December 12, 2017
By Bijan Manavizadeh, Global Handwashing Partnership
It often surprises me how much can be accomplished and learned in one year. This October, I attended the UNC Water & Health Conference for the second consecutive year. Though there were many important themes discussed, several resonated for me: gender equity, behavior change at scale, government inclusion, and the role of hygiene at the nexus of environmental resilience and global health. If we intend to achieve the Sustainable Development Goals (SDG) by 2030, and generate the long-lasting impact within the communities and populations the WASH sector strives to reach, we must learn from our failures and learn how to incorporate those lessons into our work.
Behavior change and programming at scale
The conference served as a platform to discuss challenges of implementing WASH behavior change interventions at scale. As Dr. Om Prasad Gautam, a hygiene and behavior change specialist at WaterAid, said: being a WASH expert doesn’t make one an expert in behavior change. Having WASH and behavior change specialists collaborate to assess how to best approach interventions at scale can help increase impact, overcome limitations, and reduce gaps in service delivery. What works for pilots and at the community level may not result in the same outcomes at the national level. Dr. Robert Dreibelbis, assistant professor at the London School of Hygiene & Tropical Medicine, explained that implementation at scale is substantially more complicated and challenges of intervention fidelity are harder to manage.
Dr. Dreibelbis acknowledged that even the most sophisticated trials, when leveraging a single approach, can fail to achieve desired outcomes. For example, the SuperAmma campaign in India, which succeeded in using emotional drivers to encourage handwashing at critical times by up to 40% in rural communities, yielded very modest results at the national level. Achieving impact among a wider audience requires employing multifaceted approaches. These include using multiple channels, aligning stakeholders, and ensuring that frontline workers are properly trained and resourced to reach the most marginalized populations.
Gender equity & menstrual hygiene management
The failure of WASH programming to sufficiently meet the needs of women remains a significant challenge, as poor access to water supply and sanitation facilities exacerbates gender disparities. Despite 2.6 billion people having gained access to improved water during the MDG era, according to UN Women, 663 million people still rely on unimproved sources. In 25 sub-Saharan African countries, women spend 16 million hours every day collecting water (compared to 6 million hours among men), often to the detriment of schooling or paid work. Because women are often assigned responsibility in preparing meals, feeding young children, and cleaning and bathing infants (and disposing of their feces), WASH issues often translate to gender issues through increased exposure or time poverty.
Modifying how we approach the role of women to eliminate gender disparities, from the design process to the evaluation phase, can result in the changes around gender for which we often advocate. To improve this, a number of organizations have been incorporating gender equity into their WASH programming by embracing the role of women to promote gender-related services. WaterSHED, a NGO working in southern and southeast Asia, explained that it trains women to participate in the marketing and sales of its commercial hygiene products. Learning financial literacy, marketing skills, and networking, women have become empowered to overcome barriers that have previously limited their ability to engage in leadership positions, and to improve their everyday lives.
In a session on WASH in schools convened by UNICEF, it resonated when a presenter admitted that unless there is funding and a budget, prioritization of menstrual hygiene management, particularly in schools, will continue to fail to make progress. Access to menstrual hygiene services and facilities is often assigned a low priority, and many schools in low- and middle-income regions fail to incorporate gender-sensitive infrastructure, such as sex-separate bathrooms or facilities for disposing menstrual hygiene products. Resistance to inclusion of menstrual hygiene and reproductive health services in programming and curricula often compounds the issue. However, improving awareness, education, and advocacy around the importance of MHM can help women and girls overcome barriers, stigma, and discrimination from their own communities, schools, and workplaces.
To understand how best to enhance promotion around menstrual hygiene management, formative research can help identify determinants of MHM behavior and distinguish what makes menstrual hygiene products desirable for women. WaterAid Australia learned that for women in Fiji, Solomon Islands, and Papua New Guinea, even when commercial menstrual hygiene products were available, they were often unaffordable, of poor quality, and thus undesirable. These determinants for MHM behavior also represent similar challenges for hand hygiene markets, and often render proper handwashing practice difficult for women at the lowest income levels.
Government buy-in
For countries to realize targets of the SDGs and to achieve the 2030 Agenda, governments must not be viewed simply as partners for development agencies and organizations. Several sessions made strong arguments for the WASH sector to reassess its approach to programming, and instead aim to foster the transfer of technical and financial capacities to planning and finance sectors, whereby governments are able to take ownership of interventions being implemented in their countries. By providing guidance to help align policies and strategies, governments will be better equipped to increase investment, improve supply chain management, and establish priorities and indicators for hygiene in national WASH plans. At the same time, the WASH sector should continue to harness the role of civil societies, stakeholders, and advocates to foster greater accountability, transparency, and cooperation in their countries.
Interventions that span two or more sectors require cooperation between federal ministries, local authorities, bureaucratic agencies, supply chains and service providers to align policies and regulatory systems. The various sector and finance ministries implicated must understand their roles and responsibilities to strengthen outcomes, reduce competing priorities, and prevent funding streams, indicators, and data from being siloed. For example, enhancing hygiene facilities in schools requires ministries of education, sanitation, and health to collaborate. Together with local-level stakeholders, ministries should draft a joint set of indicators for an intervention; agree on a shared budget and resource investment; harmonize cross-sector reporting systems; and elect which ministries are responsible for implementation, for compliance, and for M&E. When all stakeholders are engaged and collaborate symbiotically, countries will be better positioned to achieve the SDGs.
Resilience
Strengthening WASH infrastructure and behaviors can allow both governments and communities to mitigate the effects of natural disasters and climate change. The WASH sector can play several critical roles to cultivate resilience needed for reducing risks of infection spread and containing preventable diseases early during emergency settings. First, enhancing hygiene and sanitation infrastructure, and committing to regular maintenance in times of stability can help prevent damage to those facilities when disasters strike, thus limiting the prospect of failed substructures that could lead to rapid disease outbreak. Second, vulnerable, isolated, and geographically disadvantaged populations, who are most likely to suffer the most devastating and adverse effects, must have the means to mitigate environmental risks and health threats often caused when disasters occur and infrastructures fail.
Proper hygiene practices can help prevent diarrheal diseases and minimize health-related morbidity and mortality. Increasing awareness around the importance of handwashing with soap and safeguarding access to hygiene and sanitation services in health facilities, shelters, and throughout a community can provide affected and vulnerable populations the means to maintain hand hygiene habits during recovery and transition periods. To ensure effective promotion and delivery of essential hygiene and sanitation products and services, governments and humanitarian agencies must integrate WASH strategies into response guidelines and recovery plans, regardless of the type of disaster or setting.
Going forward
I would like to relay one final thought from my experience at the conference: Success is not the converse of failure, and we can learn a lot from both successes and failures. Reflecting on Dr. Gautam’s words, because I am not a behavior change expert or specialize in WASH program implementation, I find considerable value in attending this and similar conferences that share knowledge, learnings, and experiences. Taking those lessons learnt and incorporating them into my work going forward will enable me to better advocate on behalf of hygiene integration, gender equity, and handwashing with soap programming at scale.
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