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

Julia Rosenbaum & Sarah Fry, WASHplus

June 22, 2011

• 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?

Critical Questions about Hygiene and Sanitation Improvement at Scale

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What Do We Mean by “At Scale”?

Coordinated actions of all stakeholders working toward a common goal to significantly reduce disease rates in large numbers of affected people

AT SCALE is not the same as SCALING UP

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The SCALE Process

Reduce Diarrheal Disease

1. MAP

3. STRATEGIZE5. MONITOR

6. EVALUATE

4. ACT

2. PARTNER

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Characteristics of an At Scale Effort• Systems approach

– Looks at the whole– Involves multiple sectors, actions, options, stakeholders– Concertedly focuses on bridging across sectors and bonding

within• Hygiene Improvement Framework

– Considers hardware, promotion, institutional capacity• Behavior FIRST

– Focuses on consistent and correct PRACTICE of key hygiene behaviors

• Prioritizes sustainability• Coverage

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Well ConstructionH/W PromotionLatrine ConstructionHygiene Advocacy

Traditional WASH Coverage vs. Scale Approach…scattered, dispersed, stand-alone … coordinated and synergistic

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Media

CSOs

Educational Institutions

Commercial Businesses

MothersGovernment

Ministries

Donors/Funders

Religious Groups

NGOs

Develop Orgs

R&D Institutions

Using Hygiene

Improvement to reduce diarrheal diseases

Bringing the Whole System in the Room

& Grandmothers

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Hygiene Improvement Framework (HIF)

• Communication• Social mobilization• Community participation• Social marketing• Training

Marketing & BC

Promotion

• Water Supply• Sanitation systems• Available Household

Technologies and Materials

Access to Hardware/Goods & Services

• Policy improvement• Institutional strengthening• Financing and cost-recovery• Cross-sectoral coordination• Partnerships

Enabling Environment

Hygiene Improvement

Diarrheal Disease Prevention

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Safe storage & treatment of water

Hand washing with soap

Safe feces disposal

… Multiple behaviors

Focus on behaviors….

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Characteristics of a Scale Effort

1. Systems ApproachLooks at the wholeInvolves multiple sectors, actions, options, stakeholders

2. Hygiene Improvement FrameworkConsiders hardware, promotion, institutional capacity

3. Behavior FIRST Focuses on consistent and correct PRACTICE of key hygiene

behaviors4. Prioritizes Sustainability

By embedding, building capacity, making it local5. Coverage

at least 3 million

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At Scale Hygiene and Sanitation Improvement

in the Amhara Region of Ethiopia

through “Learning by Doing”

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The Whole System in the Room Aligning for Action: Sustainable Development through Safe Water,

Environmental Sanitation & Hygiene

• Mapping the Context – resources, partners, commitment• Agreeing to a Common Action Agenda• Leveraging Partnership

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COMMUNITY-LED TOTAL BEHAVIOR CHANGE IN HYGIENE AND SANITATION

Embedded in a national and regional process… the National Hygiene and Sanitation Strategy

Built around Health Extension Programand 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

Implementing a hybrid of …

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Use Existing Institutional Structures & Build Capacity

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Evaluation Results

• Were we effective?

• Did we achieve scale?

• Did combining individual and collective action work?

YES! 17

2008 20100%

10%

20%

30%

40%

50%

60%

70%64%

40%

19%

46%

17%14%

Practices Open Defecation

Access to Improved Facility

Access to Unimproved Facilityn = 2000 n = 1378

Practices: Access to Sanitation FacilitiesBaseline-Endline Comparison: All Respondents

**Source: Amhara LBD Evaluation Report, USAID/HIP-WSP/WB-AF, November 2010 18

Only about 30% of latrines meet minimum standards

Distance from house or water sourceCovered pitWashable platSuperstructure that provides privacy

Consider Quality as Well as Coverage

Knowledge of When to Wash Hands (percent)

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Presence of HW stations at latrines

17% 16%

Dimensions Factors p Odds Ratio

InterventionCharacteristics

Community participated in walk of shame

.00 2.23

Household visited by health work to improve sanitation

.05 1.75

Intervention -related Perceptions

Having a latrine contributes to the community’s health

.00 2.6

Having a latrine contributes to the community’s development

.00 1.8

ALL of THESE …………………………………………….. >> 8.38

Predictors of Latrine OwnershipEndline

**Source: Amhara LBD Evaluation Report, USAID/HIP-WSP/WB-AF, November 2010 22

Hygiene Improvement at Scale:

The Madagascar Experience

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Elements of Scale

• Systems Approach

• Hygiene Improvement Framework

• Behavior FIRST

• Prioritize Sustainability

• Coverage

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Multiple Channels

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ENABLING ENVIRONMENT

ACCESS TO HARDWARE + ENABLING TECH

BEHAVIOR CHANGE PROMOTION

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Hand washing with soap

Use of improved latrines

Safe drinking water

Utilisation de latrines

Conservation de la qualité de l’eau potable

Negotiation Tools for Household BCC

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HIP

SustainabilityCommunity Health Workers

NGO Subcontract

s

Scouts Red Cross Madagascar

Club Vintsy

Faith-basedorganizations

Habitat for Humanity

NGO

COMMUNITY (CLTS/RRI)

Producers

Public-Private Partnership

COMMUNITY (CLTS/RRI)

UNICEF

PSI

Voahary Salama

Santenet I and II

USAID Partners Privat

e Sector

Vendors

Public-Private Partnership

Financial Institutions

Producers

Commune

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4 Regions:Population 6,500,000

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MADAGASCARPractice: Access to Sanitation Facilities

Pre-Political Crisis Post-Political CrisisMarch 2009

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MADAGASCAR

Practice: Hand Washing

Pre-Political Crisis Post-Political CrisisMarch 2009

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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

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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

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HOW CAN WE MEASURE SCALE SUCCESS ?

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M&E Framework for Ethiopia Follows the HIF

At scale of hygiene and sanitation in the Amhara Region

Intermediate results

Partnerships to facilitate coordinated action fostered

Institutional capacity in public and civil society partners developed

Hygiene & sanitation program expanded at district level

Adoption of WASH practices at HH and institutional levels increased

Improved Enabling Environment

Behavior Change Promotion

Access to Hardware

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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

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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.

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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

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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, jrosenba@aed.orgSarah Fry, sfry@aed.org

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?

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Question 2:

Secondly, did you look at diarrheal prevalence? Was cost per DALY averted assessed?

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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?

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Question 4:

What kind of latrines were promoted in Ethiopia and Madagascar - Is it Eco -San or pit latrines?

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Question 5:

Could you please describe in a bit more detail the capacity building efforts and how these went beyond traditional training ?

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Question 6:

Can you elaborate on why disgust and shame messages were used as opposed to other messaging approaches?

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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?

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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.

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Question 9:

Is there a mechanism to sustain and monitor the changed behavior in Ethiopia and Madagascar?

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Question 10:

How do you handle the problem of people not owning their own land - and building latrines?

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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.

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