Ashok Dyalchand: Benefits of rural sanitation implemented through a clts approach implications for hsr ashok

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Presentation by Ashok Dyalchand, Institute of Health Management, Pachod, at the First Global Symposium on Health Systems Research, 17 November 2010.

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Ashok Dyalchand: Benefits of rural sanitation implemented through a clts approach implications for hsr ashok

  1. 1. Benefits of rural sanitation implemented through a community led social norms approach Implications for health systems First Global Symposium on Health Systems Research (Montreux, Switzerland - Nov 16-19, 2010) A. Dyalchand Institute of Health Management, Pachod
  2. 2. Study Setting Study Setting • Purposive Sample of 9 villages from 3 States Study Methodology Compared : • 3 Villages - TSC Approach • 3 Villages - CLTS Approach • 3 Villages - No Sanitation
  3. 3. Operational Definitions Total Sanitation Campaign (TSC) – • Creates individual demand • Involves subsidies • Success measured by No. of individuals with access to toilet Community Led Total Sanitation (CLTS) • Behaviour change through social norms approach • No subsidies • Success defined by No. of Open Defaecation Free villages Nirmal Gram Puruskar (NGP) • National award for villages with 100 % coverage with toilets
  4. 4. Research questions • Which components of communication strategy influence sanitation behaviours & how are they mediated? • What institutional arrangements are required for sustaining social change? • What evidence of social and health benefits?
  5. 5. Key Findings Contd… • CLTS modifies existing Perceptions, Attitudes & Behaviours at Community Level • Uses emotional appeal (disgust) – to trigger response • Triggering alone not sufficient for establishing individual or collective norms • Sustained persuasive communication required for sustaining collective action & behaviour change in Late Adopters
  6. 6. Key Findings Contd… • Core Group creates impression that everyone in the community is ready to change (descriptive norms) • Core Group encourages community to introduce Injunctions and Sanctions (Injunctive norms) • Injunctions imposed by Community effective in establishing Collective Norm • Injunctions imposed by Administration are often counter productive • NGP strong Incentive for communities creates (descriptive norm) But focuses on Toilet Construction not Utilisation and all actions stop after NGP award
  7. 7. Institutional Arrangements Institutional Arrangements that Enable or Constrain Sanitation • District Leadership – the most crucial element • ‘Core group’ required for implementation • Public Private Partnership – most effective for Sustainability • Specific roles and responsibilities – crucial • Systems development - predictor for scaling up • Relation-based governance – Transparency, Accountability • Negative role of monetary subsidies • Choice of Technology – crucial
  8. 8. Access and Use of Toilets by Sanitation Approach 245 152 164 5 61 146 3 41 139 0 50 100 150 200 250 No Sanit. TSC CLTS Households Households w ith Toilet Toilet use
  9. 9. Outcome Access and Utilisation • Utilization of Toilets not more than 80 % • 20 % lowest SES household excluded Environment • No change in Water Quality (E- Coli Contamination) Health Benefits • No change in Prevalence of Diarrhea and Helminths
  10. 10. Outcome Environmental • Waste water and solid waste disposal improved • Villages apparently clean Behavioural / Cultural • Inter-generational change in norms • Other hygiene behaviours influenced also Social • Large scale community participation • Privacy and dignity of women • Empowerment of Women
  11. 11. Implications for Health Systems • CLTS communication approach applicable to a host of environmental issues • Women, youth & children effective change agents • Equity – Not resolved how to reach the most marginalized • Need comprehensive approach integrating several behaviours • Inter-sectoral coordination is crucial • Convergence through NRHM – HR availability
  12. 12. Implications for Health Systems Research Multi-Disciplinary Research Skills Required Quantitative methods 1. Prevalence studies 2. Laboratory research Qualitative methods 1. PRA tools 2. Social Norms research 3. Institutional development Environmental research 1. Technology, maintenance & sustainability 2. Impact of population density on Policy analysis & Research 1. Subsidies 2. Criteria and Methodology for National Award

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