1. Improving Hygiene at Scale

2. Overview Definition Principles Process Results Timeframe Characteristics Phases

3. What is Scale? Coordinated actions of all stakeholders working toward a common goal to significantly reduce disease rates in large numbers of affected people

4. Scale Principles Participatory Process-oriented Negotiation Informed decision-making Acknowledging & valuing Moving forward together in partnership

5. Process Reduce Diarrheal Disease 1. MAP 3. STRATEGIZE 5. MONITOR 6. VALUE 4. ACT 2. PARTNER 1. Map the context & detail the stakeholders in all sectors, the levels at which they work, the networks & relationships that already exist & examine patterns of individual & institutional behaviors. 2. Leverage partnerships, strengthen existing networks & relationships, & create new, non-traditional ones. 3. Develop a common goal & delineate a behavior change strategy. 4. Implement activities & interventions detailed in the strategy around the common goal in a concerted & overlapping way. 5. Track the progress of interventions to make adjustments, adaptations & changes as needed. 6. Assess the outcomes & impact of the scale effort.

6. Expected Results Increased percentage of targeted audience adopting and sustaining key improved practices Reduced number of diarrheal diseases cases Reduced percentage of children under 5 dying of diarrheal disease

7. Timeframe Map, Partner, Strategize – 8 to 15 months Act – 1 to 3 years Monitor – during action Value – at least yearly during action TOTAL Length Required – 3 to 5 years

8. Characteristics of a Scale Effort  Systems-Approach  Behavior FIRST  Multiples  Institutionalization  Hygiene Improvement Framework.  Coverage

9. Systems-Approach Emphasize: relationships and patterns of behavior that a small event in 1 sector can have a tremendous impact elsewhere key influence points Examine: the WHOLE relationships degrees of freedom mainstreaming patterns commonalities opportunities

10. Behavior First Focus on improving key individual hygiene practices Identify, promote and facilitate improved practices Design interventions that motivate and facilitate these improved practices Practices that people are willing and able to practice

11. Multiples Multiple interventions Multiple levels Multiple stakeholders Multiple options

12. Institutionalization Any organized stakeholder group Institutional policy adjustments Human resources, budget and integration commitments Continued support for activities “political will” Heart of sustainability Institutional behavior change desired  “Making something a new routine”

13. Hygiene Improvement Framework (HIF) Communication Social mobilization Community participation Social marketing Training Hygiene Promotion Water Supply Sanitation systems Available Household Technologies and Materials Access to Hardware Policy improvement Institutional strengthening Financing and cost-recovery Cross-sectoral coordination Partnerships Enabling Environment Hygiene Improvement Diarrheal Disease Prevention

14. Coverage QUANTITY Ensure Large-Scale through: Health impact realized Total population covered and/or Geographic area(s) covered QUALITY Ensure Sustainability by: Intervention concentration Activity saturation Systems interaction Institutionalization Critical mass behavioral impact

15. Well Construction Handwashing Promotion Latrine Construction Hygiene Advocacy Traditional Coverage Focus on Geographic and Population Coverage Scattered, dispersed, stand-alone

16. Scale Coverage Concentrate, saturate, interact Using a systems-approach, focus on Geographic Area, Population, AND Multiples.

17. WellsHandwashingLatrinesAdvocacy

18. Appropriate Approaches to Promotion Needed Infrastructure, Products, & Services Supportive Environment Ensuring all the necessary elements, increases likelihood of behavior change and the sustainability of the practice. Maximum potential for change exists here. Increase the Likelihood of Improved Practice Adoption & Sustainability

19. Map, Partner, Strategize Preparation Phase: Mapping Partnering Intervention zone(s) determination ‘Whole system in a room’ process Formative research (as needed) Behavior change (BC) strategy development Effort index design Resource identification

20. Solid Preparation is ESSENTIAL! Understand the context through mapping Clarify present partner roles Agree on geographic coverage Understand behavior change approaches used

21. Mapping WHAT –Understand the setting in which the effort will take place WHY –Take a systems-wide look to effectively assess options and implications of decisions HOW – Mapping: –Geographic –Dimensional –Associative

22. Issues to Map Water sources, access, quality & supply Sanitation access, quality & supply Partner areas of intervention & activities Partner relationships Geographic location of institutional staff and kinds of interventions Geographic areas of greatest need including health and non-health platforms Existing infrastructures, e.g. clinics, churches, SES indicators, e.g. income, gender, etc. Capabilities of ancillary agencies, e.g. universities, colleges, market places, roads, railroads, schools Market paths & streams per needed product Communication channels Donor program support

23. DRC – Before: Stakeholder Relationships SANRU MOH MOW Health Ctrs DistHealth Village Chiefs USAID Mobilizers DistWS Water Cmt Village Cmt

24. DRC – After MOW MOH USAID SANRU Water Cmte Health Ctrs Mobilizers DistWS EZdS Village Chiefs MOE 3 NGOs 2 CSOs DANIDAWB DistEd DistHeatlh MOEnv DistEnv Village Cmt

25. Partnering Who & How WHO: Start with stakeholders directly related to issue Expand to: –other channels of influence –groups with potential long-term impact –all possible information channels HOW: Make individual relationships within these groups, not just institutional relationships. Treat each group with respect.

26. Partnering Systems Examination Examine the systems and ask: “What needs to be done to turn you into a partner with an active or passive influence on the targeted audience?”  Training?  Institutional strengthening?  Capacity building?  Expansion of reach?  Other?

27. Intervention Zone Determination Consider systems-approach & Scale multiples Examine appropriate, relevant statistics: –Number of children under 5 –Diarrhea disease prevalence in under 5s –Access to water –Access to sanitation Detail geographically where partners are working Examine types of interventions by partner Choose together

28. Whole System in a Room Process Focus on the past Focus on the present Focus on the future Formulate common ground Make broad commitments Formulate action plans

29. Media CSOs Educational Institutions Commercial Businesses Mothers Government Ministries Donors/ Funders Religious Groups NGOs Develop Orgs R&D Institutions Using Hygiene Improvement to reduce diarrheal diseases Whole System for HI could include:

30. Research & Experience Form basis for key behaviors Allow for community involvement Behavior Analysis & Intervention Design Analyze behaviors & identify feasible with specific audience Develop broad activities for overarching intervention areas Make/Get specific commitments for interventions & activities Encourage continued community involvement BCS Development Process Strategy Design

31. Behavior Change Strategy A. Behavior Analysis :  actual  desired  feasible B. Delineation of Overarching Intervention Areas : 1.Communication 2.Training 3.Infrastructure/Service Improvements 4.Products/Equipment 5.Policy/Advocacy 6.Mobilization 7.Financing Based on motivators & barriers

32. Behavior Analysis DesiredActualMotivatorsBarriersFeasible Diarrheal Diseases Wash hands with soap & water and towel dry at 5 critical times. Wash hands occasionally without soap/ ashes, with used, dirty water and dry on dirty clothing. Access to safe water source Access to soap Clear understanding of importance Knowledge of steps required Support from immediate community No access to safe water sources Limited access to products needed Feel unimportant or unnecessary No community agents to help with questions or concerns Wash your hands with soap & clean water and air dry before eating. Audience: Mothers aged 18 to 30

33. Communication Activities Training Activities Infrastructure Activities Product Activities Policy Activities Mobilization Activities Financing Schemes Encourage mothers aged 18-30 to wash hands before eating with soap & clean water & air dry. Demos Flipcharts Experience of “healthy families” Manuals Complete education kit Educational games Theatre, songs Train agents: Proper hand washing Basic water issues How to conduct community meeting Train community members: Pump repair Soap making Provision of adequate safe water sources Soap Basins Soap making kits Wagons Advocacy on hand washing Inclusion of govt. in activities Contest for “clean family” Support associations Creation of water committees Community participation in decision making Delineation of Interventions Voucher system WATSAN collection

34. Act Implementation Phase: Systematic roll-out of hardware, promotion, and enabling environment interventions Assistance in implementing “mix” of behavior change approaches Technical assistance Plan Development Prepare implementation plans for interventions and intervention activities Develop clear management and roll out plan Implement Keep the community involved Implementation

35. Management Plan

36. Roll Out Plan Timing is essential Activities are interdependent Activities and actions build on other activities and actions

37. Monitor Monitoring Phase: Roll out on schedule Coverage and overlaps happening “Must do’s” occurring

38. Value Evaluation Phase: Sustainability Integration Partnerships Improved practices Desired impact

39. WHAT Indices to describe the types of program efforts and monitor them over time. A composite index designed to: –measure commitment and program effort –capture inputs and outputs A score made up of 3 main components (HIF) of an effective response: –access to hardware –enabling environment –hygiene promotion WHY Standard measures needed to quantify the nature strength of efforts/activities. Hygiene Effort Index

40. HIF Component Sub- component When Did Benefit Occur Beneficiary Level Attributes to Assess Access to Hardware Sanitation New Access Household Increase the percentage of households with new access to improved sanitation facility Community Increase the percentage of communities with new access to improved sanitation facilities School Increase the percentage of public and private schools with newly established handwashing stations near toilets/latrines in rural and peri- urban areas Renovated Access Household Increase the percentage of household with renovated access to (improved) sanitation systems Community Increase the number of communities with improved access to sanitation systems School Increase the percentage of public and private schools with renovated handwashing stations near toilets/latrines in rural and periurban areas How