Improving Hygiene at Scale

Madagascar May to November 2005

Overview

DefinitionProcessCharacteristicsResultsSteps

HIP is:

• a 5-year USAID-funded project (until 2009), • led by AED, partnered with ARD, IRC

Netherlands, and Manoff and resource-partnered with Aga Khan Foundation, Hindustan Lever and IRC NY,

• designed to achieve at-scale hygiene improvement

• in 5 countries and through selected, strategic activities,

• which are centered on the key hygiene practices of hand washing, safe feces disposal, and water at point-of-use.

• At-scale country implementation• Integration of hygiene into health and non-

health platforms• Global leadership and advocacy around

hygiene improvement• Support and liaison to PVOs, NGOs, and

networks• Knowledge management to share best

practices

through 5 key tasks:

What is Scale?

Coordinated actions of all stakeholders working on a common goal to the benefit of

large numbers of affected people that significantly reduce disease rates.

Process

Reduce Diarrheal

Disease in Madagascar

1. MAP

3. STRATEGIZE5. MONITOR

6. VALUE

4. ACT

2. PARTNER

1. Map the context & detail the stakeholders in all sectors, the levels at which they work, the networks & relationships that already exist & examine patterns of individual &

institutional behaviors.

2. Leverage partnerships, strengthen

existing networks & relationships, & create

new, non-traditional ones.

3. Develop a common goal &

delineate a behavior change

strategy.

4. Implement activities & interventions detailed in the

strategy around the common goal in a concerted & overlapping way.

5. Track the progress of

interventions to make adjustments,

adaptations & changes as

needed.

6. Assess the outcomes & impact of the scale effort.

Characteristics of a Scale Effort

A. Considering Behavior FIRST is key.

B. A principle of Multiples is fundamental.

C. A Systems-Approach is instrumental.

D. Institutionalization is essential.

E. Intervention types needed are based on the Hygiene Improvement Framework.

F. Both quantity & quality define Coverage.

A. Behavior First

• Focus on improving key individual hygiene practices:– Hand washing with soap– Safe feces disposal– Water at point-of use

• Identify, promote and facilitate improved practices that people are willing and able to practice

• Design program interventions that motivate and facilitate these improved practices

B. Multiples

• Multiple interventions

• Multiple levels

• Multiple stakeholders

• Multiple options

C. Systems-Approach

Emphasize:• Relationships and

patterns of behavior• that a small event in 1

sector can have a tremendous impact elsewhere

• key influence points

Examine: • the WHOLE• relationships• degrees of freedom• mainstreaming• commonalities• opportunities

D. Institutionalization

What is Institutionalization?• Institutions are any organized stakeholder group, e.g.,

government, schools, clinics, NGO’s, CSOs, CBOs, faith groups

Institutionalization is:• More than the sum of training, and/or implementation of

field activities• Institutional policy adjustments, human resources,

budget and integration commitments sufficient to ensure continued support for activities “political will”

• Heart of program sustainability and the behavior change sought at the institutional level “making something a new routine”

E. Hygiene Improvement Framework (HIF)

Intervention Types:• Communication• Social mobilization• Community participation• Social marketing• Training

HygienePromotionIntervention Types:

• Water Supply• Sanitation systems• Available Household

Technologies and Materials

Access to Hardware

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

Enabling Environment

Hygiene Improvement

Diarrheal Disease Prevention

F. Coverage

QUANTITY - Scale because of:

• Health impact realized

• Total population covered and/or

• Geographic area(s) covered

QUALITY - Sustainable because of:

• Intervention concentration

• Activity saturation• Systems interaction• Institutionalization

realized• Behavioral impact

achieved

Well Construction

Handwashing Promotion

Latrine Construction

Hygiene Advocacy

Traditional Coverage

Focus on Geographic and Population Coverage

Scattered, dispersed, stand-alone

Scale CoverageConcentrate, saturate,

interact

Using a systems-approach, focus on Geographic Area, Population, AND Multiples.

Wells Handwashing Latrines Advocacy

Appropriate Approaches to Promotion

Needed Infrastructure, Products, & Services

Supportive Environment

Ensuring all the necessary elements, increases

likelihood of behavior

change and the sustainability of

the practice.

Maximum potential for

change exists here.

Increase the Likelihood of Improved Practice Adoption

& Sustainability

Results

• Increased #/% of targeted audience adopting and sustaining key improved practices

• Reduced # of diarrheal diseases cases (morbidity)

• Reduced % of children under 5 dying of diarrheal disease (mortality)

• Preparation – (1) map, (2) partner, (3) strategize

• Implementation – (4) act

• Monitoring – (5) monitor

• Valorization – (6) value

Steps

Prep Activities

• Mapping• Coverage determination• ‘Whole system in a room’ process• Formative research • Behavior change (BC) strategy

development• Effort index design• Resource identification

Implementation

• Systematic roll-out of hardware, promotion, and enabling environment interventions

• Assistance in implementing “mix” of behavior change approaches

• Technical assistance

Monitoring & Valorization

Monitoring•Roll out on schedule•Coverage and overlaps happening•“Must do’s” occurring

Valorization (interim, yearly and final):•Sustainability•Integration•Partnerships•Improved practices•Desired impact

Timeframe

• Preparation – 8 to 15 months

• Execution – 1 to 3 years

• Monitoring – during execution

• Valorization – at least yearly during execution and at “end” of effort

TOTAL Length Required – 3 to 5 years

Scale Effort Preparation

Solid Preparation is ESSENTIAL!

What must we know to get started?a. Context

b. Present Partner Roles and Responsibilities

c. Acceptable Geographic Coverage

d. Behavior Change Approaches

Context

• WHAT – Understand the setting in which the effort will take

place

• WHY– Take a systems-wide look to effectively assess

options and implications of decisions

• HOW – Mapping:– Geographic– Dimensional– Associative

Issues to Map• Water sources, access, quality & supply• Sanitation access, quality & supply• Partner areas of intervention & activities• Partner relationships• Geographic location of institutional staff and kinds of

interventions• Geographic areas of greatest need including health and non-

health platforms• Existing infrastructures, e.g. clinics, churches, etc.• SES indicators, e.g. income, gender, etc.• Geographic areas and capabilities of ancillary agencies, e.g.

universities, colleges, market places, roads, railroads, schools, etc…

• Market paths & streams per needed product• Communication channels and patterns of influence• Donor program support

Map Relationships

What needs to be examined?

• Existing partners/ships

• Communication between these partners

• Potential partners/ships

DRC – Before: Stakeholder Relationships

SANRU

MOHMOW

Health Ctrs

DistHealth

Village Chiefs

USAID

Mobilizers

DistWS

Water Cmt

Village Cmt

DRC – After

MOWMOH USAID

SANRU

Water Cmte

Health Ctrs

Mobilizers

DistWS

EZdS Village Chiefs

MOE

3 NGOs

2 CSOs

DANIDAWB

DistEd

DistHeatlh

MOEnv

DistEnvVillage Cmt

WEPIA Map at Start

Ministry of Water

WEPIA

+

3 People

JES/NGORSCN/NGO

USAID

Funding

WEPIAAED/COP +

3 staff

2 NGOs

US Study Tours

USAID Funding

Grant Agreements

3 Engineers

Media Specialist

US Experts

Web-BasedCurric. /CD Dev.

Private Schools

& Teachers

Ministry of Education

Curric. Reform

In 5 subjectsGrades 1-11.

Ministry of Water

Coordination

WDM Intrnt’l Conference—

Municipal/ProvincialOfficials

Faith-BasedSchool

Systems

Students in 23 private schools

5,000 home audits

Teachers in 5 gradesIn 23 pvt.schools

68 NGOs capacity bldg.

B.A degree program in Non-profit

manangement

US Indiana UnivPhilanthropy Dept..

Municipality PrivateSector Policy Changes

in Agric./Outdoor Use of Water.

Policy changes construction code

Ministry ofPublic

Works & Housing

SaleswomenOf water saving

devices

PlumbingPolicy

JISM

CSBELandscaping for six public demo.

parks

10 USUniversities

JUST Univ. Master’s Program /

Munic. YouthTraining

ArtMuseum

Municipality

Women’sNGO

VocationalSchool

CurriculumPlumbing trng.

10 USAgencies

AWWA

IWRA

Utilities

H.M.Office—

King

Ministryof Religious

Affairs

Imam trng. &Mosque

Programs

WaethatMosque Prog.

OutreachVocational

School

Water AuditsTraining—

Renovation of 760 Bldgs & All

Public Ministries

Munic.Mayors programIRC Private

SectorEval. Firm

Ministry of PlanningGrants

9 Governors &Eng. Staff

CommunityGrants /95 CBOs

MajorBroadcast &

PrintJournalists trnd.

Ref. materials

Press Releases /Materials

Int’lJournalists

RegionalJournalists

Ad AgencyMedia

Campaigns

Aqaba Economic

Zone AqabaSchools Busines

sindustry

Teachers

JREDS

Women’s Groups

Youth Groups

Shigera village& 5 community

Buildings renovated

ProvincialGovernor/Municipal

Mayors/municpalengineers

Philadelphia Univ.for NGO trng.

Env.NGO RSCNCurric. Dev.

WEPIA Map atEnd of Year 5

Map Interventions

1. Infrastructure2. Products3. Mass media4. Print materials5. Interpersonal

communication6. Traditional

communication7. Training8. PHAST9. Social Marketing

10.Community/social mobilization

11.Policy12.Advocacy13. Institutional strengthening14.Financing15.Cost Recovery16. Inter-sectoral coordination17.Public/private partnerships18.Other

What needs to be detailed?

Socios Departamentos / Provincias

MINSAEstrategias nacionales de promoción de la salud

Banco de Crédito (Programa Escolar)

Programa Escolar a través de colegios de Fe y Alegría

Backus - Programa escolar propio

Programa de Liderazgo - Lima, Chiclayo, Trujillo, Pucallpa, Arequipa y Cusco

Banco de Materiales – Mi Barrio

Programa de Mejoramiento Distrital en 10 Regiones

CARE

Programas de Promoción de la Salud: Ancash, Ayacucho, Cajamarca, Callao, Lima, Loreto, Piura y Puno.

Colgate Programa Escolar en Lima

Ebel Venta directa de cosméticos

Cuerpos de PazVoluntarios en trabajo comunitario: Salud y Medio Ambiente

PrismaONG: 70 Talleres para profesionales de salud y profesores

Scouts del Perú Cruzada Scout

Intervention TypeInterpersonal Communication

October 2005 – December 2006

What is a Partnership?

• A relationship where two or more parties, having compatible goals, form an agreement to share the work, share the risk and share the results

• The sharing of decision-making, risks, power, benefits and burdens and adds value to each partner's respective services, products or situations

• Give and take

Partnering – Who & How

WHO:• Start with stakeholders directly related to issue—water &

sanitation, health & hygiene, private & public, donors & implementers

• Expand to (systems-approach): – other channels of influence, e.g. faith-based groups, women’s

groups, local & national associations, farmer’s groups, youth groups

– groups with potential long-term impact, e.g. schools– all possible information channels, e.g. journalists

HOW:• Make individual relationships within these groups not just

institutional relationships. • Treat each group with respect.

Partnering – Systems Examination

Examine the systems and ask:

“What needs to be done to turn you into a partner with an active or passive influence on the targeted

audience?”

Training? Institutional strengthening? Capacity building? Expansion of reach? Other?

Partnering – Roles & Responsibilities

As Effective Partners, What Must We Do?CommunicateCollaborateCoordinateCompromiseCombine

WHY to ensure scale coverage and overlap of hardware, hygiene promotion, and enabling

environment interventions (HIF)

Acceptable Geographic Coverage

How does the partnership choose its intervention zones? • Examine appropriate, relevant statistics:

– Number of children under 5– Diarrhea disease prevalence in under 5s– Access to water– Access to sanitation

• Detail geographically where partners are working

• Using “interventions maps,” examine what types of interventions partners are carrying out where they work

Province de Antsiranana:- Pop = 1,888,425- < 5 ans = 8%/151,074- < 5 ans PdD = 8%/12,86- Accès à l’Eau = 12%/283,264- Accès à l’Assainissement = 28%/528,759

Province de Toamasina:- Pop = 2,593,063- < 5 ans = 18%/466,751- < 5 ans PdD = 11%/51,323- Accès à l’Eau = 19%/494,682- Accès à l’Assainissement = 42%/1,089,086

Province de Tana:- Pop = 4,580,788- < 5 ans = 27%/1,236,813- < 5 ans PdD = 7%/86,577- Accès à l’Eau = 41%/1,878,123- Accès à l’Assainissement = 77%/3,527,207

Province de Fianarantsoa:- Pop = 3,366,291- < 5 ans = 18%/605,932- < 5 ans PdD = 6%/36,355- Accès à l’Eau = 18%/605,932- Accès à l’Assainissement = 30%/1,009,887

Province de Mahajanga:- Pop = 1,733,917- < 5 ans = 12%/208,070- < 5 ans PdD = 11%/22,888- Accès à l’Eau = 20%/416,140- Accès à l’Assainissement = 20%/346,783

Province de Toliara:- Pop = 2,229,550- < 5 ans = 17%/379,024- < 5 ans PdD = 21%/79,594- Accès à l’Eau = 26%/579,594- Accès à l’Assainissement = 16%/356,728

Madagascar Stats

Province of Antsiranana: - # of players in W = 10- # of players in S = 1- # of players in H = 5

Province of Toamasina:- # of players in W = 21- # of players in S = 20- # of players in H = 12

Province of Tana:- # of players in W = 20- # of players in S = 17- # of players in H = 14

Province of Fianarantsoa:- # of players in W = 20- # of players in S = 11- # of players in H = 16

Province of Mahajanga:- # of players in W = 13- # of players in S = 3- # of players in H = 7

Province of Toliara:- # of players in W = 21 - # of players in S = 21-- # of players in H = 18

Madagascar Players(25 out of possible 105 organizations represented)

Behavior Change Approaches

IN COVERAGE AREAS, What needs to be examined?

• Social Change Approaches• Individual Change Approaches

How does each need to be examined?• What is being used?• What has proven to be effective?• What are current practices?• What are desired practices?