Going to scale: An introduction to this discussion and an invitation to engage

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Going to scale: An introduction to this discussion and an invitation to engage

Vous pouvez également lire mon message en français - s'il vous plaît voir le commentaire ci-dessous à partir de Tracey (23 Octobre : # 15094 )

Fortunately, there is no argument any longer about how critical ‘scaling up’ is when it comes to sanitation. However, unlike many other public health interventions, the sanitation challenge is complex, sometimes also called a ‘wicked problem’ – a challenge foremost, of inducing lasting behaviour change. The very nature of careful social engineering required to bring about this behaviour change seems to run contrary to some of the factors that make an intervention scalable – an ability to standardise inputs and break programme components down to easily replicable bits.

In the rush for scale, there is the real risk of perpetration of target-driven hardware interventions which will neither change behaviour, not create social cohesion. It is not unusual for organisations that rush to scale end up compromising on exactly those key design elements that made their pilots a success. For instance, government-led sanitation programmes in India have continued to fail over two decades precisely because of a narrow focus on construction. Construction is important, but even there, there is a lot one needs to get right: usable and lasting designs, and implemented in a way that promotes, rather than detracts from local ownership.

The other issue is that of total inclusion. As is now widely understood and accepted, without the inclusion of all households in a community, gains from improved sanitation cannot be realised. Unless all families adopt hygienic sanitation practices, we will not make a dent on the incidence of disease prevalence. In sanitation, (say) 70% of those currently practising ODF switching to safe disposal of faeces would not be a success if the remaining 30% are uniformly distributed across the communities that have made the switch. So models that scale on the basis of willing consumers/ participants, rather than a focus on each person adopting it (such as micro-credit or cola or condoms) may not be easily transferable to sanitation. Therefore, comparisons with the number of mobile phone users aren’t really valid at a fundamental level. But we might have a lot to learn from effective marketing (social or otherwise), as demonstrated by say, the success of the polio vaccine campaigns around the world.

In sum, we have learnt that conventional approaches are not working: those that set up a false dichotomy between hardware construction and behaviour change; those that are content with pit latrines as opposed to functional toilets; those that use reductionist conceptions such as communities being open defecation free rather than focusing on personal and environmental sanitation and hygiene as a whole; and those that settle for incremental coverage instead of full coverage from the start.

All of this raises important questions for ‘going to scale’. Through this thread, it will be great to see a free-ranging discussion on the key operational challenges. To initiate the conversation, I will set out a few leads:

1. What are some successful examples of successful scale-up? How did these models address the issues of inclusion and equity? In terms of implementation, how have these models been able to create an iterative model that avoids blueprints?

2. In the cases of successful scale-up, were programmes initiated and sustained by governmental or non-governmental actors? What are the key elements of a successful partnership? How can we strengthen national ownership?

3. What is the role of the private sector – for example, in financing, communications, sanitation marts – in implementing sanitation at scale?

Looking forward to an exciting and enlightening conversation!
Suvojit Chattopadhyay,
Monitoring and Evaluation Advisor
Adam Smith International
Nairobi, Kenya
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Re: Going to scale: An introduction to this discussion and an invitation to engage

Our colleague, Anand Shekhar, on the WSSCC CoP has responded saying:

Thanks Suvojit for these interesting questions!

Let me start by saying that partnerships and convergent action are central to scaling up. Recently Ministry of Drinking Water and Sanitation, Government of India and Global Sanitation Fund have come out with a "Shillong Declaration" which realizes the need for effective partnerships for going to scale and commits to provide an enabling framework for effective partnerships. The declaration can be seen at the website of Ministry of Drinking Water and Sanitation, Government of India.

We have some very interesting examples here in India on convergent action guided by enabling partnership frameworks that have yielded results at scale. Nadia District in West Bengal is a good case to look at. The key learning from Nadia- a district which has recently declared itself ODF is that the stakeholders need to be conscious of "key values" that ensure success at scale. Decentralization, conjoint planning, co-financing and collective action were some of the values agreed for scale up in Nadia and every partner and actor in the district worked on promoting these values in their work. This contributed to the entire district becoming free from open defecation.

Generally, programs of development organizations are guided by values which may or may not match and converge with others. Scaling up demands scaling up of core set of values that promote sustainability of benefits. The moot point being that multi stakeholder action must commit to and agree to promote key values. Only then we can take programs to scale.

Suvojit added:

Thanks for joining the conversation, Anand!

For the benefit of the group, here is the link of the Shillong Declaration on 'Promoting Sustainable Partnerships' that Anand referred to: www.mdws.gov.in/sites/upload_files/ddws/...long_Declaration.pdf
(Attached for ease of reference also.)

Also, a link on the sanitation efforts in Nadia district sabarshouchagar.in/
Sabar Souchagar (in Bengali), means 'toilets for all'
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Re: Going to scale: An introduction to this discussion and an invitation to engage

We've also heard from Kitchinme Bawa on the WSSCC CoP with his experiences and thoughts going forward.
Thank you Kitchenme!

I am delighted to see the synergy between the WSSCC network and the SuSanA. These kind of synergy is very good for the sector and though these discussions may not have an outcome in form of a silver bullet for the sanitation sector, I believe most of us here like me understand that dialogue is the beginning of solution to common problems.

From about a decade of sanitation programming, I want us to learn from what we have done so far. If one looks at the sanitation scenario globally, only a few programmes at scale have been sustainably successful, if any. Perhaps we should begin to look at it differently. What we have been doing to me is to have a one-size-fits-all approach whereby the programme does not give room for flexibility to temper with the original design. My suggestion is that we need to design at-scale programmes with a flexibility to fit into the livelihood issues or projects. I have observed that for people with improved livelihoods, the chances of adopting a new sanitation and hygiene habit is high that otherwise. Hence, we must begin to integrate our sanitation programmes into activities that are targeted towards improving the livelihoods of the people.

Another issue we need to also deal with is the involvement of anthropologists, sociologist and psychologists in sanitation programming. It is very clear that most times we are focused on construction of toilets (even the UNICEF New York HQ sanitation team calls itself 'The Toilet Team'; which I understand may be targeted at raising the awareness and facilitation discussion and removal of the stigma associated with toilets). (May be it should consider calling itself the Sanitation Behavior Change Team). Hence we in our monitoring also count the access in terms of the possession of a toilet. I believe that we may have to study mass behavior patterns like widespread corruption among a people; the love for a particular car in a country or among a particular people; the mode of dressing for a group of people and the determinants or the drivers of mass behavior. Or perhaps we need more specialists to analyze and help us find the best way to reach scale with sanitation programmes. That to me may be the best way to ensure that by 2030 everyone in Africa and the rest of the underdeveloped and the developing world have access to sanitation for all.
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Re: Going to scale: An introduction to this discussion and an invitation to engage

Thanks Kitchinme for a great post.

Two points stand out for me - one, there cannot be a successful sanitation programme if it is disconnected from issues livelihoods - income and consumption. As an old colleague would say - If you couldn't eat, what would you shit?

Second, the continuing preponderance of engineering and engineers in sanitation. I would like to believe this is changing - hoping that colleagues on the forum will help clarify. Sanitation is still managed by the Public Health Engineering Department in some Indian states, for instance. However, as I am always careful to emphasise, we cannot ignore the importance of design and execution. I have found faulty structures (which in itself is driven by many reasons, not all of which are design or construction related) are one of the major reasons for toilets falling into disuse.

Hoping to hear more from other members!
Suvojit Chattopadhyay,
Monitoring and Evaluation Advisor
Adam Smith International
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Re: Going to scale: An introduction to this discussion and an invitation to engage

Peter Bury, writing to us from Italy, has added a comment on the WSSCC CoP. Read it here...

Suvojit, nice to start up this discussion!

Two spontaneous reactions:

1. Make sure to distinguish and at the same time promote integration of sanitation and hygiene (education > behaviour). Most agencies see and treat them as two different activities.

1. You write: "The other issue is that of total inclusion. As is now widely understood and accepted, without the inclusion of all households in a community, gains from improved sanitation cannot be realised." It makes me wonder how things improved in London or anywhere else in the so-called developed part of our globe. I doubt that total inclusion was achieved or aimed for right from the start. Take up usually takes up in ripples, gradually. If this is so, this influences the most effective and efficient strategy to follow, isn't it?
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Re: Going to scale: An introduction to this discussion and an invitation to engage

Hi Peter, thanks for your post. On the second point challenging the nation of 'total coverage', I think implementers often think in terms of a tipping point or a critical mass within communities. But as sanitation coverage goes up in a community, there is a real risk that some households may get left behind - and that is what we need to guard against. As this Lancet study shows - www.thelancet.com/pdfs/journals/langlo/P...-109X(14)70307-9.pdf . coverage doesn't imply usage and partial coverage doesn't help reduce exposure to faecal matter. In this particular case, the coverage and usage levels are quite low - so it might make sense that the outcomes would be different at a higher threshold of coverage. Please do share any examples that you may know of.

On London - there are several accounts of how the city was a sanitary mess, to put it kindly in the early 19th century and saw cholera outbreaks. It took a comprehensive overhaul of the sewerage systems of the entire city to fix that - something that wouldn't have worked if say, only a part of the city's sewerage was fixed. I know this probably doesn't answer the question of individual toilet ownership and usage, but does seem to be an instructive parallel.
Suvojit Chattopadhyay,
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Re: Reply: Going to scale: An introduction to this discussion and an invitation to engage

Good morning everyone!
Here's a message from Alexis D'Agostino from the WSSCC CoP - providing some lessons learned from nutrition. Thanks, Tracey

Hello All,

Thanks for the invitation to a really interesting discussion. I just wanted to share a few quick points learned from the nutrition field that you all might find interesting and relevant for your conversation. Before even attempting to answer your 3 questions, though, I wanted to raise a point about defining what is understood by scale-up.

When the SPRING Project started to look into "nutrition scale-up" systematically there didn't seem to be a lot of agreement within our field of what that term really meant. Expanding programming to new geographic areas? Integrating it into a local system? Both? Neither? Something else? We did a literature review to get an understanding of what how it was discussed in academia. We developed a conceptual framework to pull the various pieces together, and then interviewed other implementers about what they thought the term meant...and how that, in turn, affected their work. The original framework (which our interviews supported) can be found here: www.spring-nutrition.org/publications/br...e-nutrition-projects .

In our interviews, we also heard a lot of things that relate to your specific questions...I'll have to jump on those tomorrow!

Best,
Alexis
(M&E Specialist -- JSI)
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Re: Reply: Going to scale: An introduction to this discussion and an invitation to engage

I agree, going to scale with access to sanitation is fundamentally crucial in the developing world. But does that mean that we will reach access on scale with going to scale with hygiene education? Are there not many cases of hygiene education on scale realised already? Did it lead to access to sanitation on scale?

Sanitation seem to be even more multidimensional than water. Therefore, there would be a lot more to be done before, after or simultaneously.

Roland

P.S. See also my related post here: "How do we develop access to sanitation at scale and where are the most pressing intervention areas?" forum.susana.org/forum/categories/142-go...g-intervention-areas
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Re: Going to scale: An introduction to this discussion and an invitation to engage

SVP trouver le message initiale de Suvojit. SVP écrivez vos commentaires en français et nous allons essayer de fournir de brefs résumés en anglais:

Plus besoin, heureusement de débattre de l’importance cruciale que revêt le déploiement de mesures à grande échelle (scaling up) en matière d'assainissement. Cependant, contrairement à de nombreuses autres interventions de santé publique, le défi que pose l’assainissement souvent qualifié de « sacré problème » est complexe, car il s’agit avant tout d’un défi consistant à susciter un changement durable des comportements. La nature-même d’une ingénierie sociale prudente, dont on a besoin pour provoquer ce changement de comportement, semble aller à l'encontre de certains des facteurs qui permettent le déploiement d’une intervention à grande échelle — à savoir une capacité de normaliser les contributions et de décomposer les composantes du programme en éléments facilement reproductibles.

En se précipitant vers un déploiement à grande échelle, on court un réel risque de mettre en œuvre des interventions axées sur la fourniture d'installations sanitaires et motivées par des objectifs spécifiques qui ne permettront ni d’influencer les comportements, ni de créer une cohésion sociale. Il n’est pas rare de constater que les organisations qui se précipitent dans un déploiement à grande échelle finissent par compromettre les éléments conceptuels clés qui constituaient pourtant les points forts de leurs programmes pilotes. En Inde, les programmes d’assainissement mis en œuvre par le gouvernement au cours des vingt dernières années n’ont cessé d’échouer précisément parce qu’ils n’étaient axés que sur la construction d’installations sanitaires. Toutefois, même dans un tel contexte, de nombreux facteurs doivent être considérés en termes de construction pour élaborer des installations utilisables et durables et les mettre en œuvre d’une façon qui en encourage l’utilisation au lieu d’en amoindrir l’appropriation locale.

La question de l’inclusion totale constitue l’autre versant du problème. Il ne fait désormais plus l’ombre d’un doute que, sans l’inclusion de l’ensemble des ménages de la communauté, les fruits d’un assainissement amélioré ne peuvent être récoltés. L’incidence de la prévalence des maladies sera difficilement ébranlée, sauf si toutes les familles adoptent des pratiques sanitaires hygiéniques. Dans le contexte de l’assainissement, on ne peut pas considérer que 70 % (par exemple) des populations qui ont actuellement abandonné la pratique de la défécation à l’air libre pour passer à un système d’élimination des fèces sûr constitue un résultat de réussite, si les 30 % restant sont répartis de manière uniforme à travers les communautés qui ont déjà effectué ce changement. Par conséquent, des modèles qui se déploient à grande échelle à la volonté des participants/consommateurs, plutôt que sur l’adoption du modèle par chaque individu (comme les microcrédits, le cola ou les préservatifs), peuvent s’avérer difficilement transférables au contexte de l’assainissement. Aussi, les comparaisons avec le nombre d’utilisateurs de téléphones portables ne sont-elles pas vraiment valides fondamentalement parlant. Des campagnes publicitaires efficaces (sociales ou autres) sont évidemment essentielles, comme nous avons pu le constater avec le succès mondial des campagnes de sensibilisation à la vaccination contre la polio.

Face à ces défis, nous avons compris que les approches conventionnelles ne fonctionnent pas : notamment celles qui établissent une fausse dichotomie entre la construction d’installations sanitaires et le changement de comportement ; celles qui s'en tiennent aux latrines à fosse plutôt qu'aux toilettes fonctionnelles ; celles qui ont recours à des conceptions réductionnistes comme l’éradication de la défécation à l’air libre au sein des communautés plutôt que d’être axées sur l’hygiène et l’assainissement personnels et environnementaux dans leur ensemble ; et, celles qui favorisent une mise en œuvre progressive plutôt qu’une couverture complète dès le départ.

Autant de considérations qui soulèvent d’importantes questions au sujet du « déploiement à grande échelle ». Au travers de ce fil de réflexion, il serait intéressant d’assister à une discussion libre abordant les défis opérationnels clés. Pour l’amorcer, je propose les quelques pistes suivantes :

1. Quels exemples probants de déploiements à grande échelle réussis pouvez-vous citer ? Dans quelle mesure ces modèles ont-ils pris en compte les questions d’inclusion et d’équité ? En termes de mise en œuvre, en quoi ces modèles ont-ils permis de créer un modèle itératif sans plan directeur ?

2. Dans les cas de déploiements à grande échelle réussis, les programmes ont-ils été lancés et appuyés par des acteurs gouvernementaux ou non gouvernementaux ? Quels sont les éléments clés d’un partenariat réussi ? Comment pouvons-nous renforcer l’appropriation nationale ?

3. Quel rôle joue le secteur privé (par exemple, en matière de financement, de communications, de magasins de vente de matériel sanitaire) dans le déploiement de mesures d’assainissement à grande échelle ?

J’attends avec impatience de participer à une conversation passionnante et éclairante sur le sujet !
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Re: Going to scale: An introduction to this discussion and an invitation to engage

Hi everyone, Peter J. Bury on the WSSCC CoP has provided us with some challenging and timely questions about whether we really ever reach 100% coverage with hygiene education and also about roles, responsibilities and accountabilities. Thank you Peter.

You can read his full post here:

I'd like to pick up on Roland (warmin) via Tracey, saying among other things: "Are there not many cases of hygiene education on scale realised already? Did it lead to access to sanitation on scale?"

I'm sorry but hygiene education at scale (as in 100% coverage or close) can never be definitely realized. This because of population growth and people forgetting for whatever reason. So hygiene education is only 'at scale' if done and redone permanently in schools, adult education, via media, etc. etc. Isn't it?

PS. to Suvojit, you wrote "But as sanitation coverage goes up in a community, there is a real risk that some households may get left behind - and that is what we need to guard against. " The very tricky word in this sentence is "we". Who is the we here? Who should guard, who should be overall responsible, who should be accountable, who should be empowered to demand efficient and effective "sanitation sector" management and governance?

I guess the answers are obvious, but too often put aside as they are "making things to complex and complicated", isn't it?

Peter
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Re: Going to scale: An introduction to this discussion and an invitation to engage

Hello everyone, there have been some interesting developments on the WSSCC CoP in response to issues raised so far. To keep you up-to-date, here's the latest comments...

In response to Peter's comment about how reaching 100% hygiene education at scale requires an ongoing and repeated effort and the need for clearer stakeholders' responsibilities, Suvojit added that: No doubt, sanitation campaigns need to be locally-led, and sustain on local governmental or collective community resources.

Suvojit also responded to Alexis on her comments from nutrition and the value of agreeing a common definition of 'scale up'. Clearly, if there's no common understanding and definition of what scale-up means, how can different stakeholders work to achieve it? Suvojit noted:

Thanks to Alexis for bringing in your experience from the field of nutrition. There are obvious overlaps between the two fields, not in the least demonstrated clearly by the researchers at r.i.c.e riceinstitute.org/ - the link between malnourishment levels and sanitation coverage.

Also, the questions around scale that you raise are important - "Expanding programming to new geographic areas? Integrating it into a local system? Both? Neither?" - I suspect the same questions exist in sanitation. I will be interested in hearing what the practitioners on this forum think!


So, what does scale-up mean for sanitation and hygiene behaviour change in your context or your sector?

Suvojit has also explored Roland's (user: warmin) comments here and in his post: forum.susana.org/forum/categories/142-go...g-intervention-areas

Roland, thanks for sharing your thoughts. I have posted here, a portion of the post to which you provided the link - some really thought-provoking questions in there. Thanks!

"Thus, let's rethink certain paradigms:
1. "With sufficient sensitization and hygiene campaigns the households will build their own toilets" (?). Statistics document it does not happen on scale because household priority remains lower for sanitation compared to other (basic) needs, the poor cannot afford an adequate toilet and standards are not enforced by the authority which usually is considered responsible (local).

1. "Increasing water consumption (above 20 litres) improves health" (?). It is documented ("Happiness on Tap: Piped Water Adoption in Urban Morocco", 2012; American Economic Journal: Economic Policy 2012, 4(4): 68-99, see: web.stanford.edu/~pdupas/MoroccoWaterConnections.pdf) that this is not the case when the households have already access to adequate sanitation. Improvement in health depends therefore more on sanitation once a minimum of clean (utility) water is available. Therefore, with the first acceptable service level in water supply (water kiosks of formalized providers / utilities) onsite sanitation linked to a sanitation chain has to be promoted with priority instead or parallel of further investments in water to increase consumption. The biggest step in water development is from the informal providers to the formal utility, even when shared facilities such as water kiosks are offered.

1. "The ministry of health and /or local authorities are the natural leaders in sanitation" (?). The case of Burkina Faso indicates that it is likely more appropriate to move national policy making for sanitation to the next higher level than a single ministry because of the involvement of many sectors in sanitation. Furthermore, we need to involve professionals acting on behalf of the state in sanitation as it is now the case for water with socially oriented commercial (public) utilities. Public administration has its limits when it comes to implementation / operation (e.g. of sanitation) and therefore need to recognize the role it can play.

1. "The toilet for the household is a decision (an affair) of the household" (?). This is often interpreted as "leave the household alone, it will do it". Unfortunately, such an approach leaves the sanitation chain (of onsite sanitation) and the standard setting out of consideration for many technical solutions and the fact that the poor need support.

5. "Shared facilities are not appropriate" (?). This assumption is misleading as has been proven during the development in the industrialized world where in many capitals 2 or more households shared toilets in the 20th century for decades on large scale and thereby ensuring individual and public health. It is also not reflecting the opinion of the dwellers in low income areas considering toilet sharing among a limited number of households satisfactory."


Finally, Aisha Hamza from the WSSCC CoP shares the following:

To add to previous write up, hygiene can never be sustain without adequate water. However, water is a very scare commodity both in urban and rural communities, especially in Africa my land. Unless Government and private sector and individuals improves water quantity for users, good hygiene practices will remain where it is and just a story.

Talk of sanitation; poverty , sickness , illiteracing , corruption and frustration is there knocking at our doors in our communities/ villages. Latrine will be the lease of peoples need. Typical example in the idps camps in Borno state, Nigeria. Lot of hygiene and sanitation education has been done and still on going, yet no much changes as regard their behavioural change in term of hyg/san.

Suspected cases of Cholera, vomiting and diarrhoea and open defecation among order things are still very much practiced. A lot more has to be done to make people adopt and accept good behavioural changes . Government, private sectors and individuals must come together to make lot of advocacy and educate the populace to see need and importance of hygiene and sanitation. And important to target most are children at schools and at home. Such that their generation will grow up conscious of good san/hygiene.
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Re: Going to scale: An introduction to this discussion and an invitation to engage

I agree to those commented earlier especially the fact initiatives should be locally led. Over the years, WASH programs have been implemented by governments in collaboration with other WASH sector players - most of the efforts have been project oriented and many successes have been recorded, shared and we have celebrated. However, there are no mechanisms for institutionalizing hygiene/sanitation behaviour change i.e. by setting initiatives that brings in accountability to local leaderships and communities at large. In many countries I have witnessed traditional leaders complying with monthly calls to local government offices, contributing local materials for building a local clinic or school structure, repairing a bridge etc. However, there has been little mention of internalization of hygiene and sanitation behavior change. I feel this issue should be channeled through local government systems rather than specialized sectors only! In other words, hygiene and sanitation should be central to all development efforts reaching communities. The question is how? The answer is that this would vary across countries and societies! Various tools and approaches would be employed to do this!
WASH Specialist - Consultant
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