Hygiene promotion: lessons from Save the Children’s programme in Malawi

When Save the Children launched its School Health and Nutrition (SHN) program in Mangochi, Malawi in 1998, only 42 percent of schools had access to clean water and none had hand-washing facilities. [...] Only 54 percent of schools had separate facilities for girls. In 2003, when Save the Children expanded its SHN program in Malawi to Balaka district, the situation was a marginally better than it had been in Mangochi five years before [and] as in Mangochi, no schools in Balaka had hand-washing facilities.

Qualitative surveys conducted in both districts also showed that before Save the Children’s SHN program:

• Students traveled long distances to fetch water, which often made them late [to class or] miss class altogether;
• Girls who traveled to collect water faced harassment from boys and men;
• Girls missed school when they were menstruating due to the lack of privacy in school latrines;
• Students drank from unprotected shallow wells and rivers;
• Students did not wash their hands after using the toilet because there were no hand-washing facilities; and
• Despite the availability of facilities, many children did not use them because they were locked or unhygienic

To increase access to and use of safe water and sanitation facilities, Save the Children worked with communities, schools, and water and sanitation experts to construct and rehabilitate boreholes, latrines, and hand-washing facilities and to train teachers and communities on hygiene.

Separate, ventilated latrines with doors and handwashing facilities nearby not only promote good hygiene but also enable girls to consistently attend school. Photo. Save the Children

[...] Quantitative and qualitative end line surveys conducted in Balaka and Mangochi district in 2006 and 2007 respectively showed that the presence of adequate water and sanitation facilities have had a tremendous impact on children’s lives and communities.

Despite these important achievements, the project encountered a number of challenges:

• Only 33 percent of the handwashing facilities in schools were functional and none had soap or ash. [...] When communities provide soap, it usually gets stolen. Just 41 percent of children report hand-washing after visiting the toilet and only 28 percent of children said that they used soap and water the last time they washed their hands.
• Community resource efforts were not consistent. In less active communities that did not provide sand, bricks and labor, latrines and hand-washing facilities were not constructed. However, among most communities that did provide resources, community participation helped create a sense of ownership and ensured the facilities were well-maintained.
• Community members sometimes vandalized handwashing facilities [and] school committees could not always afford to [...] fix facilities quickly. To minimize these incidents, Save the Children directed communities to report all instances of vandalism to the police.
• Rural shop owners did not regularly keep borehole parts in stock, so community members had to travel long distances to buy them.
• Water monitoring assistants conducted frequent supervision of the water point committees to ensure the committees and the boreholes functioned properly.
• Monitoring of hygiene education in schools was infrequent, as primary education advisors rarely monitored the teaching of hygiene. [...] Some teachers said they were not comfortable with the topic due to its sensitive nature and the use of words such as “defecation.”

While Save the Children’s SHN program saw tremendous progress in improving access to safe water and adequate latrines, hand-washing remained a low priority for schools and communities. Hand-washing facilities are not maintained and children rarely wash their hands with soap or ash. A targeted campaign around the importance of hand-washing is needed. Save the Children’s experience in Mangochi and Balaka districts illustrate the importance of community participation and ownership along with regular supervision.

[...] After approximately 20 years of programming and ten years supporting School Health and Nutrition in the district, Save the Children is phasing its programs out of Mangochi. Malawi’s Ministry of Education adopted most of Save the Children’s School Health and Nutrition activities when it began a nation SHN program in 2007. Unfortunately, the provision of water and sanitation facilities is expensive and the government will probably not be able to bare the full cost to equip all schools with adequate facilities.

Source: Save the Children (2008). Improving water, sanitation, and hygiene behaviors in schools : successes and lessons learned from Mangochi District, Malawi. 4 p. Download here

Hygiene promotion: lessons from Save the Children’s Bangladesh programme

Save the Children’s School Health and Nutrition (SHN) program (2002-2008) in Nasirnagar, Bangladesh, provided water, sanitation, and hygiene facilities in 127 schools, reaching over 33,500 children. In 2006, the SHN programme integrated PHASE (Personal Health and Sanitation Education program) into its approach. PHASE, a hand-washing program targeting school-aged children, was developed and funded by research-based pharmaceutical company GlaxoSmithKline. The programmes also helped to improve access to and use of household water and sanitation facilities.

School wall murals showing good health and hygiene practices. Photo: Save the Children

Despite its achievements, the SHN program encountered a number of challenges [1,2]:

• 13 percent of households continue to practice open defecation due to lack of funds for a latrine, lack of space for construction, or lack of knowledge;
• hand-washing habits were more difficult to change at the household-level than at the school-level;
• 57 percent of households still do not properly dispose of their waste, due to a lack of facilities away from households and the belief that children’s faeces is less harmful than that of adults;
• handwashing facilities were sometimes vandalised and replacement parts and repairs are costly and rely on external support;
• as there was not always enough time to provide school health and hygiene promotion lessons, Save the Children recommends adding a weekly health class to the national curriculum;
• the success of health and hygiene promotion depended largely on the participation of school management committees; and
• mothers’ gatherings and courtyard meetings needed to be held at convenient times in women’s daily schedules—usually between breakfast and lunch, and have the support of husbands and family members.

[1] Save the Children (2009). Improving water and sanitation in schools and communities : successes and lessons learned from Nasirnagar, Bangladesh. 6 p. Download here

[2] Save the Children (2009). Changing hygiene behavior in schools and communities : successes and lessons learned from Nasirnagar, Bangladesh. 5 p. Download here

Contact: Save the Children, Ikhtiar Uddin, ikhtiar@savechildren.org or Natalie Roschnik, nroschnik@savechildren.org

Web sites: Save the Children ; Schools & Health ; WASH in Schools

Can Water Services for Urban Poor in Kenya be improved?

 tsittoni@worldbank.org or Christopher Walsh at +1 202.473.4594, cwalsh@worldbank.org .

KISUMU, May 15, 2009—Water utilities must be committed to transferring existing customers to small-scale water providers, eliminate illegal connections, and take the lead in community outreach to improve water service for poor people living in urban areas,s aid a report released today by the Water and Sanitation Program (WSP).

This report, Improving water utility services through delegated management: Lessons from Kisumu, Kenya , explores a contractual relationship in Nyalenda, Kisumu’s largest informal settlement, between the local water utility and small-scale water providers as one type of partnership that can improve water service delivery for poor people.

“Experience shows that through partnership, utilities can improve water service delivery to the poor within their area,” said Wambui Gichuri, Regional Team Leader for Africa at WSP. “We hope the experience and knowledge captured here will inspire other water utilities in Africa and the world to explore a delegated approach to improving water service delivery to informal settlements.”

WSP developed this field note in order to disseminate the lessons learned in Kisumu after providing technical assistance to the Kisumu Water and Sewerage Company (KIWASCO) and the Lake Victoria South Water Services Board in the design, implementation, and post-implementation phases of the delegated management approach in Nyalenda.

For a copy of the full report, please click here.

For more information, please contact Toni Sittoni at + 254-02-322 6316,

Sanitation promotion: experiences from government-led initiative in southern Ethiopia

In Ethiopia’s Southern Nations Nationalities and People’s Region (SNNPR) an innovative programme has promoted latrine construction and use, hand washing and safe water storage and handling. The intervention is an example of how visionary government leadership can create the political momentum for low-cost sanitation and hygiene (S&H) and reach out to rural communities.

Papers from the Overseas Development Institute, in the UK, and the IRC International Water and Sanitation Centre, in the Netherlands investigate the SNNPR approach. The research was undertaken by Ethiopian researchers on behalf of the Research-inspired Policy and Practice Learning in Ethiopia and the Nile Region (RiPPLE) project.

[...] In 2003 the SNNPR Bureau of Health (BoH) began a new community health strategy, including S&H [which aimed] to reach households through paid health extension workers (HEWs) and volunteer community health promoters (CHWs) [and which] promoted latrine construction without any form of subsidy.

A combination of political promotion and institutional mobilisation was successful in launching and expanding the regional government’s strategy as a ‘movement’. [...] The key elements of the S&H strategy were designed to be politically attractive and administratively feasible, and were written in non-technical language.

The researchers found after the project:

• The proportion of households having latrines increased by a factor of eight.
• There was less acceptance of open defecation.
• Questionnaire results indicated better knowledge on hand washing, although actual practice remained poor.
• There were hand washing facilities in 82 percent of households, but only 6 percent were near the household latrine and few people used soap or detergents.
• Water storage and handling practices also remained poor.
• Men mostly decided latrine design, siting and construction, although women were involved in providing materials and plastering.

Despite these positive developments, doubts remain about sustainability and some latrines have collapsed [and] many are infested with flies. As CHWs are unpaid and receive little follow-up support or training, many have lost motivation. Higher levels of government have not provided enough technical support or monitored changes in household S&H behaviour.

[...] Aspects of the SNNPR experience which might help improve [sanitation elsewhere] include:

• promoting local, rather than donor-driven, S&H programmes and technology designs
• using community promotional change agents coordinated by local authorities in command and facilitation roles
• reviewing local S&H progress within wider health sector review processes
• ensuring that strategising, political positioning and communication are based on solid evidence
• realising that sanitation workers cannot make their case to high-level politicians without understanding the political dynamics around S&H.

Source: id21, 01 Apr 2009

Transparency: public accountability through “Citizens’ Voice” initiative, Cape Town, South Africa

The “Raising Citizens’ Voice in the Regulation of Water Services” is a public education initiative driven by the National Regulator (currently within the Department of Water Affairs and Forestry [DWAF]). It supports a bottom-up approach to water services regulation by actively involving citizens in the local monitoring of water and sanitation services.

It aims to empower citizens to hold local government accountable through:

• Training citizens about their rights and responsibilities, and then
• Setting up “User Platforms” which serve as monthly meetings between the municipality and the community for ongoing civil society water services monitoring and problem solving.

The initiative aims to build partnerships between the three spheres of government (national, provincial and municipal levels) and civil society.

Important lessons learned so far are:

• the need to secure political support, through getting endorsement and providing training to local government officials;
• after citizens are trained, User Platforms should be established as soon as possible to keep them engaged;
• ensure citizen ownbership of User Platforms and not let them become a public relations vehicle for local government.

Read the full story in the WIN-SA lesson series no. 20 “Public accountability through “Citizen’s Voive”: City of Cape Town shares good practice (March 2009).

Community-Led Total Sanitation: breaking a dirty old habit in Bangladesh

Dinajpur district residents have stopped defecating in the open because of the children’s total sanitation campaign that follows a radical community-led approach.

A procession of children march through a village in Dinajpur demanding an end to open defecation. Photo: Pal Bangladesh

Whistle blowing is a favorite pastime among children in the villages of Dinajpur district in northern Bangladesh. They would blow their whistles when they spot fellow villagers, often adults, defecating in the open, chasing the surprised offenders who would then pull their pants up and attempt to escape the noise and humiliation. [...] Within 6 months, they shamed some 250 people from different villages. Besides the whistling and flag-marking, the children also march around villages, chanting slogans against open defecation (OD), sending a direct message to all villagers about the dirty old habit.

The children’s involvement in this direct action against OD is part of the Community-Led Total Sanitation (CLTS), “an integrated approach to achieving and sustaining open defecation free status.” The children know that their efforts help protect their own and their communities’ health, and adults include them in community decision-making.

[...] Designed by social development specialist Dr. Kamal Kar, CLTS was introduced by Plan, an international development agency, to some 200 villages in Dinajpur in 2004.

[...] In CLTS, hands-off facilitation is important. The rule of thumb for social development facilitators is to trigger self-realization, and not to lecture. Instant provision of hardware-latrines or toilets-are also discouraged. Villagers have to realize first that the problem is staring at them right in the face. The CLTS approach helps communities recognize that they need such sanitation facilities, that they should mobilize themselves to build their own toilets, and that everyone in the village should contribute to achieve “total sanitation.”

[...] Today, most Dinajpur villages have achieved “open defecation free” (ODF) status and, thanks to Plan’s efforts, a number of villages in several districts have also adopted the CLTS approach.

The children’s campaign is the just the beginning. CLTS allows villagers to generate their own ideas for improvement, take control of development processes and decision-making, and manage and sustain the activities. Often, CLTS has led to improving latrine designs, adopting hygienic practices, managing solid waste and wastewater, protecting drinking water sources, and other environmental activities.

Some villagers, however, can prove to be more difficult than others. Ferdousi said, “Two years to convert everyone is not enough, but we will keep on raising awareness.”

Plan now promotes CLTS in other countries in Asia, Africa, and the Middle East. A CLTS Handbook, published in 2008, is also available for social development facilitators.

Related web site: Community-led Total Sanitation – Bangladesh

See also: Whistle blowers put a stop to open defecation, Plan Bangladesh, 28 Mar 2008

Source: Cezar Tigno, ADB, Jan 2009

Community kiosks: learning from water supply failures in Malawi

The Lilongwe Water Board is the sole water supply authority in Malawi’s capital city. However, its service suffered from inadequate response to system and community problems and lack of transparency in water billing. In response to a request for assistance from the community, WaterAid Malawi developed a strategic partnership with the Lilongwe Water Board, aimed at improving management of water services in unplanned low-income neighbourhoods.

An [April 2008] paper from WaterAid Malawi describes its partnership with the Lilongwe Water Board and a local non-governmental organisation – the Centre for Community Organization and Development (CCODE).

WaterAid research indicated that the system to distribute water through water kiosks was not working. Poor households owed huge sums to the Lilongwe Water Board – the monopoly water provider. They were paying far too much: prices at communal kiosks in low-income areas were twice as high as those in high-income areas. Charging systems were inconsistent and billing was not transparent. Some households paid equal monthly fees for different levels of consumption while others were paying per bucket.

Political and traditional leaders corruptly controlled kiosk management committees and failed to pass on funds they collected from communities to the Lilongwe Water Board. The private operators who were able to pay their utility bills resold water to poor people at high and unregulated tariffs. Many meters were vandalised but even those still working were often not read for over a year. The water board charged customers for estimated, not actual, consumption. Without consultation with users, the utility factored in arrears into water bills to cover money misused by community leaders.

Further problems included: illegal installation of boreholes, failure to check water quality, dependence of on unsafe sources when kiosks were disconnected, high leakage rates

[Following a reform programme] the utility now regards itself as a public service provider with obligations to consult users and to extend the network to unserved communities, while also embracing private sector principles to improve the efficiency of billing, debt collection and reduction of water losses.

Reform has also involved:

• establishing a focal point within the Lilongwe Water Board to whom community kiosk users could take their grievances: the Kiosk Management Unit regulates prices and promotes timely reporting of faults and prompt action to fix them
• WaterAid providing technical and financial advice and funding to rehabilitate communal water kiosks, replace meters, construct meter boxes and improve drainage facilities at kiosks
• building CCODE’s capacity to mobilise communities’ capacities to identify kiosk management options, settle debts, monitor the utility and promote hygiene education.

Source: id21, 01 March 2009

Urban water supply: potential of pro-poor water connection subsidies in Cambodia

After decades of conflict, Cambodian water planners are struggling to provide supplies to urban residents. Many households do not use water from a network connection. Instead they rely on dirty and unreliable sources. Getting poor householders connected is unlikely without subsidies and regulatory reform.

A new journal article [...] uses household data from a range of Cambodian urban settings to assess the demand for water and identify the main factors determining household access to network water.

[O]utside the capital {Phnom Penh] the urban [water] coverage rate is only 15 percent. Many people obtain their water from rivers, streams, tanks, wells or private vendors [who charge] prices that are usually about ten times higher than the official rate.

[...] An examination of 200 household variables and price data reveals that:

• Educational attainment levels are higher among connected households compared to non-connected ones.
• Members of an ethnic (mainly Chinese) minority are more likely to be connected compared to the majority Khmer group.
• Connected households have significantly greater assets than non-connected ones: a household with a telephone is 33 percent more likely to be connected than a household without a telephone.
• A one percent increase in the water connection fee reduces the probability of a household getting connected by about two-fifths.

The researchers advise policymakers – in Cambodia and other developing countries – to use targeted subsidies to encourage more poor households to connect. Once they are connected even the less well-off households may be able to afford a non-subsidised tariff. This advice is based on growing evidence that with targeted connection subsidies, the probability of excluding a deserving household is significantly smaller than with a general consumption subsidy. Poorer households are often willing to pay more for water and sanitation services than what they cost to operate and maintain.

The [article urges] the Cambodian authorities to:

• better manage existing resources aimed at the provision of safe water targeted at the poorest, which could then provide the financial resources for a connection subsidy programme
• discuss with donors and concession operators how to finance a connection subsidy programme
• in addition to connection subsidies, consider other factors to improve service access and provision, such as developing sound regulations for the sector
• give an autonomous regulator a clear remit to promote accountability, transparency and competition between the public and private sectors
• undertake research comparing the efficiency of the private and public sectors
• generate data regarding the welfare effects associated with connection to and use of a water system.

Full reference: [1] Basani, M., Isham, J. and Reilly, B. (2008), The determinants of water connection and water consumption : empirical evidence from a Cambodian household survey. World development ; vol. 36, no. 5 ; p. 953-96. doi:10.1016/j.worlddev.2007.04.021. Read the full article here.

Source: id21, 01 March 2009

Urban sanitation: putting people at the centre of informal settlement upgrading in Pakistan

The Orangi Pilot Project (OPP) has transformed sewage systems in low income, informal settlements (‘katchi abadi’), where 60 percent of Karachi’s population lives. OPP has challenged development approaches, which are very technical and overly-dependent on government and donor support. Such approaches treat poor communities as objects, rather than drivers, of development.

A report for the International Institute for Environment and Development, in the UK, explores how OPP has expanded from a focus on the ‘katchi abadi’ of Orangi to become an important voice on issues related to sewerage, drainage sanitation and informal settlement upgrading across Karachi.

[...] OPP has achieved credibility over years of rigorous mapping and documentation. [...]. OPP’s model of low-cost sanitation gives residents the responsibility of building household and lane-level sanitation infrastructure. Municipal authorities are responsible for building and maintaining secondary infrastructure. [...] Infant mortality rates have declined dramatically.

[...] In order to ensure individuals are driven by ideals, not [...] financial reward, OPP salaries are lower than those of other NGOs.  [...] OPP does not seek large-scale funding from donors. High standards of openness and financial transparency are central to building relationships. Staff numbers are kept low by training community members as activists and mappers, and encouraging them to work themselves.

OPP rejects all form of subsidy, believing it inevitably leads to dependence [and] increases costs and causes waste. When the community contributes towards a project – [..] costs are immediately cut: designs are simplified, methods of construction are cost-efficient, and profiteering, kickbacks and professional fees for contractors, engineers and supervisors are eliminated.

OPP’s experience shows that:

• It important to work on a single issue – or only a small number of issues – comprehensively before taking on related issues.
• In order to influence government it is vital not to be confrontational: it is necessary to work patiently over a period of time with department staff and build trusting relationships with civil servants.
• Meticulous documentation of findings, observations and processes, leading to the preparation of alternatives is critical to being taken seriously by decision-makers.

Source: id21, 01 March 2009

Urban sanitation: Changing the Sanitation Landscape in Bangalore, India

The residents of Sudhamnagar, a slum community in Bangalore, made the big leap from defecating in the open until 2007 to having household latrines in 2009, proving that once people understand what they’re missing, they will find ways to get it.

The community’s efforts easily demystify many myths about sanitation: that sanitation requires expensive and high-tech solutions, that the poor have more important needs than sanitation, or that governments and utilities do not have access to financing for sanitation.

Sudhamnagar comprises 300 households of mostly daily wage earners. For a long time residents had no access to safe water supply, no basic sanitation facility in their homes, limited educational opportunity for children, and very little hope for a better quality of life.

“Everything changed when AVAS [Association for Volunteer Action and Services] stepped in and helped us by constructing a community toilet,” says Josephine, a local resident and member of the WATSAN committee.

In a dialogue faciltated by AVAS, residents identified basic facilities like housing, water, sanitation, and electricity as their most urgent needs. The dialogue later branched out to wider grounds-from education to health to land tenure to livelihood.

After ensuring that the community had stable land rights, AVAS and the WATSAN Committee negotiated with the local government and the Bangalore Water Supply and Sewerage Board (BWSSB) for the installation of water connections and construction of public toilets.

The public toilets were so popular that frequent use led to maintenance and cleanliness problems. As a result residents began constructing household latrines with technical guidance from AVAS, a little financial assistance, and the support of the WATSAN Committees.

“The poor are willing to pay if they have access to the service,” says Anita Reddy, AVAS’ Managing Trustee. “Accessibility, affordability, and participation in decision making are the critical ingredients that helped the residents change their lifelong habits,” she added.

See also: Water rights: access to water means access to education in the slums of Bangalore, India, Source South Asia, 19 Nov 2007

Contact: Association for Voluntary Action and Service (AVAS), No. 9, 5th Cross, Puttaiah Compound, Ashwath Nagar, Bangalore 560094, India, Ph: +91-80-23516227, Email: avas [at] vsnl.com

Source: Ma. Christina Dueñas, ADB, Feb 2009