What is needed to promote behaviour change along the sanitation value chain? Report of a WASH Debate.
The Netherlands WASH strategy includes Community-Led Total Sanitation (CLTS) as a key approach to end open defecation. At the same time it recognises that sustaining hygienic behaviour over time remains a challenge as confirmed by a recent study in Odisha, India. The strategy mentions complementary approaches and methods to climb the sanitation ladder and develop the sanitation value chain: supply side development, "sanitation marketing, financial inclusion and strengthening of local institutional frameworks".
Building institutional capacity for behaviour change was the topic of a WASH Debate jointly organised by IRC and IHE Delft. The debate attracted some 90 sector professionals to The Hague on 11 September 2018 and over a 160 viewers who followed or replayed the Twitter livestream. Participants engaged in a lively discussion with lecturers from IHE Delft’s MSc Programme in Sanitation.
Watch a short introduction to the WASH Debate by the three presenters: Kamal Kar, Om Prasad Gautam and Lisa Taing.
The renowned pioneer of the Community-Led Total Sanitation (CLTS) approach Dr Kamal Kar presented his ideas on fast tracking nations to become open defecation free (ODF). Many villages are now ODF but this has not been scaled up to district and state levels. The CLTS approach of triggering behaviour change at community level needs to replicated at the institutional level – a process that takes 4-5 years.
Dr Kar mentioned Benin as a showcase for institutional triggering. By involving several ministries, 100 villages becoming ODF within six months. IRC Associate George de Gooijer tells this success story in his blog “Starting rural sanitation in Benin with CLTS: how it became a game-changer”.
Moving up the sanitation ladder requires institutional handholding, says Dr Kar. This becomes easier if you can piggyback on villages where community power already helped to achieve ODF status. How this all fits together is the topic of a new book by Dr Kar called “Scaling up Community Led Total Sanitation: From Village to Nation”. Watch Dr Kar's presentation and see his PowerPoint.
WaterAid has 20 years experience in hygiene behaviour change and is now focusing on promoting hygiene behaviour change at scale. Senior WASH Manager Dr. Om Prasad Gautam provided an overview of what works and doesn’t work in behaviour change:
What doesn’t work
Systematic approach and intervention based on emotional drivers (disgust, status, nurture, affiliation)
Use of health, germs/diseases, death related messaging
Intervention based on change in behavioural settings (disturbing settings)
Training or education only
Motivation + law enforcement (urban context)
Distribution of posters, leaflets, caps, t- shirt only; or Messaging through media only
Umbrella campaign with identity led by Govt with full support from multiple partners
Single blanket approach to everyone implemented without institutional leadership
Two WaterAid-supported national hygiene promotion programmes presented by Dr Gautam are worth highlighting. The first programme in Nepal embedded hygiene promotion in an immunisation programme that reached mothers at least five times in the critical first nine months of their children’s life. Check the video below to see how this worked in practice:
The second programme Dr Gautam referred to is Pakistan’s National behaviour change campaign on WASH. Targeting 90 million people, the programme focused on strengthening health systems and behaviour change rather than raising awareness. Both programmes were fully government (Ministry of Health) owned. Watch Dr Gautam's presentation and see his PowerPoint.
Both Dr Kar and Dr Gautam are guest lectures for the 2 week course module on Behaviour Change and Advocacy, which is part of IHE Delft’s MSc Programme in Sanitation. IHE Delft researcher Dr Lisa Taing is Coordinator/Lead Lecturer for the module. She stressed that institutions are crucial to sustaining behavioural change throughout the entire sanitation value chain: from toilet access to emptying and transport, treatment and disposal or reuse. Institutions do this by supporting programming, research and different behaviour change strategies. The Behaviour Change Wheel (BCW) can be used a guide to design interventions. Watch Dr Taing's presentation and see her PowerPoint.
Following the three presentations participants and presenters engaged in a lively discussion on behaviour change in different contexts and institutional capacity building.
Behaviour change in urban areas
Compared with rural areas, the urban context is more complex. In urban areas you are confronted with unauthorised settlements, public toilets and a greater variety of supply chains. This makes it even more important to involve institutions, especially local authorities at an early stage. Dr Gautam gave examples from urban Nepal on the use of hygiene message reminders (nudges) on mirrors and baby bibs (see image below).
Fragile states and weak/corrupt institutions
What do you do when government institutions don’t exist or are weak? Dr Gautam admitted that governments may be weak but they still have the ability to scale. WaterAid’s strategy is to strengthen systems rather than create parallel ones. Dr Kar gave the example of refugees who come from ODF villagers and will benefit from their experience in behaviour change once they end up in camps. Strong NGOs can have a positive impact, said Dr Taing, if they know to choose the right setting – the “power of settings” determines 90% of our behaviour.
A participant mentioned it took 4-5 years in North East Ghana to get people to wash their hands. Dr Kar blamed NGO crowding in a limited number of districts for low ODF rates at regional level in Ghana. He suggested allocating NGOs evenly over all the districts. Dr Gautam said an intervention time frame of 1 year is too short. It’s better is to institutionalise behaviour change through a programmatic approach exposing people several times a year over a 3-year period.
Sanitation costs can deter uptake. Costs can be reduced by introducing sanitation marketing and offering different technology options.
Building institutional capacity
What do you do when users demand silver bullet solutions? Dr Taing told the story of the inhabitants in low-income areas of Cape Town, South Africa, who demanded full flush residential toilets instead of the “2nd rate” portable toilets they were offered. To temper their resistance, authorities introduced a system that focused on the full sanitation chain involving regular toilet emptying and waste disposal. Dealing with this kind of situation requires a set of skills that cover negotiation and conflict resolution, policy making and documentation, writing tender documents and understanding public health.
Moderator Stef Smits from IRC summarised the key conclusions of the WASH Debate on how to institutionalise the capacity to promote behaviour change. Short-term projects are not going to do the trick: we need to build and strengthen national systems in the sector. That is difficult in low capacity contexts and in fragile states, but there are examples where it can work. At the other end of the spectrum are urban areas where the institutional setting is complex and you need to trigger various people along the sanitation value chain. Institutionalisation of hygiene behaviour change is not only or not at all happening in the WASH sector. The examples from Nepal and Pakistan show that it does happen where there are established institutions in the health and education sector, which have a larger reach and work at scale. Institutional triggering starts by creating political leadership and developing the necessary skills.
Secondly, it is not only about institutionalising behaviour change to get on the sanitation ladder but also across the entire sanitation chain. This requires linking up complementary approaches such as CLTS, sanitation marketing and other supply chain measures in combination with tools including enforcement, rules and nudging.
Watch the full recording of the WASH Debate below.
Recorded live stream @ircwash / @ihedelft #WASH Debate: “Building institutional capacity for #behaviourchange & #sanitation programming", 11 Sept 2018 with Dr Kamal Kar, CLTS Foundation; Dr Om Prasad Gautam, WaterAid; and Dr Lina Taing, IHE Delft https://t.co/H8EP3TNJse— dietvorst (@dietvorst) September 26, 2018
You can find the three presentations under Resources.
Acknowledgements: Livestream and video: Dechan Dalrymple, review/editing: Stef Smits and Tettje van Daalen.