Lessons Learned from Working At Scale for Better Hygiene & Sanitation Practices


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  • Good morning/ good afternoon depending upon our listener’s time zoneToday we will present and discuss an approach to at scale hygiene and sanitation improvement, we’ll first break down the approach-- reviewing the elements and staging of the process-- then talking about how the approach was applied in 2 at scale settings – Ethiopia and Madagasgar.. ONE OF HIP’s central tasks was to develop approaches for implementing hygiene and sanitation improvement at scale.Six years later, we reflect on 5 cricial questions… as we review HIPs experience of at scale programming in Madagascar and Ethiopia…
  • AMhara’s TBC trained cadres of community workers to facilitate and support change….Focusing on Health Extension Workers, but we also trained Development Agents, District WASH Teams and more trained through a ToT cascade approachTo ignite communities…And then provide back up support through household visits, already part of the HEW routine….Carry out a number of other mobilization and household BC activitiesBut now strengthened to draw on newly ignited commitment….…. To achieve total sanitation and hygiene behavior change…
  • So they were trained in all CLTS Tools…Like the walk of shame… [run video]To ignite communitiesTo commit to end open defecation
  • RANDOMREPRESENTATIVE OF ALL OF AMHARA… anecdotally… we couldn’t randomly find a control group for the evaluation… No districts were ‘untouched’ … Combining and comparing
  • 69 – 44 = 25% drop in OD14 > 40 = 26% rise in unimproved latrines
  • Recent monitoring visit to 10 focus woredasOverall latrine coverage at 71% Only about 30% of these meet minimum standardsDistance from house or water sourceCovered pitWashable platSuperstructure that provides privacy
  • Not more likely to have a HW station … but more latrines out there.. So more HW stations in Amhara as wellMore likely in 2010 to have a HW station with necessary supplies…5.8 million people in Amhara Regional State reached2.8 million more people stopped practicing open defecation and now use a basic pit latrineAs a testiment to scale… The National Total Sanitation Working Group formed by the Federal Ministry of Health adopted much of the CLTBCHS approach (and used soft copy of documents) To develop “the National Approach to Achieve Universal Hygiene and Sanitation”
  • I am going to present an overview of how the Scale approach played itself out in Madagascar in the 5 years of the Hygiene Improvement Project program that operated in 4 regions of Madagascar.
  • HIP used multiple communications channels to saturate zones of intervention with hygiene improvement messages and methods.In the upper corner you can see local radio announcers broadcasting hygiene promotion spots, then WASH friendly Scouts carrying out a community mobilization day, and bottom left is a local vendor selling improved latrine slabs with the posterpromoting use of improved latrines and hygiene products – that’s in the upper left. In the middle is a community facilitator reviewing a community map of open defecation sites.Other means for communicationinclude printed IEC material (posters, banners, fliers, tear-offs) And of course, counseling and demonstrations
  • APPLYING THE HYGIENE IMPROVEMENT FRAMEWORKFor the Enabling environment: HIP worked through Diorano WASH, the national sector platform that provides leadership and coordination, and fosters partnerships among sector actors. In this platform, HIP brought the “software” or hygiene promotion element to the forefront. HIP also led the charge to harmonize WASH indicators that have now been adopted as the national indicatorsFor Access to Hardware:HIP rehabilitated school, health center and small community WASH infrastructure, then progressed to public toilet/shower facility rehabilitation. We also promoted community-level latrine slab construction and sales by training and supporting local masons, and marketed sanitation products such as SanPlat slabs and SurEau water treatment chlorine solutionIn terms of Behavior ChangePromoting the 3 key WASH practices was HIP’s mission, and therefore…
  • We placed Behavior First by actively promoting Hand washing with soap or equivalent substitute (e.g. ash or sand) Safe feces disposal Safe storage and treatment of water at the point of useHIP applied the WASH friendly model first for schools and health centers: it includes promoting the 3 key practices along with enabling technologies and strengthening of the enabling environment. HIP then expanded to focus on promoting “WASH Everywhere,” moving from WASH-friendly schools and health centers, to markets, transportation hubs, communes, neighborhoods, highway rest stops, tourist attractions and more. The general model remains the same: promoting the adoption of the 3 key hygiene practices, assuring that enabling technologies and facilities are available, and building the capacity of the institutions responsible for providing services to the communes.
  • Along with message saturation HIP/Madagascar adopted the face to face Behavior Change methodology of negotiating improved practices one small doable at a time to eventually attain the ideal practice. This tool was adapted from the models developed in Ethiopia and Peru. We have a tool for each practice – this one shows washing hands with soap. HIP staff trained community extension agents (Agents Communautaires) and Malagasy Red Cross volunteers in negotiating skills with households.
  • Even if you can’t work with the government, you can prioritize sustainability.Following the coup of 2009, USAID halted direct support to government institutions, so HIP readjusted its institutional network model as shown here, connecting more with the private sector, other USAID WASH partners, local NGOs and the commune as the only government point of contact. This rapid change of strategy from embedded within government institutions to no contact was possible because at scale programming is by nature flexible and responsive to new opportunities
  • In terms of coverage, HIP’s work in Madagascar covered 4 regions shown here, with a population of 6,500,0000 million.
  • HIP conducted annual outcome monitoring surveys that allow comparison between the 2007 baseline with the 2010 endline. As in Ethiopia, open defecation dropped over time while the adoption of unimproved latrines rose. Uptake of improved latrines stayed almost level, indicating that the challenge now is combining demand creation through CLTS with supply of improved products as well as the means to purchase them with loans or vouchers.
  • A proxy indicator for handwashing with soap is the presence of a device and cleansing supplies near a latrine. Both of these rose significantly in project areas between 2007 and 2010.
  • All these steps, approaches, capacity building, in both countries were well documented. Here is a list of the many knowledge products that were developed over the course of the Ethiopia and Madagascar programs. They are all available on the HIP website.
  • A key question we asked ourselves is how can we measure success in applying the at scale approach?
  • One way of doing this is to use the Hygiene Improvement Framework. This example comes from evaluating the Amhara Scale program and shows how the elements of the HIF have been used to define Intermediate Results that are measured in annual surveys: Partnerships and institutional capacity are used to measure the enabling environment; the expansion of the program to district level measures Access to Hardware; and increase in adoption of WASH practices at HH and institution level measure the behavior change efforts.
  • After these experiences, we are pretty confident when we say,
  • Lessons Learned from Working At Scale for Better Hygiene & Sanitation Practices

    1. 1. Lessons Learned from Working At Scale for Better Hygiene & Sanitation Practices<br />Julia Rosenbaum & Sarah Fry, WASHplus<br />June 22, 2011<br />
    2. 2. Critical Questions about Hygiene and Sanitation Improvement at Scale<br /><ul><li> What do we mean by at scale programming?
    3. 3. How do we work at scale in different country contexts?
    4. 4. How do we measure it? How do we know it works?
    5. 5. What were the results of applying at scale programming?
    6. 6. What have we learned?</li></ul>2<br />
    7. 7. What Do We Mean by “At Scale”?<br />Coordinated actions of all stakeholdersworkingtoward a common goal to significantly reduce disease rates in large numbers of affected people<br /> AT SCALE is not the same as SCALING UP<br />3<br />
    8. 8. The SCALE Process<br />1. MAP<br />6. EVALUATE<br />2. PARTNER<br />Reduce Diarrheal Disease<br />3. STRATEGIZE<br />5. MONITOR<br />4. ACT<br />4<br />
    9. 9. Characteristics of an At Scale Effort<br />Systems approach<br /><ul><li>Looks at the whole
    10. 10. Involves multiple sectors, actions, options, stakeholders
    11. 11. Concertedly focuses on bridging across sectors and bonding within</li></ul>Hygiene Improvement Framework<br /><ul><li>Considers hardware, promotion, institutional capacity</li></ul>Behavior FIRST <br /><ul><li>Focuses on consistent and correct PRACTICE of key hygiene behaviors</li></ul>Prioritizes sustainability<br />Coverage<br />5<br />
    12. 12. Traditional WASH Coverage vs. Scale Approach<br />…scattered, dispersed, stand-alone … coordinated and synergistic<br />6<br />Well Construction<br />H/W Promotion<br />Latrine Construction<br />Hygiene Advocacy<br />
    13. 13. Mothers<br />Government Ministries<br />Commercial Businesses<br />Donors/<br />Funders<br />Using Hygiene Improvement to reduce diarrheal diseases<br />Educational Institutions<br />Religious Groups<br />CSOs<br />Media<br />NGOs<br />R&D Institutions<br />Develop Orgs<br />Bringing the Whole System in the Room <br /> & Grandmothers<br />7<br />
    14. 14. <ul><li>Water Supply
    15. 15. Sanitation systems
    16. 16. Available Household Technologies and Materials
    17. 17. Communication
    18. 18. Social mobilization
    19. 19. Community participation
    20. 20. Social marketing
    21. 21. Training</li></ul>Marketing & BC Promotion<br />Access to Hardware/<br />Goods & <br />Services<br />Enabling <br />Environment<br /><ul><li>Policy improvement
    22. 22. Institutional strengthening
    23. 23. Financing and cost-recovery
    24. 24. Cross-sectoral coordination
    25. 25. Partnerships</li></ul>Hygiene Improvement<br />Diarrheal Disease Prevention<br />Hygiene Improvement Framework (HIF)<br />8<br />
    26. 26. Focus on behaviors….<br />Safe feces disposal<br />Hand washing with soap<br />Safe storage & treatment of water<br />… Multiple behaviors<br />9<br />
    27. 27. Characteristics of a Scale Effort<br />Systems Approach<br />Looks at the whole<br />Involves multiple sectors, actions, options, stakeholders<br />Hygiene Improvement Framework<br />Considers hardware, promotion, institutional capacity<br />Behavior FIRST <br />Focuses on consistent and correct PRACTICE of key hygiene behaviors<br />Prioritizes Sustainability <br />By embedding, building capacity, making it local<br />Coverage <br />at least 3 million<br />10<br />
    28. 28. At Scale <br />Hygiene and Sanitation Improvement <br />in the <br />Amhara Region of Ethiopia <br />through “Learning by Doing”<br />11<br />
    29. 29. The Whole System in the RoomAligning for Action: Sustainable Development through Safe Water, Environmental Sanitation & Hygiene<br /><ul><li>Mapping the Context – resources, partners, commitment
    30. 30. Agreeing to a Common Action Agenda
    31. 31. Leveraging Partnership</li></ul>12<br />
    32. 32. COMMUNITY-LED TOTAL BEHAVIOR CHANGE IN HYGIENE AND SANITATION<br />Implementing a hybrid of …<br />Embedded in a national and regional process… the National Hygiene and Sanitation Strategy<br />Built around Health Extension Program<br />and carried out by HEWs <br /> .. Among other actors…<br />A key sector to involve were the “development partners” <br /> … active in total of 90/150 districts of Amhara ... <br />To support with capacity building, transport, other items<br />13<br />
    33. 33. Use Existing Institutional Structures & Build Capacity <br />14<br />
    34. 34.
    35. 35.
    36. 36. Evaluation Results<br /><ul><li>Were we effective?
    37. 37. Did we achieve scale?
    38. 38. Did combining individual and collective action work?</li></ul>YES!<br />17<br />
    39. 39. Practices: Access to Sanitation Facilities<br />Baseline-Endline Comparison: All Respondents<br />**Source: Amhara LBD Evaluation Report, USAID/HIP-WSP/WB-AF, November 2010<br />18<br />
    40. 40. Consider Quality as Well as Coverage<br />Only about 30% of latrines meet minimum standards<br />Distance from house or water source<br />Covered pit<br />Washable plat<br />Superstructure that <br /> provides privacy<br />
    41. 41. Knowledge of When to Wash Hands (percent)<br />20<br />
    42. 42. Presence of HW stations at latrines<br />17%<br />16%<br />
    43. 43. Predictors of Latrine Ownership<br />Endline<br />**Source: Amhara LBD Evaluation Report, USAID/HIP-WSP/WB-AF, November 2010<br />22<br />
    44. 44. Hygiene Improvement at Scale: The Madagascar Experience<br />23<br />
    45. 45. Elements of Scale<br />Systems Approach<br />Hygiene Improvement Framework<br />Behavior FIRST <br />Prioritize Sustainability<br />Coverage<br />24<br />
    46. 46.
    47. 47. Multiple Channels <br />26<br />
    49. 49. Hand washing with soap<br />Use of improved latrines<br />Utilisation de latrines<br />Safe drinking water<br />Conservation de la qualité de l’eau potable<br />
    50. 50. Negotiation Tools for Household BCC<br />29<br />
    51. 51. Scouts<br />NGO Subcontracts<br />Red Cross Madagascar<br />Sustainability<br />Community Health Workers<br />Faith-based<br />organizations<br />NGO<br />Commune<br />Club Vintsy<br />HIP<br />Habitat for Humanity<br />PSI<br />UNICEF<br />USAID Partners<br />Voahary Salama<br />Producers<br />Public-Private Partnership<br />COMMUNITY (CLTS/RRI)<br />Private Sector<br />Public-Private Partnership<br />COMMUNITY (CLTS/RRI)<br />Santenet <br />I and II<br />Financial Institutions<br />Producers<br />Vendors<br />30<br />
    52. 52. 4 Regions:<br />Population 6,500,000<br />31<br />
    53. 53. Madagascar<br />Practice: Access to Sanitation Facilities<br />March 2009<br />Pre-Political Crisis<br />Post-Political Crisis<br />32<br />
    54. 54. Madagascar<br />Practice: Hand Washing<br />March 2009<br />Pre-Political Crisis<br />Post-Political Crisis<br />33<br />
    55. 55. Knowledge Products: Madagascar<br />Guide Illustré – Illustrated guide of PAFI and Méthodes Alternatives (in Malagasy and French) <br />3 posters - 1 for each key practices<br />Flyers and tear-offs with poster images and more text <br />SODIS counseling cards<br />Integration of 3 key hygiene practices in USAID/SanteNet 1 and 2 Champion Community handbook<br />Guide Ecole Amie de WASH – French<br />Guide CSB Ami de WASH/Guide for WASH friendly Health Centers (French and English)<br />Negotiation Tools on the 3 key practices (Malagasy and French)<br />WASH Guide for Scouts – How to earn a WASH Badge (Malagasy and French)<br />WASH Guide for Scout Troop Leaders – How to integrate WASH into your scouting program (Malagasy and French)<br />Sermonette guide for WASH friendly churches<br />Construction guide for improved latrines: with sanplat slabs and superstructure. <br />Consumer research report – French<br />LQAS Comparison Report 2007-2010 (English and French)<br />Available at: http://www.hip.watsan.net/page/250<br />34<br />
    56. 56. Knowledge Products: Ethiopia<br />Regional Behavior Change Strategy<br />District Resource Book for Community Led Total Behavior Change<br />Facilitators Guide for Training<br />Health Extension Workers Handbook<br />Guide to WASH Friendly Schools<br />Training Parents, Teachers and Youth Leaders to be Champions of WASH Friendly Schools<br />M&E Framework<br />Baseline & Endline Survey Report<br />All available at http://www.hip.watsan.net/page/485<br />35<br />
    57. 57. How Can we measure SCALE success ?<br />36<br />
    58. 58. M&E Framework for Ethiopia Follows the HIF<br />Improved Enabling Environment<br />Behavior Change Promotion<br />Access to Hardware <br />37<br />
    59. 59. Scale Challenges<br />Dilemma of “attribution” of results - the fruit of relinquishing control<br />Quality – in a push for coverage, quality lags behind. Whether it improves over time, or stalls, is still unclear. <br />Sustainability – we think the HIF and our institution-centered approach leads to sustainable programs, but we don’t yet have the clear proof<br />38<br />
    60. 60. What have we learned through the HIP approach of STARTING at scale?<br />1. Leadership buy-in is critical for setting the enabling environment; coordination with three technical ministries: Health, Education, Water, plus partners<br /> = reach and coverage<br />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.<br />39<br />
    61. 61. What have we learned about the HIP approach of STARTING at scale?<br />3. Implementation ethos of flexibility, innovation, experimentation “Learning by Doing” – critical!<br />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<br />40<br />
    62. 62. STARTING AT SCALE <br />WORKS!<br />For more information on working at scale see: <br />“At-Scale Hygiene and Sanitation in Ethiopia and Madagascar: Experiences and Lessons Learned” at: http://www.hip.watsan.net/page/5306<br />Julia Rosenbaum, jrosenba@aed.org<br />Sarah Fry,sfry@aed.org<br />All Hygiene Improvement Project Resources: www.hip.watsan.net<br />WASHplus Project: www.washplus.org<br />
    63. 63. Question 1:<br /> 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?<br />42<br />
    64. 64. Question 2:<br />Secondly, did you look at diarrheal prevalence? Was cost per DALY averted assessed?<br />43<br />
    65. 65. Question 3:<br /> How do we make the changes we see sustainable? Does CLTS need to be modified as it matures into a more detailed approach?<br />44<br />
    66. 66. Question 4:<br />What kind of latrines were promoted in Ethiopia and Madagascar - Is it Eco -San or pit latrines?<br />45<br />
    67. 67. Question 5:<br /> Could you please describe in a bit more detail the capacity building efforts and how these went beyond traditional training ?<br />46<br />
    68. 68. Question 6:<br />Can you elaborate on why disgust and shame messages were used as opposed to other messaging approaches?<br />47<br />
    69. 69. Question 7:<br /> 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?<br />48<br />
    70. 70. Question 8:<br />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.<br />49<br />
    71. 71. Question 9:<br /> Is there a mechanism to sustain and monitor the changed behavior in Ethiopia and Madagascar?<br />50<br />
    72. 72. Question 10:<br /> How do you handle the problem of people not owning their own land - and building latrines?<br />51<br />
    73. 73. Question 11:<br /> 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.<br />52<br />