Improving Hygiene at Scale

1. Improving Hygiene at Scale Madagascar May to November 2005

2. Overview • Definition • Process • Characteristics • Results • Steps

3. 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 centeredon the key hygiene practices of hand washing, safe feces disposal, and water at point-of-use.

4. 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

5. 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.

6. 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

7. Characteristics of a Scale Effort • Considering BehaviorFIRST is key. • A principle of Multiples is fundamental. • A Systems-Approach is instrumental. • Institutionalization is essential. • Intervention types needed are based on the Hygiene Improvement Framework. • Both quantity & quality define Coverage.

8. 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

9. B. Multiples • Multiple interventions • Multiple levels • Multiple stakeholders • Multiple options

10. 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 C. Systems-Approach

11. 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”

12. Intervention Types: • Water Supply • Sanitation systems • Available Household Technologies and Materials • Intervention Types: • Communication • Social mobilization • Community participation • Social marketing • Training Access to Hardware Hygiene Promotion Enabling Environment • Intervention Types: • Policy improvement • Institutional strengthening • Financing and cost-recovery • Cross-sectoral coordination • Partnerships Hygiene Improvement Diarrheal Disease Prevention E. Hygiene Improvement Framework (HIF)

13. 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 F. Coverage

14. Traditional Coverage Scattered, dispersed, stand-alone Focus on Geographic and Population Coverage Well Construction Handwashing Promotion Latrine Construction Hygiene Advocacy

15. Scale CoverageConcentrate, saturate, interact Using a systems-approach, focus on Geographic Area, Population, AND Multiples.

16. Wells Handwashing Latrines Advocacy

17. Increase the Likelihood of Improved Practice Adoption & Sustainability Needed Infrastructure, Products, & Services Appropriate Approaches to Promotion Ensuring all the necessary elements, increases likelihood of behavior change and the sustainability of the practice. Maximum potential for change exists here. Supportive Environment

18. 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)

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

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

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

22. 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

23. 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

24. 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

25. 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

26. 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

27. Map Relationships What needs to be examined? • Existing partners/ships • Communication between these partners • Potential partners/ships

28. DRC – Before: Stakeholder Relationships MOH MOW USAID Water Cmt SANRU Health Ctrs DistHealth DistWS Village Cmt Village Chiefs Mobilizers

29. DRC – After MOE MOW USAID MOH MOEnv WB DANIDA 3 NGOs Water Cmte 2 CSOs SANRU Health Ctrs DistWS DistHeatlh Village Cmt EZdS DistEnv DistEd Mobilizers Village Chiefs

30. Ministry of Water JES/NGO RSCN/NGO WEPIA + 3 People USAID Funding WEPIA Map at Start

31. Ministry of Water Coordination WDM Intrnt’l Conference— Ministry of Education Curric. Reform In 5 subjects Grades 1-11. Env.NGO RSCN Curric. Dev. Waethat Mosque Prog. Outreach Vocational School 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. Master’s 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. Private Schools & Teachers US Study Tours Women’s 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 engineers Regional Journalists Press Releases / Materials Imam trng. & Mosque Programs Int’l Journalists Shigera village & 5 community Buildings renovated Aqaba Economic Zone 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 Teachers Ministry of Planning Grants Women’s Groups

32. Infrastructure Products Mass media Print materials Interpersonal communication Traditional communication Training PHAST Social Marketing Community/social mobilization Policy Advocacy Institutional strengthening Financing Cost Recovery Inter-sectoral coordination Public/private partnerships Other Map Interventions What needs to be detailed?

33. Intervention Type Interpersonal Communication October 2005 – December 2006

34. 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

35. 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.

36. 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?

37. 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)

38. 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

39. Madagascar Stats 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 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 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 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 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 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

40. 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

41. 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?