WASHplus Year Five Annual Report, October 2015

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In its Year Five Annual Report, WASHplus has stories to tell, results to share, events to celebrate, and studies that add to the evidence base. WASHplus activities serve as the backdrop for many stories: the Zambian school girl who has access to privacy and menstrual supplies when she needs them, the Malian household that can now build an improved latrine on their rocky soil, the mother in Bangladesh who understands the importance of a feces-free environment, the Nepali home breathing cleaner air as it trials an improved cookstove. And perhaps more compelling than the individual stories are the results the project is beginning to record through endline data collection in Kenya and formative research on school enrollment and in Zambia. Providing water, sanitation, and hygiene (WASH) infrastructure to schools is having a notable impact on enrollment. Community-led total sanitation (CLTS) may be inoculating communities exposed to cholera. Numbers also tell the story of the project’s impact. Look for a snapshot of those figures throughout the report.

The conclusion of field activities in Uganda and Zambia this year provided opportunities to reflect, celebrate accomplishments through end-of-project (EOP) events, and share lessons learned. Several articles were published this year in peer-reviewed journals and others submitted on topics ranging from consumer preferences and willingness to pay for improved cookstoves to habit formation and costing of handwashing. WASHplus also played a key role in preparing the joint document on WASH and nutrition for publication and distribution.

WASHplus’s focus on integrating WASH into other development initiatives enabled the project to get in on the ground floor on subjects that are gaining traction at USAID and globally, such as WASH and nutrition, neglected tropical diseases, and MHM. This integration focus dovetailed nicely with the project’s mandate to serve a technical leadership role, and project staff had many opportunities this year to share its work and lessons from the field on a global stage, strategize with partners on important advocacy issues, inform policy, and develop guidance in multiple countries. Also toward that end, WASHplus launched its first two learning briefs on small doable actions and WASH and nutrition. This series details the variety of approaches WASHplus uses to improve WASH and household air pollution (HAP) across its portfolio of countries.

And finally, it’s been an exciting year for innovation with pilot projects underway in Ethiopia and Bangladesh focusing on sanitation marketing and sand envelopment. These two efforts will add to WASHplus’s body of knowledge on sanitation innovation and aligns closely with USAID’s global interest on the topic. WASHplus is also documenting its fecal sludge management work in Madagascar to tell the next chapter in that story.

WASHplus Project in Kenya Shares Experiences in Transitioning Workshop

By George Nyairo Obanyi, FHI 360

george_obanyi1About the Author: George Nyairo Obanyi is the Information Officer for FHI 360/Kenya based in Nairobi. George provides communications support to the country office and field programs.

The USAID-funded WASHplus project ended its four years in Kenya with an experience-sharing workshop for key stakeholders held in Nairobi on September 25th 2014.

Representatives from USAID, government, other partners and community members converged for the one-day event during which the project showcased its achievements through plenary presentations, video shows and a photo gallery.

Kenya is one of seven countries where the WASHplus project works with partners to create supportive environments for healthy households and communities by creating and delivering interventions that lead to improvements in water supply, sanitation, and hygiene (WASH) and household air pollution.

In Kenya, the project partnered with the Ministry of Health to strengthen the capacity in public and private sectors as well as communities to implement sustainable WASH interventions.

WASHplus introduced and successfully promoted the small doable action (SDAs) concept, which has been accepted by government and other WASH actors to encourage hand washing, use of latrines, menstrual hygiene management and water treatment and safe storage.

Another key WASHplus achievement was its pioneering role in promoting inclusive sanitation approaches under an innovative, value-added community-led total sanitation (CLTSplus) approach to promote open defecation free (ODF) communties, which was successfully piloted in two rural counties and one urban site.

In its role as a national mechanism, the project helped to develop policies and training guides including a training curriculum for WASH-HIV integration and a module for training community volunteers.

Other notable achievements include:

  • Over 650 trainers from government and 8,000 CHWs trained on WASH-HIV integration and inclusive sanitation through Community Strategy
  • Improving access to sanitary pads for girls and women in communities
  • Community volunteers and leaders trained to help make supportive devices for individuals with disabilities

Interventions initiated and supported by WASHplus have now been transitioned to the government and other USAID-supported health projects.

Kenya’s deputy Chief Public Health Officer Dr John Kimani addresses the WASHplus Kenya end-of-project experience-sharing workshop held in Nairobi on September 25th 2014. Photo: Elisha Ratem
Kenya’s deputy Chief Public Health Officer Dr John Kimani addresses the WASHplus Kenya end-of-project experience-sharing workshop held in Nairobi on September 25th 2014. Photo: Elisha Ratem

Speaking at the experience-sharing workshop, the Deputy Director for Public Health at Kenya’s Ministry of Health, Dr. John Kariuki, said the WASHplus program had made strategic contributions to improving WASH interventions in the country.

“County legislators should now invest money to continue the process,” he said. “As we have worked with WASHplus, we will as a Ministry continue to give policy direction and guidelines to the counties.”

Said Dr. Kariuki: “The biggest lesson is about equity and sanitation. We cannot talk about a county being ODF if the people who are disabled or the old people are not using latrines. They are Kenyans and have a right to sanitation.”

The official urged stakeholders to lobby county governments to allocate funds for WASH activities:  “It does not happen automatically. You must be proactive, not wait for thing to happen.”

Representatives of organizations that partnered with WASHplus also praised the project for helping to shape the WASH interventions. Charles Ngira of the NGO Plan International said: “We should be talking of inclusive CLTS, not just CLTS. This model will totally solve our sanitation problem.”

Dr. Kariuki called for integrated CLTS programs that promote practices such as hand washing, menstrual hygiene management, the work of traditional birth attendants and air pollution, among other aspects.

“Let’s use CLTS as a vehicle to ensure we improve the health of our people,” he said.

“Sanitation has improved but we need to address equity and inclusion,” said Dr. Mores Loopapit, deputy project director of the USAID-funded APHIAplus Imarisha. “There is need to consider health outcomes in studies on access to hygiene and sanitation.”

Simon Makori, associate director of APHIAplus Nuru ya Bonde, urged stakeholders to support community health volunteers because they play a critical role on promoting WASH practices.

“Community health workers should be engaged in income-generating activities for sustainability,” he said.

For more information about the project, visit the WASHplus Kenya page: http://www.washplus.org/countries/kenya

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WASHplus Kenya End of Project Experience Sharing Workshop and Report

From January 2010 to September 2014 WASHplus worked with the Kenyan government to generate demand for sanitation; improve water, sanitation, and hygiene (WASH) practices among all households; and introduce simple supportive technologies to vulnerable households. The project supported the Ministry of Health (MOH) and its partners to integrate improved WASH practices into HIV policies, programs, and training. To do so WASHplus worked within existing structures under the MOH, such as the departments of Environmental Health, Sanitation and Community Health Services and the National AIDS and STI Control Program, as well as with other U.S. government bilateral partners—the APHIAplus projects and Centers for Disease Control and Prevention partners.

The two WASHplus program components—integrating WASH into HIV and advancing improved sanitation uptake—worked together to improve WASH practices across Kenya. The program objectives were to:

  • Assist government and NGO programs in Kenya to integrate improved WASH practices into HIV policies and programs, with special emphasis on inclusive approaches
  • Support uptake of improved sanitation practices using a community-led total sanitation (CLTS)-plus approach
  • Help to build a vibrant private sector to address demand for sanitation especially focused on quality latrines that meet minimum standards

What started as an activity to integrate sanitation and hygiene practices into HIV/AIDS care and support programs has grown over the years into a holistic approach to prevent diarrhea among households at risk. USAID’s WASHplus project helped communities and households in Kenya make the connection between improved sanitation, healthy hygiene habits, and positive outcomes for people living with HIV and AIDS (PLHIV), their families, children, the elderly, and other vulnerable households. Along the way WASHplus technical support, participatory training, partner engagement, and behavior change efforts yielded valuable lessons for other countries battling to improve sanitation and health outcomes in the context of uncertain funding. Innovation, flexibility, and commitment to working hand-in-hand with the government proved to be keys to the project’s success. With the government’s endorsement and adoption of WASHplus’s signature approach, small doable actions are likely to continue to resonate with many audiences long after the WASHplus transition.

On September 24th the WASHplus Kenya project held an end-of-project experience-sharing workshop in Nairobi. Photos from the workshop are presented below. The WASHplus Kenya end-of-project report “Integrating WASH into HIV Interventions and Advancing Improved Sanitation Uptake” can be downloaded from the WASHplus website.

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Kenya’s deputy Chief Public Health Officer Dr John Kimani addresses the WASHplus Kenya end-of-project experience-sharing workshop held in Nairobi on September 25th 2014. Photo: Elisha Ratem
Kenya’s deputy Chief Public Health Officer Dr John Kimani addresses the WASHplus Kenya end-of-project experience-sharing workshop held in Nairobi on September 25th 2014. Photo: Elisha Ratem
Kenya’s deputy Chief Public Health Officer Dr John Kimani addresses the WASHplus Kenya end-of-project experience-sharing workshop held in Nairobi on September 25th 2014. Photo: Elisha Ratem
Caroline Vata, a government public health officer, presents a case study during the WASHplus Kenya end-of-project experience-sharing workshop  of in Nairobi September 25th 2014. Photo: George Obanyi
Caroline Vata, a government public health officer, presents a case study during the WASHplus Kenya end-of-project experience-sharing workshop held in Nairobi on September 25th 2014. Photo: George Obanyi
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Evelyn Makena, WASHplus manager in Kenya, makes a presentation during the end-of-project experience-sharing workshop held in Nairobi on September 25th 2014. Photo: George Obanyi
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Charles Odira of Plan International makes a point during the plenary session of an experience-sharing workshop held in Nairobi on September 25th, 2014 to enable other partners scale up its approaches. Photo: Elisha Ratemo
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A community health volunteer admires his own photo displayed in  gallery showcasing achievements of WASHplus program in Kenya. This was during the Kenya end-of-project experience-sharing workshop held in Nairobi on September 25th 2014 to enable other partners scale up its approaches. Photo: Elisha Ratemo
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Public Health Officer James Yatich explains about a commode he improvised for chronically ill patients. The innovation was displayed in a gallery showing the works of WASHplus program in Kenya over the past four years. Photo: Elisha Ratemo

Kenya – Ministry alarmed by ‘long calls’ along highways, to build toilets along Nairobi-Nakuru highway

Sanitation Updates

Kenya – Ministry alarmed by ‘long calls’ along highways, to build toilets along Nairobi-Nakuru highway | Source: by Antony Gitonga, Standard Digital, Aug 8, 2014 |

NAKURU COUNTY: The ministry of health has expressed its concern over the high number of people who defecate in the open mainly along the main highways in the country. Following the revelation, Nakuru County has announced plans in major centres along the Nairobi-Nakuru and Naivasha-Mai Mahiu road to construct public toilets. According to the department of health, the open defecation was one of the leading causes in the increase in the number of typhoid and diarrhoea cases in the county.

Nakuru County director of health Dr Benedict Osore with county public health officer Samuel King’ori and USAID's WASHplus project manager Evelyn Makena examine some chairs used for defecation for the disabled at Longonot village in Naivasha. He said that around 300 of the 1,949 villages in the county had been declared open defecation free.  [PHOTO: ANTONY GITONGA/STANDARD] Nakuru County director of health Dr Benedict Osore with county public health officer Samuel King’ori and USAID’s WASHplus project manager Evelyn Makena examine some chairs used for defecation for the disabled at Longonot village in Naivasha. He said that around 300 of the…

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WASHplus Attends National Sanitation Conference in Kenya

In April 2014, the Ministry of Health in conjunction with partners hosted the 1st National Sanitation Conference in Nairobi, “Accelerating Access to Improved Sanitation under Devolution: Making the Right a Reality.” More than 200 participants from 47 counties attended, including county health officials and NGO and development partners. As a key partner in the sector, and the national facilitator for the Hygiene Promotion Technical Working Group, WASHplus/Kenya played a major role in planning and preparing for the conference. WASHplus exhibited various products, including WASH-HIV integration training guides and job aids, fact sheets, posters, banners, and success stories. Samples of improvised toilet seats created to improve sanitation access and tippy taps were also displayed. The small doable actions and inclusive sanitation concepts elicited a lot of interest; participants about taking the concepts to scale in other counties. This conference marked a turning point for Kenya as the country seeks to make the right to sanitation a reality as stipulated in the constitution of Kenya 2010. Cabinet secretaries from each of the 47 counties have since committed to increased budgeting for sanitation.

Below, Evelyn Makena, WASHplus Kenya country program manager, talks about the WASHplus program with Cabinet Secretary for Health James Macharia at the National Sanitation Conference in Kenya. Photo credit: George Obanyi/FHI 360.

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Simple Commodes for HIV/AIDS Patients

James Yatich, a public health officer in Kenya’s Central Province, has been supporting frontline community health workers involved in home-based care for people living with HIV.

James realized that bedridden clients who could not use the toilet on their own posed a major challenge. “When I told them that they had to use the toilet to prevent diarrhea, they asked me how?”

In June 2012, James finally found a solution after attending a WASH-HIV integration training workshop organized for government public health officers under the USAID-funded WASHplus project. During the training, participants learned about the small doable action approach and supportive technologies to improve water, sanitation and hygiene practices.

Small doable actions are incremental, feasible steps to improve practices. Using knowledge acquired from the training, James returned home and started working on the design of a simple aid to help bedridden patients and the elderly “go to the toilet” in a dignified way. The result was a homemade commode that can be made from locally available materials and yet ensure proper disposal of fecal waste.

“I sketched a design and asked a carpenter to make one piece for demonstration,” says James. “We used mainly leftover pieces of wood and furniture and the cost came to just 200 shillings (about US $ 2.50). But the cost can be negligible if the materials are available in homesteads.

The improvised seat is placed where the patients can easily reach it and lined with disposable plastic bags that are readily available. It can be used by bedridden clients and the elderly, especially those who are overweight and cannot easily be supported by others.

“We don’t see very many bedridden patients, but even one such patient can pose a big challenge to the family and needs assistance,” says James.

According to James, the technology gives patients independence and dignity as they do not need a caregiver to hold them on the toilet seat. It also allows the caregiver to do other chores rather than take the patient to the toilet – which can happen frequently for patients with diarrhea.

Asked why he had not thought of the solution earlier, James says: “It could not have been developed earlier because we were not able to conceptualize the link between hygiene and HIV until we went for the training.”

James now wants to share his idea and is looking to work with local stakeholders to train community health workers to make the portable toilet seats for their clients.

Central Provincial Public Health Officer Samuel Muthengi says the region has high latrine coverage at 97 percent but usage is a challenge for bedridden patients and the elderly. If such a simple technology is replicated, it can help improve disposal of fecal waste.

See a demonstration of a simple commode made with easy to find materials. It can be used by elderly with limited mobility or HIV/AIDS patients or others who are weak and unable to walk far. 


A String, a Jug, and a Bucket

Blind Danson Mwangi walking to the latrine using the string 6

In Kenya WASHplus and the Ministry of Health (MOH) are training community health workers and recruiting natural leaders to advance sanitation among vulnerable households. Using a small doable action approach, trainees work with households to make simple  improvements to ensure all family members can access a latrine and a hand washing station. This often means that community health workers are improvising and innovating to help address the particular needs of a given family. The following three stories illustrate simple innovations that made a profound impact on individuals’ lives.

WASHplus Toilet Solution Puts a Smile on a Grandmother’s Face

Maria Njeri sits by her bed with an eager face.  Said to be over 100 years old, she is blind and cannot walk. A team from the USAID-supported WASHplus project and the Ministry of Health is visiting the grandmother in the Maai Mahiu area of Nakuru County in Kenya’s Rift Valley region. They want to find out first-hand how community health worker volunteers trained by the project are helping Maria cope with the daily challenges that elderly people like her face.

When her daughter and granddaughter are away during the day, she has no one to help her to the latrine, located a few meters from the house. A small bucket indoors is her only alternative, but it is not easy to use because of her old age and ailing legs. The strain can be unbearable and sometimes she does not make it to the bucket in time.

The WASHplus program trains public health officers and volunteers to find alternative solutions to make it easier for elderly people like Maria to practice good hygiene. Maria’s plight came to light when local volunteers went round the village to educate people. They helped the family members devise a solution to Maria’s mobility problems—an improvised toilet seat with the bucket fixed at the bottom, which is comfortable and easy to clean. The team also attached an arm string to the roof to help Maria stand and exercise. Her joy is evident. With regular exercise the pain in her legs is gone and she no longer dreads using the toilet.

Maria’s neighbors, also elderly women in their 60s and 70s, have also benefitted from the intervention. One neighbor, Naomi Muthoni, describes what she learned at a community meeting: “We were taught that after every visit to the toilet, you must wash your hands with water and soap, or use ash. We wash hands all the time and make our children also wash their hands. Our children used to defecate openly in the garden and in the bushes around our homesteads,” she adds. The community is strict about reminding them to use latrines and ensuring that all neighbors have tippy taps (a simple water-saving hand washing device) installed. Since these approaches were adopted, the community has seen a reduction in diarrhea among its children.

Elderly Mother and Son Benefit from Simple Innovation

At 80 years old Leah Njoki still has the energy to do most of her chores and work on her small farm; her only problem is failing memory and pain in one of her legs. Mrs. Njoki was among the first people to adopt the good hygiene practices promoted by WASHplus after a visit by health worker volunteers, who were promoting community-led total sanitation.

Mrs. Njoki says health workers taught her how to keep her latrine clean and the importance of using it instead of defecating in the open to prevent disease. A lot has changed since that visit. She recalls days when she never washed her hands after using the latrine. Sometimes she would wash in kitchen containers, not knowing the health risks. Now she and her grandchild always wash their hands after visiting the toilet using soap or ash. She has installed a tippy tap near the toilet. Previously she used to put water in a basin for hand washing. The same water was used over and over.

The grandmother has also benefited greatly from an arm string that health workers fixed in the latrine to help her support herself and reduce the strain on her bad leg. “Whenever I have a problem getting up, I support myself with the arm string” she says.

Mrs. Njoki’s second son, Paul Mwaura, who lives in another district, is amazed by the innovations his mother has adopted. Paul’s right leg was amputated following a road accident in 2003, and he walks with crutches. Using the pit latrine is usually a big challenge because he has to balance on his good leg. He found out that with the string, he can balance with ease. “These days when I go to the toilet I don’t fear falling down, since there is a string to support me. Now if I find someone else with a problem similar to mine I will inform them also about the innovation,” he says. Mr. Mwaura plans to install a string for support in the latrine back at his new home along with a tippy tap.

A Simple String Solves Problem for Blind Youth

Three years ago Danson Ndung’u was a popular mechanic and driver in Nairobi’s biggest slum Kibera. Today he can neither drive nor fix cars. The 20-year-old’s career ended when a violent mob beat and blinded him during election year violence in 2010. The attack changed Danson’s life for good, ending his promising career, independence, and ability to support his mother and four younger siblings.

After three months in the hospital, he struggled to adapt to the fast-paced lifestyle of home and moved to a quieter rural area, Sision Village in Maai Mahiu, Rift Valley, to live with his married elder sister. In the serenity of the village, Danson slowly began to cope with life as a blind person. He enrolled in a knitting course at Thika School for the blind.

Whenever he came home for holidays, Danson felt robbed of his privacy. He felt helpless having to depend on somebody to get him to the toilet, a few meters from the house. Even though he has learned to use a white cane, he still finds it hard to move around at home because of the rocky terrain.

Peter Maina Njoroge, a WASHplus-trained volunteer, visited Danson’s home and heard about the challenge Danson faced reaching the toilet. Although Mr. Njoroge and his colleagues had not come across such a problem before, they quickly came up with a solution. They tied a blue nylon string running from the house to the toilet to guide Danson. This simple modification worked. Two months later Danson reports, “I can now go to the toilet alone even when there is no one around. Before I used to wait for them to come from the farm so that one could come and help me.”

Although he still faces many challenges in moving around his village, the simple string has eased his life and given him back his privacy. To him it is a step toward regaining the joyful life he once had.

Monitoring and Evaluation of the Jiko Poa Cookstove in Kenya

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Photo Credit: Paradigm Project

The WASHplus project also works towards testing new and innovative approaches and tools for implementation of high-impact indoor air quality interventions. in 2012, WASHplus funded Berkeley Air Monitoring Group to evaluate the Jiko Poa stove, a locally manufactured rocket-type biomass cookstove being distributed in Kenya by the Paradigm Project, a social enterprise. 

The aim of this study was to provide a performance assessment for the Jiko Poa in Kenyan homes by analyzing its effects on household air pollution and fuel use, and by collecting qualitative and quantitative data on how the households valued and used it.The evaluation results are expected to assist the USAID mission in Kenya and its implementation partners as they work to scale-up improved biomass stoves and to inform the sector more broadly on the field performance of rocket biomass stoves in Africa.