These are a couple of additional comments that came in to the WSSCC CoP:

From Aisha Hamza:

Anwer. S. The problem is all. One can not practice hygiene/sanitation without adequate water no matter the sensitization done. Unless water supply is improved or made adequate, people wl just hear/listen but cannot adopt to the behavioural changes we desired from them. Thats why l gave example of ldps camps in my place. We have done alot on sanitation/hygiene promotion and still ongoing but no much impact. Reasons could be those l stated earlier. But above all, water is not adequate for usage. Therefore hygiene/sanitation practice is low. So unless water availability is increase, or hygiene and sanitation practice will still be where it is for people in Africa , most especially amongst the rural populace.

From Hitesh Chakravorty:

I am residing in Assam India have abundance of surface as well as ground water but hygiene /sanitation practice is low due to lack of hygiene education. There are large scale construction of lowcost sanitary latrine and school sanitation in the locality. My personal experience behavioural changes not come overnight for example wash hand before taking Mid Day Meal teacher should tell the student to every day and make it habit its responsibility of school teacher during school hour. Same way after latrine during school hour student should instructed to wash hand with soap.

After 4 days of discussions, there have been some interesting points made in relation to Suvojit’s opening comments. Here’s a quick summary of what’s been said so far (viewed through my biased perspective of course… ☺... please feel free to disagree with me...)

What is really meant by scaling up and ‘going to scale’ in sanitation and hygiene programming?

As we anticipated, there’s been a good level of debate trying to understand what ‘scaling up’ means in different contexts for sanitation and hygiene; and therefore “programming for scale” depends on having a clear, coherent and accepted definition – which is easier said than done!

As Elisabeth von Muench said:

So what is it that we are scaling up? Purely those things that don't require hardware intervention? Actually, everything, even handwashing and stopping [open defecation] OD needs some form of hardware intervention. So that can't be it. When we say "scaling up (access to) sanitation", what do we really mean in this discussion? … I thought it's all about hygiene behaviour change (mainly handwashing and not doing OD when you have a toilet) - and not really about getting toilets to the people, right?

Alexis D’Agostino introduced the challenge of defining scale-up in the context of nutrition programmes, saying:

… 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?

What does it mean for those of us working in WASH? Expanding? Integrating? We started by saying that sanitation hardware interventions need to be ‘right’ with usable and lasting designs and implemented in a way that promotes local ownership (Lalita Pulavarti and Suvojit). However, as regards hygiene behaviour change Suvojit noted

The very nature of careful social engineering required to bring about (lasting) 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.

So to scale up or replicate interventions on a large scale, sanitation hardware supply and hygiene education (> behaviour change) require tailored efforts as they probably won’t happen at the same pace nor be comprehended together as a health improvement ‘package’. This is the primary challenge when considering ‘programming for scale’ – the different elements of our programmes don’t scale up in the same way or through the same mechanisms.

There was an example provided of how partnerships and convergent action are central to scaling up – Anand Sheckhar told us how the Ministry of Drinking Water and Sanitation, the Government of India and the Global Sanitation Fund have announced the “Shillong Declaration” on ‘Promoting Sustainable Partnerships’. In Nadia District in West Bengal (see sabarshouchagar.in/ for more), the whole District has declared its open-defecation free (ODF) status. Key to this was ensuring that stakeholders need to share “key values” that ensure success at scale. These values include, "Decentralization, conjoint planning, co-financing and collective action" No doubt, sanitation campaigns need to be locally-led (as Godwin reaffirmed), and sustained on local governmental or collective community resources plus inter-ministry buy-in and coordination (Roland).

As Peter Bury highlighted we need to distinguish between but also promote integration of sanitation and hygiene (education > behaviour) and not treat them as separate activities. Aisha Hamza also reminded us that

hygiene can never be sustained without adequate water

– so the focus remains on water quantity too. Roland also noted

Improvement in health depends therefore more on sanitation once a minimum of clean (utility) water is available.

So we know that, dependent on the context, there has to be some water access integrated with a sanitation service (onsite, shared, household) and behaviour change to have the impact we want. Our views on how we sequence interventions, who we work with and who leads the process (community, government, private sector, NGOs) differ of course and depend on the context (rural, urban, peri-urban, in schools or health centres, post-conflict, IDPS camps, etc.) – surely what we do agree on, as Suvojit asserted at the start, is that scaling up our approaches is critical and we need to keep learning about how to effect systemic hygiene behaviour change in different contexts. Not because behaviour change at scale alone will mean we reach scale on access to sanitation (as Roland pointed out on SuSanA), but because, until recently, hygiene education was less prioritised in WASH interventions, budgets, our discourse and our mind-sets. Aiming for ODF communities, increasing handwashing at critical times (as Hitesh Chakravorty highlighted) and actually talking about menstrual hygiene have all prompted a shift towards a better understanding of the inter-linkages between WASH, health outcomes and a clean environment.

So does scaling up hygienic sanitation practices always mean reaching 100% of the population – so as to ensure total inclusion and intended health gains? Again Peter questioned this and asked how this has happened in the past (in places such as London) – does take-up happen gradually in ripples as Peter suggested? Peter also challenged how we can ever reach 100% of hygiene education at scale due to population growth, people forgetting, the need for on-going education in schools and through media, etc. Several people commented on how we wont find a one-size-fits-all approach and we need to look beyond the WASH sector more, to integrate our efforts with those of others working on livelihoods (as Kitchenme Bawa noted and Suvojit agreed). We also need to work more with non-traditional partners / experts perhaps – Kitchenme pointed out the value of working with "anthropologists, sociologists and psychologists" in sanitation programming to better understand the determinants of mass behaviour patterns. Plus, perhaps they can assist us more in raising awareness of the need for sanitation and hygiene amongst people, notably the poorest, who have so many competing priorities for their time and money (Aisha and Roland). Roland also drew our attention to a previous post he made where certain paradigms require a rethink. (See: forum.susana.org/forum/categories/142-go...g-intervention-areas)

So, coming back to Suvojit's question about examples of successful scale-up - who can tell us more about their experiences of scaling up handwashing for example?

Next week we will talk more about how sustaining changed behaviours and then in the third week, we'll return to ODF and slippage.

Thank you for reading!

Following on Aisha Hamza's comment yesterday, another colleague called Anwer Sahooly from the WSSCC CoP asked:

Dear Aisha; Having read your comment I am not sure what the problem is; Is it scarce water resources, poverty and corruption or inadequate hygiene education??


Also, Lalita Pulavarti from the WSSCC CoP responded to Suvojit's comments about the preponderance of engineers...

Thank you for letting us join in on the discussion. Addressing Suvojit's point:

"Second, the continuing preponderance of engineering and engineers in sanitation. I would like to believe this is not changing - hoping that colleagues on the forum will help clarify. Sanitation is still managed by the Public Health Engineering Department in some Indian states"....

We had an opportunity to visit six districts in Orissa and six in Tamil Nadu (India) last year as a part of a BMGF funded project to study Citizen Voices in the implementation of the Nirmal Bharat Abhiyan (NBA) in India. Yes, in Orissa the Executive Engineers (of a joint WATSAN department) are still in charge of the sanitation program. However, this does not mean that they are paying attention to structural or design issues either! It only means they are in charge of the money that flows in through the scheme. They sub contract the building of the toilets to empanelled "NGOs" (who are actually local contractors) who build large numbers of sub-standard toilets that don't survive. To my knowledge, no Executive Engineer actually visited to inspect the toilets built.

Sub-contracting (and the resultant kickbacks), and not giving ownership to the citizens to get the toilet built themselves (due to scale issues/ labor issues [skilled masons, etc.] or any other reason) is killing the scheme. Unless this changes under SBM, we will see more of the same in India.

Our estimate is that the numbers on paper - of coverage - don't hold any water (pardon the unintended pun). Between already low coverage numbers, toilets in disrepair, and low usage for other reasons, we would put real coverage at much lower numbers than published by the government. If interested, you could read our report here:

pacindia.org/uploads/default/files/publi...0cd6bd77fb9d31c7.PDF

Suvojit has since clarified...

Thanks Lalita for sharing your experience - also, for pointing out a typo in my line - "I would like to believe this is not changing" - I wanted to write "I would like to believe this is changing"!
The Executive Engineers I have worked with have been more interested in water projects, which come with bigger budgets...

Now that we are half-way through this week's discussion, Suvojit and I will send some consolidate comments later in the day to see where we are on considering his initial questions and what we're learning / sharing so far. Watch this space!

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!

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.

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

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 !

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

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)

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.

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?

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!