Improving Hygiene at Scale

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Improving Hygiene at Scale

• Madagascar
• May to November 2005

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Overview

• Definition
• Process
• Characteristics
• Results
• Steps

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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.

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through 5 key tasks

• 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

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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.

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Process
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.
6. Assess the outcomes impact of the scale
effort.
1. MAP
6. VALUE
2. PARTNER
5. Track the progress of interventions to make
adjustments, adaptations changes as needed.
2. Leverage partnerships, strengthen existing
networks relationships, create new,
non-traditional ones.
Reduce Diarrheal Disease in Madagascar
3. STRATEGIZE
5. MONITOR
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.
4. ACT
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Characteristics of a Scale Effort

1. Considering Behavior FIRST is key.
2. A principle of Multiples is fundamental.
3. A Systems-Approach is instrumental.
4. Institutionalization is essential.
5. Intervention types needed are based on the
   Hygiene Improvement Framework.
6. Both quantity quality define Coverage.

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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

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B. Multiples

• Multiple interventions
• Multiple levels
• Multiple stakeholders
• Multiple options

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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

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D. Institutionalization

• What is Institutionalization?
• Institutions are any organized stakeholder group,
  e.g., government, schools, clinics, NGOs, 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

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E. Hygiene Improvement Framework (HIF)
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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

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Traditional Coverage
Scattered, dispersed, stand-alone
Focus on Geographic and Population Coverage
Well Construction
Handwashing Promotion
Latrine Construction
Hygiene Advocacy
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Scale CoverageConcentrate, saturate, interact
Using a systems-approach, focus on Geographic
Area, Population, AND Multiples.
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Wells
Handwashing
Latrines
Advocacy
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Increase the Likelihood of Improved Practice
Adoption Sustainability
Appropriate Approaches to Promotion
Needed Infrastructure, Products, Services
Ensuring all the necessary elements, increases
likelihood of behavior change and the
sustainability of the practice.
Maximum potential for change exists here.
Supportive Environment
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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)

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Steps

• Preparation (1) map, (2) partner, (3)
  strategize
• Implementation (4) act
• Monitoring (5) monitor
• Valorization (6) value

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Prep Activities

• Mapping
• Coverage determination
• Whole system in a room process
• Formative research
• Behavior change (BC) strategy development
• Effort index design
• Resource identification

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Implementation

• Systematic roll-out of hardware, promotion, and
  enabling environment interventions
• Assistance in implementing mix of behavior
  change approaches
• Technical assistance

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Monitoring Valorization

• Monitoring
• Roll out on schedule
• Coverage and overlaps happening
• Must dos occurring
• Valorization (interim, yearly and final)
• Sustainability
• Integration
• Partnerships
• Improved practices
• Desired impact

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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

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Scale Effort Preparation

• Solid Preparation is ESSENTIAL!
• What must we know to get started?
• Context
• Present Partner Roles and Responsibilities
• Acceptable Geographic Coverage
• Behavior Change Approaches

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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

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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

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Map Relationships

• What needs to be examined?
• Existing partners/ships
• Communication between these partners
• Potential partners/ships

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DRC Before Stakeholder Relationships




MOH
MOW


USAID
Water Cmt

SANRU

Health Ctrs



DistHealth
DistWS

Village Cmt
Village Chiefs
Mobilizers









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DRC After

MOE
MOW
USAID
MOH



MOEnv

DANIDA
WB

3 NGOs
Water Cmte

SANRU
2 CSOs

Health Ctrs



DistWS
DistHeatlh

Village Cmt
EZdS
DistEnv
Mobilizers
Village Chiefs
DistEd









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JES/NGO
RSCN/NGO
WEPIA 3 People
USAID Funding
WEPIA Map at Start
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Teachers in 5 grades In 23 pvt.schools
Private Sector
10 US Universities
Policy Changes in Agric./Outdoor Use of
Water. Policy changes construction code
US Indiana Univ Philanthropy Dept..
Municipality
Students in 23 private schools 5,000 home audits
Municipal/ Provincial Officials
Philadelphia Univ. for NGO trng.
JUST Univ. Masters Program / Munic.
Youth Training
Ministry of Public Works Housing
68 NGOs capacity bldg. B.A degree program in
Non-profit manangement
Faith-Based School Systems
CSBE Landscaping for six public demo. parks
Plumbing Policy
Saleswomen Of water saving devices
Art Museum
JISM
Municipality
2 NGOs
Media Specialist
Vocational School Curriculum Plumbing trng.
US Study Tours
Private Schools Teachers
Womens NGO
H.M. Office King
WEPIA AED/COP 3 staff
AWWA
USAID Funding
Web-Based Curric. / CD Dev.
10 US Agencies
US Experts
3 Engineers
IWRA
Grant Agreements
Major Broadcast Print Journalists trnd. Ref.
materials
Ministry of Religious Affairs
Utilities
Water Audits Training Renovation of 760 Bldgs
All Public Ministries
Provincial Governor/ Municipal Mayors/municpal en
gineers
Imam trng. Mosque Programs
Press Releases / Materials
Regional Journalists
Intl Journalists
Aqaba Economic Zone
Shigera village 5 community Buildings renovated
Ad Agency Media Campaigns
Munic. Mayors program
Community Grants / 95 CBOs
IRC Private Sector Eval. Firm
Aqaba Schools Business industry
JREDS
Youth Groups
WEPIA Map at End of Year 5
9 Governors Eng. Staff
Ministry of Planning Grants
Teachers
Womens Groups
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Map Interventions
What needs to be detailed?

1. Infrastructure
2. Products
3. Mass media
4. Print materials
5. Interpersonal communication
6. Traditional communication
7. Training
8. PHAST
9. Social Marketing

1. Community/social mobilization
2. Policy
3. Advocacy
4. Institutional strengthening
5. Financing
6. Cost Recovery
7. Inter-sectoral coordination
8. Public/private partnerships
9. Other

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Intervention Type Interpersonal
Communication October 2005 December 2006
Socios Departamentos / Provincias
MINSA Estrategias 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 Paz Voluntarios en trabajo comunitario Salud y Medio Ambiente
Prisma ONG 70 Talleres para profesionales de salud y profesores
Scouts del Perú Cruzada Scout
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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

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Partnering Who How

• WHO
• Start with stakeholders directly related to
  issuewater sanitation, health hygiene,
  private public, donors implementers
• Expand to (systems-approach)
• other channels of influence, e.g. faith-based
  groups, womens groups, local national
  associations, farmers 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.

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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?

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Partnering Roles Responsibilities

• As Effective Partners, What Must We Do?
• Communicate
• Collaborate
• Coordinate
• Compromise
• Combine
• WHY ? to ensure scale coverage and overlap of
  hardware, hygiene promotion, and enabling
  environment interventions (HIF)

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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

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Madagascar Stats
Province de Toamasina - Pop 2,593,063 - lt 5
ans 18/466,751 - lt 5 ans PdD 11/51,323 -
Accès à lEau 19/494,682 - Accès à
lAssainissement 42/1,089,086

• Province de Antsiranana
• - Pop 1,888,425
• - lt 5 ans 8/151,074
• lt 5 ans PdD 8/12,86
• - Accès à lEau 12/283,264
• - Accès à lAssainissement 28/528,759

• Province de Tana
• - Pop 4,580,788
• - lt 5 ans 27/1,236,813
• lt 5 ans PdD 7/86,577
• Accès à lEau 41/1,878,123
• - Accès à lAssainissement 77/3,527,207

Province de Mahajanga - Pop 1,733,917 - lt 5
ans 12/208,070 - lt 5 ans PdD 11/22,888 -
Accès à lEau 20/416,140 - Accès à
lAssainissement 20/346,783
Province de Fianarantsoa - Pop 3,366,291 - lt 5
ans 18/605,932 - lt 5 ans PdD 6/36,355 -
Accès à lEau 18/605,932 - Accès à
lAssainissement 30/1,009,887

• Province de Toliara
• - Pop 2,229,550
• - lt 5 ans 17/379,024
• lt 5 ans PdD 21/79,594
• Accès à lEau 26/579,594
• - Accès à lAssainissement 16/356,728

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Madagascar Players(25 out of possible 105
organizations represented)
Province of Toamasina - of players in W 21 -
of players in S 20 - of players in H 12
Province of Antsiranana - of players in W
10 - of players in S 1 - of players in H 5
Province of Tana - of players in W 20 - of
players in S 17 - of players in H 14
Province of Mahajanga - of players in W 13 -
of players in S 3 - of players in H 7
Province of Fianarantsoa - of players in W
20 - of players in S 11 - of players in H
16

• Province of Toliara
• - of players in W 21
• of players in S 21
• - of players in H 18

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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?