Just a bit of background about Malawi’s context – and to set the basis for why this integrated diarrhea prevention program was so important. In additional to the morbidity and mortality associated with diarrhea, about 7% of children were presenting with pneumonia, another result of lack of safe water and unimproved sanitation and hygiene. Only about 51% of households have improved sanitation facilities; 13% practice open defecation. Improved water sources, when available, are often a long distance from the family home, placing a disproportionate burden on women and girls who collect and fetch water.
The project targeted all three regions in Malawi (just more than 13 million people) focusing on scale up of PSI’s previous involvement with prevention and treatment of diarrhea in Malawi (WaterGuard (2002) and Thanzi ORS launched in 1999). Under this program, there was a unique social marketing strategy focusing on community mobilization.Distribution of WaterGuard and Thanzi took place through commercial outlets on a national scale.Nationwide behavior change communications were designed to promote correct and consistent use of the prevention and treatment products, along with the adoption of improved hygiene and sanitation practices.
PSI/Malawi worked with local NGOs and CBOs to establish community based distribution channels with almost 2,500 CHWs. These CHWs were called “Safe Water and Hygiene Promoters.” As volunteers, they sold WaterGuard and Thanzi at HIGHLY subsidized prices to their communities. During the conversation with the buyer / caregiver, the promoters also taught and reinforced proper hygiene and sanitation behaviors. They taught caregivers the key signs to recognizing diarrhea early and seeking prompt treatment with ORS. **Focus on improved access in RURAL areas.**PSI/Malawi developed audience profiles using PSI’s DELTA process. Audience profiles and position statements were developed in order to create key messages that resonated with caregivers of children under 5. Health communications materials were developed for specific community contexts. There were also targeted outreach campaigns in clinics and in the community to reach people with messages on safe drinking water, treating dehydration with ORS and handwashing with soap at key times.IEC included posters, billboards, etc – and used the new packaging. There was a radio spot / jingle – aired during peak programming – a women’s program. Messaging also encouraged mothers to keep “emergency” Thanzi sachets at home for when their children fall ill.
There are several positive results from the final evaluation. More mothers and caregivers report treating their water. And more caregivers report treating their children with ORS when they suffered from diarrhea in the 4 weeks preceding the survey. A growing percentage of mothers in all three regions knew where to buy Thanzi and knew it was available within a 20 minute walk of their home. Messages seem to have reached caregivers: almost 90% agreed that if they washed their hands with soap after visiting the toilet / latrine, they can reduce the chances of their children falling sick (up from 83.4%). And 96.5% of caregivers understand that if they keep their drinking water covered, it is less likely to become contaminated.However, some questions changed during the time between the 2005 baseline and the 2011 evaluation so results for these questions are not inherently comparable. One finding that raised questions was the drop in handwashing practices. There were questions about the manner in which hygiene practices were measured and reported – and then what caused the drop
More than 337,000 DALYs avertedTreated almost 4 billion liters of water since launching
Field visits by the evaluation teams turned up many handwashing stations in communities targeted by PSI and project partners. Since the project started more than 2,200 household constuctedhandwashing facilities using locally available materials. Some homes had ash at the station but most had soap. This provided the evaluation team with evidence that communities adopted handwashing with soap as one of their daily practices.Malawi school attendance is fairly high (thanks to a school feeding program). School hygiene clubs were formed and students were taught hygiene practices that they could do at school and then take home to share with their families.
When the IDPP launched, it was decided to move forward during delays with zinc inclusion as the MoH didn’t see zinc supplements as a priority. It was recommended that IDPP proceed without zinc until the MoH determined its zinc policy. Now that that has happened, PSI/Malawi is looking to launch bundled and copackaged ORS into diarrhea treatment kits. Even though Thanzi and WaterGuard are increasingly available, there is question about how to sustain the subsidy that was part of IDPP. PSI/Malawi will explore various cost recovery mechanisms to make sure these products remain available. The final evaluation also highlighted some areas where additional research would help to answer certain questions. Ideally this will happen so that continual programming has this knowledge.
Scale Experience from CSHGP's Expanded Impact Category_Latimer_5.1.12
Integrated WASH in Malawi Ashley Latimer May 1, 2012 COREgroup Spring Meeting
Malawi Background Child mortality = 112 deaths per 1,000 live births Pneumonia and diarrhea leading causes of death 18% of children suffering from diarrhea Only 51% of households have improved sanitation facilities 17% of households have access to unimproved water sourcesPAGE 2
Integrated Diarrhea Prevention Program USAID funded – Child Survival Health Grants Program Goal: To reduce morbidity and mortality from diarrheal diseases Improvement of diarrhea case management Focus on increased adoption of safe drinking water and improved hygiene and sanitation practicesPAGE 3
Implementation Community based distribution channels – 2,500 “Safe Water & Hygiene Promoters” PSI’s DELTA process (for marketing planning) – Developed audience profiles – Targeted messages to caregivers page 4
Results 2005 Baseline 2011 Evaluation % of caregivers of CU5 who 4.9 17.8 report that they treated their drinking water in the last week with WaterGuard Increase of CU5 with diarrhea in 48.0 64.1 the past 4 weeks who were reported to have received ORS Increase of caregivers who 52.0 33.8* practice immediate handwashing using soap after toilet/latrine usepage 5
Distribution Since 1999… – More than 1.7 million diarrhea episodes averted – More than 10,000 deaths averted – More than 6.7 million bottles of WaterGuard distributed – More than 14.6 sachets of Thanzi ORS distributedpage 6
Hygiene and Sanitation Practices Targeted communities built handwashing stations 2,200 households built stations using local materials Soap available at stations School hygiene clubspage 7
Thinking about the Future Zinc is now approved as a diarrhea treatment – Will look to launch bundled ORS + zinc Cost recovery mechanism for WaterGuard and Thanzi Additional research to understand decrease in handwashing page 8
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