Lessons Learned from Working At Scale for Better Hygiene & Sanitation Practices Presentation Transcript
Lessons Learned from Working At Scale for Better Hygiene & Sanitation Practices Julia Rosenbaum & Sarah Fry, WASHplus June 22, 2011
Critical Questions about Hygiene and Sanitation Improvement at Scale
What do we mean by at scale programming?
How do we work at scale in different country contexts?
How do we measure it? How do we know it works?
What were the results of applying at scale programming?
What have we learned?
What Do We Mean by “At Scale”? Coordinated actions of all stakeholdersworkingtoward a common goal to significantly reduce disease rates in large numbers of affected people AT SCALE is not the same as SCALING UP 3
The SCALE Process 1. MAP 6. EVALUATE 2. PARTNER Reduce Diarrheal Disease 3. STRATEGIZE 5. MONITOR 4. ACT 4
Characteristics of an At Scale Effort Systems approach
Focuses on consistent and correct PRACTICE of key hygiene behaviors
Prioritizes sustainability Coverage 5
Traditional WASH Coverage vs. Scale Approach …scattered, dispersed, stand-alone … coordinated and synergistic 6 Well Construction H/W Promotion Latrine Construction Hygiene Advocacy
Mothers Government Ministries Commercial Businesses Donors/ Funders Using Hygiene Improvement to reduce diarrheal diseases Educational Institutions Religious Groups CSOs Media NGOs R&D Institutions Develop Orgs Bringing the Whole System in the Room & Grandmothers 7
Available Household Technologies and Materials
Marketing & BC Promotion Access to Hardware/ Goods & Services Enabling Environment
Focus on behaviors…. Safe feces disposal Hand washing with soap Safe storage & treatment of water … Multiple behaviors 9
Characteristics of a Scale Effort Systems Approach Looks at the whole Involves multiple sectors, actions, options, stakeholders Hygiene Improvement Framework Considers hardware, promotion, institutional capacity Behavior FIRST Focuses on consistent and correct PRACTICE of key hygiene behaviors Prioritizes Sustainability By embedding, building capacity, making it local Coverage at least 3 million 10
At Scale Hygiene and Sanitation Improvement in the Amhara Region of Ethiopia through “Learning by Doing” 11
The Whole System in the RoomAligning for Action: Sustainable Development through Safe Water, Environmental Sanitation & Hygiene
Mapping the Context – resources, partners, commitment
Agreeing to a Common Action Agenda
COMMUNITY-LED TOTAL BEHAVIOR CHANGE IN HYGIENE AND SANITATION Implementing a hybrid of … Embedded in a national and regional process… the National Hygiene and Sanitation Strategy Built around Health Extension Program and carried out by HEWs .. Among other actors… A key sector to involve were the “development partners” … active in total of 90/150 districts of Amhara ... To support with capacity building, transport, other items 13
Use Existing Institutional Structures & Build Capacity 14
Were we effective?
Did we achieve scale?
Did combining individual and collective action work?
Practices: Access to Sanitation Facilities Baseline-Endline Comparison: All Respondents **Source: Amhara LBD Evaluation Report, USAID/HIP-WSP/WB-AF, November 2010 18
Consider Quality as Well as Coverage Only about 30% of latrines meet minimum standards Distance from house or water source Covered pit Washable plat Superstructure that provides privacy
Knowledge of When to Wash Hands (percent) 20
Presence of HW stations at latrines 17% 16%
Predictors of Latrine Ownership Endline **Source: Amhara LBD Evaluation Report, USAID/HIP-WSP/WB-AF, November 2010 22
Hygiene Improvement at Scale: The Madagascar Experience 23
Elements of Scale Systems Approach Hygiene Improvement Framework Behavior FIRST Prioritize Sustainability Coverage 24
Hand washing with soap Use of improved latrines Utilisation de latrines Safe drinking water Conservation de la qualité de l’eau potable
Negotiation Tools for Household BCC 29
Scouts NGO Subcontracts Red Cross Madagascar Sustainability Community Health Workers Faith-based organizations NGO Commune Club Vintsy HIP Habitat for Humanity PSI UNICEF USAID Partners Voahary Salama Producers Public-Private Partnership COMMUNITY (CLTS/RRI) Private Sector Public-Private Partnership COMMUNITY (CLTS/RRI) Santenet I and II Financial Institutions Producers Vendors 30
4 Regions: Population 6,500,000 31
Madagascar Practice: Access to Sanitation Facilities March 2009 Pre-Political Crisis Post-Political Crisis 32
Madagascar Practice: Hand Washing March 2009 Pre-Political Crisis Post-Political Crisis 33
Knowledge Products: Madagascar Guide Illustré – Illustrated guide of PAFI and Méthodes Alternatives (in Malagasy and French) 3 posters - 1 for each key practices Flyers and tear-offs with poster images and more text SODIS counseling cards Integration of 3 key hygiene practices in USAID/SanteNet 1 and 2 Champion Community handbook Guide Ecole Amie de WASH – French Guide CSB Ami de WASH/Guide for WASH friendly Health Centers (French and English) Negotiation Tools on the 3 key practices (Malagasy and French) WASH Guide for Scouts – How to earn a WASH Badge (Malagasy and French) WASH Guide for Scout Troop Leaders – How to integrate WASH into your scouting program (Malagasy and French) Sermonette guide for WASH friendly churches Construction guide for improved latrines: with sanplat slabs and superstructure. Consumer research report – French LQAS Comparison Report 2007-2010 (English and French) Available at: http://www.hip.watsan.net/page/250 34
Knowledge Products: Ethiopia Regional Behavior Change Strategy District Resource Book for Community Led Total Behavior Change Facilitators Guide for Training Health Extension Workers Handbook Guide to WASH Friendly Schools Training Parents, Teachers and Youth Leaders to be Champions of WASH Friendly Schools M&E Framework Baseline & Endline Survey Report All available at http://www.hip.watsan.net/page/485 35
How Can we measure SCALE success ? 36
M&E Framework for Ethiopia Follows the HIF Improved Enabling Environment Behavior Change Promotion Access to Hardware 37
Scale Challenges Dilemma of “attribution” of results - the fruit of relinquishing control Quality – in a push for coverage, quality lags behind. Whether it improves over time, or stalls, is still unclear. Sustainability – we think the HIF and our institution-centered approach leads to sustainable programs, but we don’t yet have the clear proof 38
What have we learned through the HIP approach of STARTING at scale? 1. Leadership buy-in is critical for setting the enabling environment; coordination with three technical ministries: Health, Education, Water, plus partners = reach and coverage 2. Systematic capacity building of many actors at all levels is key- must include refresher courses, job aids, supportive supervision, incentives to have it work at scale. 39
What have we learned about the HIP approach of STARTING at scale? 3. Implementation ethos of flexibility, innovation, experimentation “Learning by Doing” – critical! 4. Mobilizing political leadership and engaging communities though community-led processes and household outreach – the key components of the scale approach – show encouraging results and outcomes 40
STARTING AT SCALE WORKS! For more information on working at scale see: “At-Scale Hygiene and Sanitation in Ethiopia and Madagascar: Experiences and Lessons Learned” at: http://www.hip.watsan.net/page/5306 Julia Rosenbaum, firstname.lastname@example.org Sarah Fry,email@example.com All Hygiene Improvement Project Resources: www.hip.watsan.net WASHplus Project: www.washplus.org
Question 1: Was there any investigation of the determinants of the different behaviors that you were promoting (e.g., via Barrier Analysis or Doer/Non-Doer Analysis)? If not, why not? If so, what did you find? 42
Question 2: Secondly, did you look at diarrheal prevalence? Was cost per DALY averted assessed? 43
Question 3: How do we make the changes we see sustainable? Does CLTS need to be modified as it matures into a more detailed approach? 44
Question 4: What kind of latrines were promoted in Ethiopia and Madagascar - Is it Eco -San or pit latrines? 45
Question 5: Could you please describe in a bit more detail the capacity building efforts and how these went beyond traditional training ? 46
Question 6: Can you elaborate on why disgust and shame messages were used as opposed to other messaging approaches? 47
Question 7: What type of contribution and activities of government in both countries? Did you find any political challenges, e.g. the rapid changes of government personnel or leaders? 48
Question 8: Have there been any studies of the long term impact of CLTS in communities? In addition, will your study be followed up over the next few years? It appears that following training many communities become open defecation free; however, I'm curious if communities remain ODF over time. 49
Question 9: Is there a mechanism to sustain and monitor the changed behavior in Ethiopia and Madagascar? 50
Question 10: How do you handle the problem of people not owning their own land - and building latrines? 51
Question 11: Were there observations regarding the ability to clean the surface, around the opening to the latrines? I ask because, for the slab it would appear as if the plastic surfaces could be cleaned easily, while this would not be the situation with the slab of the concrete surfaces. 52