Supporting the Project Soaiegna – A Community Led Approach to Address the Urgent Sanitation Situation in Ambinanikely, South East Madagascar
Project location: MADAGASCAR, Ambinanikely
Project start date: June 2012 - Project end date: September 2013
Project number: 2012-042
This project is an immediate health intervention for people living in the urban commune of Fort Dauphin in the remote Anosy region of Madagascar. Madagascar is one of the most impoverished and least developed countries in the world: 77% of its 20 million population now live below the poverty line ($1.25 per day); it ranks 151/187 in the UNDP 2011 Human Development Index and is the 10th poorest country in terms of purchasing power per capita (IMF, 2011). Further, national figures for 2010 show the second highest level of poverty since measurements began in 1993 (UNICEF, 2011), and a drop in government health spending of some 75% since 2008 (IRIN, 2011). Less than 11% of the Malagasy population have access to improved sanitation facilities (UNICEF, 2011), well below the average for sub-Saharan Africa. The impacts of this are worst among Madagascar's 10 million children, the majority of whom live in rural areas. Diarrhoeal illnesses are the second major cause of child mortality, while poor hygiene is linked to typhoid, polio, acute respiratory infections and trachoma - the most common cause of blindness from infection. Diarrhoeal illnesses also hinder both economic and social development through the loss of some five million working days and three million school days every year in Madagascar (World Bank, 2011), and poor sanitation impacts negatively on the natural environment, considered one of the country's most significant assets and a critical factor in its future economic development. Improvements in the field of public health and sanitation are recognised as among the greatest challenges to the country's development and are a priority objective in the Madagascar Action Plan, a national strategic document developed in response to the Millennium Development Goals; however, the effects of the ongoing political impasse have significantly reduced the capacity of government bodies to fulfil these commitments, with public services investment and maintenance spending cut by 67% (World Bank, 2010) and widespread major cuts in international donor support which had previously formed half of the total national budget (World bank, 2011).
Within the Anosy region in south east Madagascar, facets of chronic poverty are seen at their most extreme with over 90% the population living below the poverty line. Health and education facilities are seriously underfunded and the region suffers some of the highest rates of illiteracy (over 80%), illness and disease, while the average annual population growth rate of 3.1% - compared with national average of 2.8% - places even greater pressure on already inadequate resources. 4 in 10 children die before their 5th birthday in Anosy, a staggering child mortality rate maintained by a cycle of open defecation, surface water pollution, poor hygiene practices, diarrhoeal illness and subsequent malnutrition: in 2009 Azafady partnered with the World Food Programme to distribute food aid to more than 90,000 pregnant women and children throughout the region following a crisis that prompted an international emergency response.
Fort Dauphin is the urban centre of the Anosy region. The majority of the town live in crowded residential quartiers, or fokontanys, and water and sanitation infrastructures do not reach the level of the household. The population of this small town has exploded in recent years as impoverished people migrate from rural areas in search of some form of employment; with the initial construction phase of a huge mining development in town now over, however, the job opportunities associated with its development are inaccessible to the majority of the local population and unemployment is a massive issue. As a result of over-crowded living conditions along with lack of access to and understanding of the importance of latrines, the practice of open defecation is widespread in Fort Dauphin, posing a major health hazard to both its people and its environment. In recent years the situation has become critical as open defecation has spread to the shores of Lac (lake) Amparihy which connects to Lac Lanirano and the town's water supply, increasing the urgency of need for intervention. However, regional taskforces previously established to coordinate health service delivery are no longer operational, and there is a chronic lack of coordinated and focused health interventions to counter an ever growing need in the local population. Within this context of deteriorating state and institutional capacity, the role of grassroots NGOs such as Azafady in building the capacity of communities to safeguard their and their families' health is increasingly important.
This project, which received a grant from the Nando Peretti Foundation, will address the following issues.
1. Methodology and operational procedures
Project Soaiegna has been developed as a result of ongoing community requests, and aims to address the urgent sanitation situation in Ambinanikely, one of the poorest fokontanys in Fort Dauphin where the majority of households do not have access to a latrine and so use public spaces including alleys and beaches to defecate. It will directly benefit 4,000 people, with indirect benefits extending across the community - some 70,000 people - generating sustained demand for latrines as households in neighbouring fokontanys hear of the project's success. The project utilises an approach combining sanitation infrastructure provision with participatory activities to facilitate lasting hygiene behavior change; an approach developed as a result of previous project evaluations which have highlighted that didactic education is ineffective in facilitating actual and long-lasting behaviour change, and that increased knowledge does not necessarily result in a change in communities' health and hygiene practices. Barriers to communities changing deeply entrenched habits are often tied to long-standing cultural beliefs, and motivating factors are more closely related to convenience, status, esteem and financial gain than perceived health benefits, particularly in the face of recurrent economic and social crises to which impoverished communities in Anosy are frequently subject. Within Anosy culture, strong taboos exist around the subject of defecation, posing difficulties to any project attempting to address this issue, and people hold to traditional beliefs that open defecation is a cleaner alternative to managing faeces disposal within the home. Further, the chronic poverty in which the majority of Anosy communities live compounds this situation - daily, tangible survival needs take precedence over consideration of micro-bacterial disease transmission which, unlike other survival factors, is neither visible nor immediate in its effect. As a result of ongoing evaluations, Project Soaiegna will therefore combine subsidised infrastructure of individual SanPlat latrines with a participatory and community-led awareness raising and behaviour change programme.
The design of the SanPlat latrine incorporates concrete-lined pit (vital in sandy and unstable soils), a concrete slab with foot rest and drop hole, and a superstructure containing a PVC ventilation pipe. In 2008 Azafady secured funding for a pilot project to provide 25 SanPlat latrines to the community of Fort Dauphin, an initiative that was expanded in 2010 to a further 180 households. Having trialled several forms and levels of community contribution (vital in securing a sense of ownership of the project within the community) with varying levels of uptake from the community, Azafady have most recently set the community contribution at 5,000 Ariary (approximately £1.50), with all other inputs provided by Azafady. Evaluations have shown high levels of uptake and sustained use of the latrines, and Azafady now has a waiting list of some 100 people who have requested a SanPlat latrine.
Provision of sanitation infrastructure alone, however, is not enough and it is vital that hygiene behaviours are improved in order to ensure sustained use and maintenance of any sanitation infrastructure. Over the last 12 years, Azafady has worked with 60 rural communities across the Anosy Region in the provision of health education - an activity that has traditionally relied on the PHAST (Participatory Hygiene And Sanitation Transformation) approach through which communities are guided to identify their own health issues and potential solutions through a process of learning about routes of disease transmission and modes of prevention. However, ongoing evaluations have shown that this approach is not effective in facilitating long term behavior change. This has been recognised by the national WASH network in Madagascar which is now promoting an innovative approach called ‘Community-Led Total Sanitation' (CLTS) as an alternative to the traditional PHAST methodology. Facilitated by a trained community health agent, CLTS taps into the motivating factors of pride and esteem, and motivates whole communities to confront their practice of open defecation, resulting in immediate community responses to address their sanitation needs. While CLTS is designed specifically for use in rural communities, there are elements of the approach and activities that are transferable to urban communities to similarly stimulate a robust collective response to their sanitation needs. Azafady has already implemented CLTS successfully in rural communities; Project Soaiegna will draw on lessons learned from this process along with over a decade of experience of implementing community health interventions in Anosy, piloting the first ever combined CLTS and infrastructure project in Fort Dauphin.
The initiative will contribute to the achievement of the Malagasy government's regional objectives in the fields of community health and environment, enabling it to work towards meeting national and international development targets including the Millennium Development Goals, and as such has the full support of the Ministries of Health, Environment and Tourism.
2. Project activities
1. Consultation with local opinion leaders
In January 2012 a delegation from Azafady's Community Health department visited Ambinanikely's chef de fokontany (head of the fokontany) to identify the households most in need of improved sanitation. It was found that there are more than 200 households keen to participate in this project and willing to use a latrine. At the start of the project, another meeting will be held with the chef de fokontany and other local opinion leaders to introduce them to the project methodology and ensure their support for the project.
2. Awareness raising and community mobilisation
Following these consultations, a number of community sensitisation and mobilisation activities will be carried out by Azafady's skilled community agents in conjunction with local opinion leaders to ensure that community motivation is sufficient to produce significant and lasting hygiene behaviour change. The evaluation of an urban sanitation programme implemented by Azafady last year indicated that there are a number of factors that encourage community members to want to build, use and maintain a latrine, including the convenience of having a latrine close to home (53%), the privacy of using a latrine in comparison to defecating in the open (44%) and the reduction in diarrhoeal diseases and consequent health benefits (66%). In order to capitalise on these motivating factors, community mobilisation - in addition to hygiene education (see Activity 3) - is essential.
Activities will begin with an introduction to the project using a CLTS approach in order to immediately engage all participants. A transect walk will be conducted with community members through common open defecation sites in the area, at each of which the community will be asked respectful but provocative questions about transmission routes from faeces to water sources or animals, and other ways into human food or drink. The method is not to lecture but to stimulate discussion to explore sanitation issues, particularly drawing on the strong emotions of pride and shame.
Following this a process of community action planning will be facilitated by Azafady's agents, in which community members develop and agree on activities and a timeframe to address open defecation in their community. Particularly motivated members will be identified and encouraged to work with other households in their hamlet to support the transition to latrine use. Common barriers to latrine use will be discussed, and the community will be encouraged to work collaboratively to identify possible solutions to these. As part of this planning, the community will be led through a process of open defecation site mapping, creating a map of the geographical features and common defecation sites in their community, many of which they will have just walked through. The community will encouraged to adapt the map as people begin building and using latrines (see Activity 4), and defecation sites are cleared. This map, displayed in the chef de fokontany's office for all to see, will be a visual record of each household's sanitation status, providing a source of additional community motivation. The progress of these maps will be supported by Azafady's community agents and once the fokontany is considered to be totally open defecation free, a high profile celebration will be held and a community totem provided, decorated by the community themselves with a celebratory message.
3. Hygiene education
In addition to these community mobilisation activities, Azafady's community agents will also provide hygiene education to each participating household through focus groups and household visits. The purpose of these discussions will be to support motivational activities with simple information relating to routes of disease transmission and the role of latrines in preventing this.
Azafady's community agents will also run workshops at primary schools in the fokontany to reinforce the messages being given to the community and encourage children to adopt safe hygiene practices from a young age. Positive and negative hygiene behaviours will be identified by pupils through a variety of interactive exercises such as plays and songs that promote the importance of hand washing and the use of latrines.
4. Provision of household sanitation infrastructure
Azafady will provide materials and construction support for 200 subsidised latrines to some of the poorest households in the fokontany. With recent project evaluations showing that around 20 people use each household latrine provided by Azafady, 4,000 people are expected to benefit from these latrines. The latrines are specifically designed for the local context and are simple to build, easy to clean and cheap to maintain. Each one consists of concrete ring to line and reinforce the pit, a concrete foot slab with a drop hole and PVC ventilation pipe, and a shelter for privacy. In previous projects Azafady has trialled a variety of forms and quantities of beneficiary contribution towards subsidised infrastructure to ensure ownership whilst maintaining accessibility for the poorest members of the community. The most successful form of this to date, and the approach that will be used in Project Soaiegna, is to ask each household to contribute 5,000 Ariary (approximately £1.50) along with their labour in digging the hole and building the structure. Azafady will then construct the concrete foot slab, supply all the other materials, and provide any technical guidance needed.
Monitoring from previous projects has indicated that it takes 20 people an average of 9 months to fill a 1.8m deep latrine - the minimum time anticipated as required to establish sustained behaviour change through repeated use and association of the latrine with benefits including convenience and status. Once the latrine is full it requires emptying, a crucial stage at which, as a result of deep-set cultural taboos around faeces and cleanliness, households are more likely to revert to open defecation. Maximising the period before emptying the latrine is required is therefore vital, as is the provision of targeted support in preparation for the time when the latrine will become full. For households reporting a number of users in excess of 20, the project will therefore encourage the construction of multiple or larger latrines, promoting the message that the greater the size or number of latrines per family, the less frequently they will require emptying. Practical latrine maintenance training will be provided to recipients of subsidised latrines along with an information booklet in the local dialect detailing how families can empty their latrine. Previous studies show that the majority of families who do not revert to open defecation are more likely to pay someone to empty the latrine rather than empty it themselves. The cost of this is approximately 20,000 Ariary (£6) per latrine, which will be detailed in the information booklet and promotional sessions, encouraging the adult users of each latrine to work together to collect this amount once each year in order to facilitate its ongoing use. Combined with this project's activities promoting behaviour change, it is anticipated that tackling the issue of emptying the latrine in this way will provide all the necessary motivation and support for communities to continue using their latrine beyond the point of it first becoming full.
5. Monitoring and evaluation
Monitoring and evaluation will be an integral and ongoing part of Project Soaiegna, feeding back directly into project implementation. A comprehensive work plan has already been established, with target outputs and outcomes agreed, and measures identified to locate where communities are on the behaviour change spectrum. Important qualitative information, including attitudes relating to sanitation and hygiene practices, will be gathered by project staff through interactive feedback sessions and semi-structured interviews with local opinion leaders, participating households and school children. Monitoring will be undertaken by the beneficiaries themselves with support from project staff and Azafady's Head of Community Health and Head of Project Development, who will also conduct field visits to the communities to evaluate project progress. Azafady's agents will hold regular meetings with the chef de fokontany and other local opinion leaders to coordinate these activities and ensure their continued involvement. Analysis of indicators achieved relative to target outputs and outcomes will be undertaken in project team meetings with Azafady's Head of Community Health and Head of Project Development. These meetings will be an opportunity to discuss general project progress, evaluate the effectiveness of the approach, identify areas for improvement or adaptation as necessary, and reflexively develop appropriate strategies to further support each community as they move towards eliminating open defecation. Monitoring data will be collated on a monthly basis, quarterly reports will be made available to all stakeholders, and a mid-term and final report will be produced for the donor. Detailed financial monitoring will be in place as with all Azafady projects.
Azafady anticipate the following outcomes from this project:
• 200 households in Ambinanikely are motivated to build, use and maintain latrines
• Ambinanikely residents implement their own community action plan to eliminate the practice of open defecation in the fokontany.
• Ambinanikely residents monitor their progress towards becoming open defecation free using their community defecation maps.
The effects of Project Soaiegna are expected to reach well beyond the fokontany of Ambinanikely as neighbouring communities see and hear about the project and learning from the project is shared with family and friends. This has been strongly demonstrated with Azafady's recent rural CLTS projects where extensive "tache d'huile" (ripple effects) have been experienced around project sites, with nearby communities requesting support to become open defecation free themselves and even starting the process on their own in some cases.