WATER AND SANITATION PROGRAM: LEARNING NOTE 64289 Scaling Up Rural Sanitation Key findings Learning by Doing: Working • Cultivating political will is crucial to achieve widespread, at-scale, at Scale in Ethiopia successful sanitation projects. • Consensus building among July 2011 all actors at all levels in an administrative unit is the entry point to working at scale. INTRODUCTION to expand on to all 30 International Develop- In 2005, an estimated 15.2 million people ment Association (IDA)/Department for In- • Developing high quality, or 80 percent of the total population of the ternational Development (DFID)-supported Amhara Region in Ethiopia lived in rural districts as well as 60 additional districts, evidence-based, tested tools areas where sanitation-related indicators in collaboration with WASH sector partners and training manuals can were low. Open defecation was common; working in the region. LBDI launched in facilitate replication of successful hand washing, particularly after defecation, June 2006 and was the first ‘at scale’ initia- tive of its kind. activities. was practiced infrequently; and general housing environments were unsanitary, PROBLEM STATEMENT • Building the capacity and with cohabitation with animals a common occurrence. There was a high prevalence At onset, there were two major challenges motivation of community-based of health issues correlating to poor sanita- with respect to sanitation and hygiene Health Extension Workers is vital tion and hygiene such as intestinal para- deficits. First, the Government of Ethio- to working at scale. sites, diarrhea, and eye and skin diseases. pia‘s Universal Access Plan called for one hundred percent coverage and inclusion During that timeframe, the Water and of sanitation. To achieve these very ambi- Sanitation Program (WSP) worked with tious goals of family health, the Ministry the Ministry of Health, providing sup- of Health Extension Program developed port to design a Sanitation Strategy and a sixteen component program, of which On-Site Sanitation protocol. WSP also seven dealt directly with sanitation and gained experience in scaling up sanita- hygiene. However the actual process to tion by working closely with the South- achieve sanitation and hygiene objectives ern Nations, Nationalities, and People’s was not developed: step-by-step guid- Regional Government Health Bureau. ance was not provided, tools not available, These experiences and government mo- nor were community-led, behavior change tivation to change conditions provided approaches harnessed to achieve goals. an opportunity to design a community- Second, political commitment at all levels led, systematic approach to implement a had focused on sanitation coverage, with sustainable at-scale sanitation program less attention given to improving safe water, based on the strategy and protocol. sanitation and hygiene (WASH) practices such as hand washing, safe water storage WSP partnered with the Government of and handling, and latrine maintenance and Ethiopia, the Amhara Regional Health Bu- usage. reau, and USAID’s Hygiene Improvement Project (HIP), to design and implement ACTION the Learning by Doing Initiative (LBDI), an Working at the kebele (sub-district) level, at-scale project focusing on total behavior LBDI mobilized the community through change in sanitation and hygiene. The roll building the capacity of resource people in- out strategy was to launch LBDI at scale, cluding Health Extension Workers, Agricul- but to focus WSP/HIP intensive assistance ture Extension Workers, kebele leaders, and in four woredas (districts), reaching an es- other partners. These training sessions fo- timated 93,000 households and a popula- cused on both community mobilization and tion of 418,000, and to immediately roll out focused, household-level behavior change tools and approaches from this experience tools, and included consensus-building 2 Learning by Doing: Working at Scale in Ethiopia Scaling Up Rural Sanitation Figure 1: Progress of latrine coverage in selected Workers to assess current practice and “negotiate� which sanita- districts (2006–2009) tion and hygiene options or “small doable actions� were feasible and best suited to each family’s need. The behavior change strat- 100 egy focused on three behaviors: hygienic disposal of human feces; 90 hand washing with soap at critical moments; and household water 80 treatment and safe storage of drinking water, with an ultimate goal 70 of total behavior change in sanitation and hygiene in the region. Percent 60 50 KEY LESSONS 40 Based on implementation to date, several key lessons have 30 emerged: 20 10 The combination of CLTS plus individual or household hy- 0 giene promotion that focuses on “doable actions� is ef- fective in increasing latrine coverage and reducing open ria en r re a s m ha et fe ia m w ke de tg ec Zu he defecation in Ethiopia. Although sanitation and hygiene devel- El ko Ke m la le M Ac Le re r Ke Te hu de opment is not uniform throughout the learning woredas, latrine eb a Te ay on bo et D eb coverage in the first two years in many targeted kebeles climbed G gg Li D Fa from as low as 5 percent to as high as 100 percent (Figure 1). Spot assessments of sanitation coverage over thirteen districts 2006 2007 2008 2009 indicated an average coverage rate of 80 percent. A systematic and representative endline survey representative of the entire Amhara Region of 20 million showed open defecation dropping activities with a ‘whole system’ approach to involve all stakeholders from 64 percent to 40 percent (Figure 2). Traditional, unimproved engaged in sanitation and hygiene. latrine development also improved dramatically—increasing from roughly 17 to 46 percent. Next, LBDI began to operate through a participatory community mobilization tool known as Community-Led Total Sanitation (CLTS). Based on an analysis of endline research conducted in 2010, the In CLTS, community members engage in a mapping exercise or chances of owning a latrine were about 9 times higher in house- “shame walk� to identify open defecation (OD) sites. Further activi- holds located in villages that participated in a walk of shame (an ties demonstrate how OD contaminates food and water sources, activity typically during CLTS triggering); that were visited by an leading community members to feel shame and disgust at the real- outreach worker to improve sanitation conditions; and where child ization that through widespread open defecation, they are consum- caretakers held beliefs that reflected motivational factors promoted ing their neighbors feces; and to commit to ending the practice of by the initiative (e.g., having a latrine contributes to their commu- open defecation. nity’s (not just household) health and development). These activities were complemented by a novel approach to in- CLTS plus interpersonal hygiene promotion is an effec- terpersonal communication for behavior change: individual and tive hybrid approach to address multiple, complimentary household behavior negotiation was conducted by Health Extension practices to improve hygiene and sanitation. While sanitation BOX 1: CORNERSTONES OF THE LBDI IN AMHARA Consensus Building—Regional, district and local workshops (termed Whole System in a Room, or WSR) were conducted with representatives from all levels of eight main stakeholder groups—Health, Education, Water Resources, Women, Youth and Teachers, Faith Based, Private Sector, and Political Leadership. Alignment of Regional and National Strategies—The CLTS and Hygiene (CLTS+H) approach is now integrated into the Ministry of Health’s national approach and the National Health Extension Program (HEP) which is cascaded to the regions. Common ground was formed with the Regional Health Bureau to integrate the at-scale sanitation program with the existing HEP where seven out of the sixteen targeted community based programs deal with environmental sanitation. Multi-tiered Advocacy—WSP/HIP and regional partners conducted multi-level advocacy in regions, zones, woredas (districts), kebeles (sub- districts), and gotts (community clusters) to garner broad buy-in. Community Mobilization and Ignition—Using CLTS tools to spark commitment to change eliminate open defecation forever. Promoting Behavior Change—Household-level outreach focused on multiple behaviors and doable actions that leveraged community/group dynamics to ignite action. Building Capacity—A comprehensive capacity-building training focusing on community mobilization, data collection and collation, and negotiation or problem-solving to increase sustained uptake of doable actions at household level was conducted for government-paid Health Extension Workers (HEWs) prominent community-resource people, and volunteer community health promoters (VCHPs) who supported HEWs by following-up on action plans at the village level. Implementation—Based on mapping data that showed an absence of any systematic system to scale up sanitation and sustain behavior change in the region, several well-tested tools were used for implementation. These included: CLTS for community mobilization; Jobaides (laminated pictures) and dialogue cards to help HEWs initiate simple doable actions at household levels; additional manuals and guidelines to support HEW and VCHP activities; and the Woredas Resource Book, sharing a twelve-step plan for multiple districts to follow the program and work toward achieving the same standards. www.wsp.org Scaling Up Rural Sanitation Learning by Doing: Working at Scale in Ethiopia 3 coverage increased, an independent, randomized survey of the re- Figure 3: Progress in handwashing practices (2008–2010) gion indicated that presence of handwashing stations (tippy-taps) proportionally kept pace with increasing number of latrines, but re- 17% mained at a low level, about 16 percent. The presence of both water 16% and soap or ash at the latrine remained low and, statistically speak- ing, constant. There were more latrines in the region, so more hand washing stations as well; but still at a constant and low percent- age. The self reported use of any cleansing agent increased from 55 to 60 percent and that difference is statistically significant. Knowl- edge of when to wash hands increased significantly, particularly knowledge to wash hands after defecation; but was not yet linked to increases in actual practice (Figure 3). Effort was made to increase handwashing stations with soap/ash and water. However, the limiting factor for handwashing behavior change is lack of water. In water- 0% scarce areas people are less interested with that behavior. Baseline (n = 821) Endline Learning (or model) woredas have a ripple effect. Learning Presence of handwashing station near a latrine districts have been used by zones as training sites for non-targeted Water and cleansing agent districts. Districts that learned CLTS+H in this manner have shown an increase in latrine coverage equal to—or in some cases greater than—the learning districts themselves. This ripple effect contrib- uted to an increase in sanitation coverage from 37 to 71 percent over important. A survey of 231 households in 28 villages in East and the life of the program, as reported in the Amharra Regional Health West Amhara showed only 36 percent of available latrines were Bureau’s 2009 Annual Report. The ripple effect was so strong that well-maintained and only 26 percent of squat hole latrines were it was impossible to identify an ‘untouched’ control group in the covered. Moving from open defecation to fixed-point defecation region, because components of the approach had spread to most achieves little health impact if the latrine is not used by all families, districts in the region. including children, is not maintained, or is not kept hygienically Household dialogue that focus on small “doable� actions Handwashing behavior change is constrained by access is an effective means to improve hygiene and sanitation to water and soap. The availability of a hand washing facility at practices. Household visits that focused on small “doable� actions strategic location in a household can be an important behavior rather than pushing one “ideal practice� leads to new behaviors. indicator. A concurrent survey in few districts showed that while Based on a regional survey, the use of narrow-necked containers to 40 percent of households had handwashing facilities, only 7 per- protect water from contamination increased from 20 to 38 percent cent have water and soap for washing and cleansing purposes. (Figure 4); and the percentage of people reporting that they treated drinking water increased from 8 to 36 percent. Building latrines is not enough. A focus on quality or build- WHAT ELSE DO WE NEED TO KNOW? ing to minimum standards, maintenance and use are equally LBDI followed a “learning by doing� approach. While latrine cover- age and hand washing facilities increased, many challenges remain. These challenges are mostly related to meeting quality standards, maintaining and sustaining the changes. Figure 2: Progress in cessation of open defecation (2008–2010) Mobilizing communities to build latrines is a proven concept, but we need to work more to improve hygienic behaviors and practices and move people up the sanitation ladder. 64% Ending open defecation is a noble and achievable but ambitious effort. What is critical, and still unclear, is householder behavior mov- ing ‘up’ the sanitation ladder; if a household digs an unimproved pit latrine that does not meet minimum standards, will they progressively 46% move up to better practices, or stop at the first small doable action? The next steps are to assure the importance of minimum standards, 40% operation and maintenance of latrines; support communities to have more permanent types of latrines than the present temporary ones; and to build a viable market for sanitation goods and services where 19% consumers make choices and sellers respond to these demands, 17% which results in moving households up the sanitation ladder. Over the 14% next two years sustainable behavior change and sanitation market- ing in Amhara will address these steps. Initial messaging has been successful, and this success has Baseline (n=2000) Endline (n=1378) been partially due to intensive household visits. Identifying Practices open defecation emotional triggers magnify the message, reaching broader Has access to unimproved facility and deeper via multi-media/channel approaches. One of the Has access to improved facility gaps identified in the Amhara program was that the communication www.wsp.org 4 Learning by Doing: Working at Scale in Ethiopia Scaling Up Rural Sanitation Figure 4: Change in distribution of water treatment methods (2008–2010) Acknowledgements The authors are extremely grateful to 8 all partners, stakeholders, community 11 Other 4 based organizations, and WASH line sectors in the region and districts for 20 their encouragement, participation and 38 Herbs support, in developing and executing 20 the total behavior change endeavors in Safeguard Amhara. 9 52 About Strain/Filter Today, 2.6 billion people live without 44 access to improved sanitation. Of these, 75 percent live in rural 17 Boiling communities. To address this challenge, WSP is working with Baseline (n = 105) Endline (n = 501) governments and local private sectors to build capacity and strengthen performance monitoring, policy, strategy developed was designed based on results. One of the most important reasons financing, and other components international knowledge and local experi- for not having sustained behavior change needed to develop and institutionalize ences and was not based on a local elicita- in handwashing and the development of a large scale, sustainable rural tion of people’s knowledge, aspirations and permanent type of latrine technology was sanitation programs. With a focus on motivators. In order to fill this gap and attain because there was no systematic follow- building a rigorous evidence base to sustained behavior change a comprehen- up and supportive supervision rendered support replication, WSP combines sive formative research will be conducted to by the districts. It has been stated by many Community-Led Total Sanitation, see and identify behavior approximations, prominent CLTS advocates and others behavior change communication, motivators, barriers, and determinants of be- that the key for behavior change is the fol- and sanitation marketing to generate havior change in about 4 nations and nation- low up efforts carried out after community sanitation demand and strengthen alities found in Amhara. Based on the study mobilization. the supply of sanitation products and result message positioning and a broad services, leading to improved health communications campaign will be designed. for people in rural areas. For more —By Kebede Faris (WSP/World Bank- information, please visit www.wsp.org/ Promoting follow up communications AF) and Julia Rosenbaum (FHI 360 scalingupsanitation and visits will lead to more sustainable Development/ WASHplus1) Contact us 1 For more information please visit Previously AED/USAID’s Hygiene Improvement Project (HIP) www.wsp.org or email Kebede Faris at wsp@worldbank.org, or Julia Rosenbaum at jrosenba@aed.org. WSP is a multi-donor partnership created in 1978 and administered by the World Bank to support poor people in obtaining affordable, safe, and sustainable access to water and sanitation services. WSP’s donors include Australia, Austria, Canada, Denmark, Finland, France, the Bill & Melinda Gates Foundation, Ireland, Luxembourg, Netherlands, Norway, Sweden, Switzerland, United Kingdom, United States, and the World Bank. WSP reports are published to communicate the results of WSP’s work to the development community. The findings, interpretations, and conclusions expressed herein are entirely those of the author and should not be attributed to the World Bank or its affiliated organizations, or to members of the Board of Executive Directors of the World Bank or the governments they represent. © 2012 Water and Sanitation Program