in safe water management at household level. Limited knowledge of women on water contamination routes is found to be a factor for this. As shown in Table 16 below, the majority of women do not know when and how drinking water could be contaminated by disease causing organisms. Less than half (41%) of women knew drinking water could be contaminated at home during storage. The percentage of women who knew drinking water could be contaminated while withdrawing water from the storage container was only 21%. Relatively higher proportion of women knew water could be contaminated at source, indicating the belief that water is safe for drinking if it is from improved sources irrespective of the handling practice. Table 16: Knowledge of women on occasions in which drinking water could be contaminated by disease causing organisms according to residence, December 2016 Occasions drinking water could get contaminated Urban Rural pastoralist Rural non-pastoralist Total At source During transportation from source to home At home during storage During withdrawing from storage containers Don't know Other Sample number Willingness to Pay for Water Services Figure 11 presents the percentage of households having access to improved water sources that are currently paying water fee. As shown in the figure, six households in every ten (62%) currently pay a water fee. Nearly all (92%) of households are currently paying water fee while only 47% of them in rural non-pastoralist areas pay for water services. The percentage of households that are currently paying water fee is 71% for rural pastoralist areas. Across regions, the highest proportion of households that are currently paying water fee is recorded in Tigray (91%) while the lowest is in Gambella (44%). On average, a household pays 42 Birr per month, with the highest payment of 57 Birr among rural pastoralists followed by 55 Birr among urban households and 27 Birr among rural non-pastoralists. 20

39 90.6% 78.3% 77.4% 51.2% 59.2% 53.2% 53.8% 43.5% 62.2% Tigray Afar Amhara Oromia Somali Benishangul Gumuz SNNP Gambella Total Figure 11: Percentage of households with access to improved water sources currently paying water fee by region, December 2016 When respondents of the household survey were asked if they are willing to pay for water services, 57% of respondents replied yes. As shown in Figure 12 below, more proportion of households in urban areas are willing to pay for water services (85%) as compared with rural households. 85.1% According to informants from woreda water offices, willingness to pay is relatively better in towns than in rural areas. People in rural areas often consider water as a natural gift and believe they should not have to pay for it. Unavailability of wellorganized payment systems in rural areas is also a challenge. One expert at woreda water office in Amhara region said: The urban community is willing to pay whatever the payment it is but the rural community sometimes resist to pay because they think that water is a natural resource for which payment shouldn t be asked. Both community members participating in FGDs and interviewed experts at woreda water offices emphasized that not getting water supply at all times is the main factor affecting willingness to pay. The majority of FGD participants from the community said that they are willing to pay if they get adequate and uninterrupted water supply. In addition to the prerequisite of getting water supply at all times, FGD participants also wish the collected money to be managed in a better way. They expressed their concern the extent to which WASHCOs properly manage the money collected from water fees and whether it is used to improve water services. Most FGD participants prefer the government to manage the water schemes than WASHCOs. An informant from woreda water office in Somali region explained about willingness to pay for water services as: They [the community] are always willing as long as there is a constant water supply. There was a time when they even are willing to increase the monthly payment to 15 Birr per month because there were extra costs for fixing generators. Another informant from woreda water office in Tigray region also availing water supply at all times should be given due emphasis for improving willingness to pay saying: In order to improve willingness to pay for water services among the community, the foremost task should be availing safe water without interruption. Limited economic capacity among the community, dependency on outside support - expecting the government to cover all costs are also among the factors affecting willingness to pay, according to informants from woreda water offices. The community is willing to pay for the water service, but they are economically poor, that is why that they are not willing to pay. In addition, there is also expectation for the government to cover all expenses, said one expert at woreda water office in Benishangul Gumuz region. Urban 48.4% 51.1% Rural pastoralist Rural nonpastoralist 57.1% Total Figure 12: Percentage of households that are willing to pay for water services in the future, December

40 According to informants from woreda water offices, the monthly payment system is preferable as the community lives based on a monthly plan. Water price that is increasing according to the amount of the household water usage is also likable as this system enables people use water based of their paying capacity Challenges related to water supply among marginalized groups With the aim of assessing challenges related to water supply among disadvantaged community groups, FGDs were conducted with marginalized groups such as people with disability and the elderly. The findings showed that collecting water is the major challenge for people with physical disability and the elderly. Their limited physical fitness makes it difficult to collect water traveling long distance. According to FGD participants, there is no special arrangement to allow them get priority to fetch water and they should have to wait queuing at water points. One elder participating in FGD in Erbeti Woreda of Afar region described the challenge related to water collection as: It is very difficult to collect water for us [the elderly] person in our area as the spring is found far away from our village and we need to travel long distance. Marginalized community members also reported that water points, especially wells fitted with hand pumps, are not userfriendly for them. Fetching water from these facilities is very difficult for people with physical disability and the elderly as it needs physical ability to pump water using hand pumps. As I said above, the well is fitted with a hand pump and needs pumping that make it difficult for disabled people as it [pumping the water] requires strength, said one individual with physical disability in Alamata Woreda of Tigray region. Regarding payment for water services, there is no special arrangement like subsidy for community members who are not able to afford to pay water fee. The majority of marginalized community members participated in FGDs said that there are no discriminations towards them in getting water services. However, a few in some areas reported that they sometimes face teasing and discrimination due to their health and physical conditions while they collect water. Such teasing and discrimination are related to the general attitude towards people with disability, not specifically about refusal to use water facilities with them. A girl with a physical disability in Alamata Woreda of Tigray region said: As a disabled person, I always face discrimination whenever I go to the borehole to fetch water. The women didn t say anything but girls with my age tease me and call me different names like limp (Ankasa), and when they push me, I fell on the ground and they laugh at me. I refuse to go to the borehole, but there is no another daughter in our house who can collect water for the family Status of Water Points As part of this survey observations were conducted on 26 hand-dug wells, 35 springs and 26 boreholes and interviews were conducted with WASHCO members and water scheme caretakers. The findings showed that 10.5% of the water schemes (hand-dug wells, springs and boreholes) and 24.1% of water distribution points were non-functional during the time of visit. In addition, damages, leakages on the physical structure of the water points were observed in 12.8% of the water points. The fact that only 30.1% of the observed water points have a guard could be a factor for frequent non-functionality of water schemes. Most key informants also reported water scheme non-functionality as a major challenge regarding water supply. According to informants from woreda water offices and health extension workers, non-functionality of water points is a major challenge in ensuring continuous safe water supply. A HEW in rural Kebele of Mengesh Woreda of Gambella region described the problem of non-functionality of water schemes as; There are eight pumps and a spring in the Kebele. However, they are not working now. An informant from woreda water office in Tigray region also said; There are around 778 water schemes [in the woreda], of which 60 are non-functional. Improving functionality of water schemes entails having a strong management system and local capacity. Although, 67.4% of interviewed WASHCO members reported that the members are actively involved in management of the water schemes, only 51.2% of the WASHCOs have a by-law. Less than half (42.5%) of WASHCOs have an operation and maintenance plan. Moreover, only 30% interviewed WASHCO members said that their WASHCO have the capacity to cover the cost for maintenance and repair of the water scheme. Availability of trained water caretaker was found to be very limited. Only 23.2% of interviewed caretakers are trained on maintenance and repair of water schemes and a few (19.6%) interviewed 22

41 caretakers reported that they have the necessary tools and equipment to undertake maintenance and repair of the water scheme. These findings showed the limited capacity for proper management, maintenance, and repair of water schemes. Given the fact that majority of WASHCOs do not have an operation and maintenance plan and they lack the financial capacity, it is apparent that WASHCOs are not able to provide immediate maintenance service when water schemes are damaged. Unavailability of trained caretakers and maintenance tools is another challenge for proper maintenance and repair of water schemes. In addition to non-functionality which affects availability of adequate water at all times, findings from this observation also showed risks related to water quality. From the observed water points, only 25.9% of the water points have a functioning drainage canal. Water pollution sources, such as animal and human excreta and rubbish, were seen in 38.8% of the facilities Household sanitation facilities Household Toilet Facilities Figure 13 shows that 10% of households use improved toilet facilities that are not shared with other households, with a notable disparity among urban and rural areas. A quarter (24%) of households in urban areas use improved, not shared toilet facilities while the figure is 5% and 7% for rural pastoralist and non-pastoralist households respectively. As shown in the figure, there is no difference in the percentage of households using improved not shared toilet facilities across emergency and nonemergency woredas. Four percent of households use shared toilet facilities that can be considered as improved facility if otherwise not shared. Overall, more than a third (37%) of households do not have access to toilet facilities and family members use open defecation. Access to toilet facilities is the lowest in rural pastoralist areas in which seven households in every ten (73%) do not have access. As shown in the Table 17 below, open pit, which is non-improved facility, is the common type of toilet facility used by 47% of households. Table 17: Percent distribution of households by type of toilet/latrine facilities according to residence, December 2016 Characteristics Urban Rural pastoralist Rural non-pastoralist Total Improved, not shared facility Flush to piped sewer system Flush to septic tank Flush to pit latrine Ventilated improved Pit latrine (VIP) Pit latrine with slab Composting toilet Shared facility Flush to piped sewer system Flush to septic tank Flush to pit latrine Ventilated improved Pit latrine (VIP) Pit latrine with slab Composting toilet Non-improved facility Flush/pour flush not to sewer/septic tank/pit latrine Total Emergency woredas Non-emergency woredas Rural non-pastoralist Rural pastoralist Urban 4.9% 6.7% 9.8% 9.8% 9.8% 24.3% Figure 13: Percentage of households that use improved not shared toilet facilities according to residence and by WASH emergency hotspot classification, December

42 Pit latrine without slab/open pit Bucket toilet Hanging toilet/hanging Latrine No facility/bush/field Other Sample number A-third (34%) of the shared toilet facilities are used by 2 households and another 32% by 3-5 households. 6-5 households use twenty percent of the shared toilet facilities and the remaining 14% facilities are used by more than 10 households. Almost all (96%) of women from households using shared toilet facility reported that the facilities provide service 24 hours a day. Not only do the majority of households not have access to toilet facility, the available facilities are characterized by poor superstructure. Only 30% of the toilet facilities have proper wall that provide privacy and 17% of them have door lockable from inside. A third (34%) of the toilet facilities have a well-maintained roof that protects users from rain and sun. Only 8% of the toilet facilities have hand washing facility attached to it. The percentage of households having hand washing facility near toilets is relatively higher in non-emergency woredas (9%) as compared with 4% in emergency woredas. During observation, water was found in 77% of the hand washing facilities and soap or ash was found in 53% of them. Two-third (67%) of the hand washing facilities have signs indicating recent use Defecation Practices and Disposal of Child Faeces Practices in using toilet facilities Among women respondents from households having toilet facility, 94% said they always (day and night) use the facilities, with the highest in urban areas (97%), followed by rural non-pastoralists (94%) and rural pastoralists (88%). A-quarter (27%) of respondents said that there are family members in the household who do not regularly use the toilet facilities. Two women in every ten (21%) said that children under the age of 5 years do not regularly use toilet facilities. Adult men are the second most common individuals that do not regularly use toilet facilities (5%) followed by adult women (3%). Not using toilet facilities on regular basis among adults is more common in rural pastoralist areas (17% for adult men and 13% for adult women). Men respondents were asked where they usually defecate while at home and away. The findings showed that men usually use toilet facilities while at home (66%) while only 37% of men said they use toilets while away from home. Men tend to practice open defecation more when they are away from home (62%) than when at home (34%). Figure 14 presents the proportion of men using toilet facilities while at home and away from home. 80.5% 25.0% At home 59.7% 24.4% 16.8% 17.1% Away from home 73.1% 64.7% 50.0% 36.5% 28.2% 26.5% 88.3% 89.6% 56.8% 68.8% 65.5% 36.8% Tigray Afar Amhara Oromia Somali Benishangul Gumuz SNNP Gambella Total Figure 14: Percentage of men using toilet facilities while at home and away from home by region, December