WASHplus Presents Poster at ASTMH 2015

Renu at ASTMH 2015

@wasplusinfo’s Renu Bery presents a poster on integrating into at 2015 ASTMH Meeting!

In October 2015, WASHplus presented a poster at the American Society of Tropical Medicine and Hygiene Annual Meeting on the current situation, intervention design, behavior change plan, and expected results of its Burkina Faso WASH and neglected tropical disease (NTD) pilot activity, called “How Can Integrating Sanitation and Hygiene into an NTD Control Program Accelerate Reduction in NTDs?” View the poster here.

World Toilet Day = Systems Day = Nutrition Day

By Ron Clemmer, Strategy and Business Development Manager, WASH, FHI 360.

World Toilet Day is about more than toilets! It is about the whole system of the sanitation chain. This whole “system” of household latrines; school and health facility toilets; septage haulers; wastewater and septage treatment, reuse and disposal, has become more and more a focus of international development professionals. As with development practitioners in other sectors, we work in complex social systems that require organizational change, behavioral change, and personal change for transformative social change to result in sustainable impact. A systems lens helps us to see our roles in development programs to understand the impact that is needed in the big picture of the “system.”

FHI 360’s 2015 Challenge Conference Deepening Systemic Engagement addressed an important question for systems thinking: “How do we as practitioners and change agents unify systems theory and practice to bring forth healthy and inclusive human development?”

FHI 360 brought together speakers who are leaders in the area of systems thinking and also practitioners who are implementing a systems approach for international development for the Challenge Conference. The keynote speaker was Otto Scharmer from the MIT Sloan School of Management, who with Katrin Kaufer co-authored, Leading from the Emerging Future: From Ego-System to Eco-System Economies.

Being the pragmatic engineer that I am, some of the presentations that peaked my interest the most were from FHI 360 colleagues discussing the application of systems approaches in their development programs. A systems approach that FHI 360 staff has developed in conjunction with USAID is SCALE (System-wide Collaborative Action for Livelihoods and Environment). Ten years of learning through the implementation of the SCALE systems methodology to accelerate broad stakeholder engagement in sustained collaborative action to address a complex development issues has now resulted in FHI 360’s development of SCALE+.

If you want to explore more of Deepening Systemic Engagement, the Challenge Conference highlight videos and materials can be found here.

World Toilet Day is also about more than toilets because of the significant impact of good sanitation on maternal and child health, neglected tropical diseases, HIV/AIDS, education, and nutrition. World Toilet Day has a special linkage to nutrition this year, and 2015 World Toilet Day was chosen as the day that WHO/UNICEF/USAID are releasing the important publication Improving Nutrition Outcomes through Water, Sanitation and Hygiene: Practical Solutions for Policies and Programmes. My FHI 360 WASHplus colleagues managed the development of this publication in collaboration with the publishing agencies. And the integrated activities in different countries implemented by WASHplus and its partners are contributing practical knowledge and tools that will help guide WASH-nutrition integration in the future.

ABOUT THE AUTHOR: Ron Clemmer joined FHI 360 in May 2015 after working with World Vision as Senior Technical Advisor for WASH for six years. Ron is passionate about building sustainable water and sanitation services through the public and private sectors, hygiene behavior change that becomes habit, and integrated programming of WASH with nutrition, HIV, neglected tropical diseases, education, and women’s empowerment.

Improving Nutrition, One Latrine at a Time: WASH 1,000 Strategy in Ghana Takes Hold

By Christa Elise Reynolds, Knowledge Management Officer, JSI Research & Training Institute, Inc. with USAID SPRING.

Gmangun Charles, of Kubone community in Ghana, shows off his household’s new latrine. (Photo by David Nunoo, SPRING/Ghana WASH Advisor)
Gmangun Charles, of Kubone community in Ghana, shows off his household’s new latrine. (Photo by David Nunoo, SPRING/Ghana WASH Advisor)

Toilets might not be the first thing you think of in conjunction with basic human nutrition, but inadequate sanitation poses a real danger for 2.5 billion people around the world. When crops become contaminated through open defecation, communities are at risk for disease outbreaks and chronic malnutrition.

This November 19, designated as World Toilet Day, we are reminded of the people lacking access to toilets and improved sanitation. About 1.1 billion people defecate in the open, according to UN-Water. Diarrheal disease, which can prevent nutrients from being absorbed, is a common outcome of improper human waste disposal. This is an issue in Ghana, where approximately 19,000 people die yearly from diarrhea. Nearly 90 percent of those deaths can be attributed to poor water, sanitation, and hygiene (WASH), according to the Water and Sanitation Program.

At the Strengthening Partnerships, Results, and Innovations in Nutrition Globally (SPRING) project, funded by the U.S. Agency for International Development’s (USAID), we are working to improve nutrition through our “WASH 1,000 strategy,” a multifaceted approach stresses the importance of key household behaviors during the first 1,000 days, spanning the mother’s pregnancy to the child’s second birthday. Numerous factors influence a child’s well-being during this time. Our WASH 1,000 strategy focuses on four key behaviors: ensuring the child has a safe and clean play space, safely disposing of human and animal feces, handwashing at critical times, and using only boiled or treated water for the child’s consumption.

Mobilizing communities to build latrines is one of the first steps toward improving sanitation. Working with country partners, we facilitated discussions about the importance of latrines and sanitation in communities in the northern and upper eastern regions of Ghana, and participants have been receptive to the ideas. Installing tippy taps, or simple handwashing stations, near latrines and in households promotes handwashing after using the latrine and before meals, another WASH 1,000 goal.

“I am happy that I and my family do not defecate in the open again. I have restored my lost dignity,” said Gmangun Charles, a resident of the Kubone community in the Mion District of Ghana, who recently constructed a latrine for his household’s use.

Since February 2015, 47 household latrines have been built in the Kubone community. After learning about the benefits of using latrines, residents are increasing community awareness of open defecation’s health risks and shaming those who refuse latrines.

The link between open defecation, hygiene, and nutrition is not obvious and many community members may not be aware of the connection. Because people in the northern and upper eastern regions of Ghana often defecate on farm fields and near water sources, crops can become contaminated. Children might be exposed to human and animal feces while playing, which can lead to infection and diarrhea. Eating with unwashed hands can cause further contamination. Properly built latrines and use of tippy taps reduce this health risk. These latrines are a source of pride for the community members who build them, 14-year old Emmanuel Loteba said.

Though the idea of feces getting into our foods is disgusting, I also felt guilty because we all defecate openly in this village. We were told that the best way to avoid contaminating our food and to live healthy lifestyles is to build household latrines,” Loteba commented.

Loteba lives in Boagnab Yare, a community in Ghana’s upper east region, where diarrheal disease and low nutritional absorption are common. He learned about the WASH 1,000 strategy through one of our trainings. In the Kugbar-Bulug community, another of our WASH 1,000 Ghana sites, 19 of 28 households have already built household latrines. Kwame Awin, a local farmer, is happy with his new latrine because he and his family can finally eat fresh beans from their fields without risking contamination.

World Toilet Day highlights the sanitation needs of billions of people around the world who can’t wait for better hygiene. By encouraging a more holistic understanding of nutrition as it is impacted by WASH, our work in Ghana has begun changing perceptions of latrines and sanitation in the country’s northern and upper eastern regions. SPRING continues to promote WASH 1,000 behaviors to communities and trainers so that they may improve sanitation access, nutrition, and health.

ABOUT THE AUTHOR/ PROJECT: Christa Elise Reynolds is a Knowledge Management Officer working on the USAID SPRING project at JSI Research & Training Institute, Inc. Funded by USAID, the Strengthening Partnerships, Results, and Innovations in Nutrition Globally (SPRING) project strengthens country efforts to scale up high-impact nutrition practices and policies. To learn more about SPRING visit the project website at www.spring-nutrition.org and follow @SPRINGProject2 on Twitter.

DISCLAIMER: The contents of this blog post are the responsibility of JSI, and do not necessarily reflect the views of USAID or the United States Government. SPRING’s work is made possible by the generous support of the American people through the United States Agency for International Development (USAID) under the terms of the Cooperative Agreement AID-OAA-A-11-00031 (SPRING), managed by JSI Research & Training Institute, Inc. (JSI).

Handwashing Resources from WASHplus

Make it a habitOn Global Handwashing Day and every day we dedicate ourselves to increasing awareness and understanding about the importance of handwashing with soap to prevent diseases and save lives. Please see below handwashing resources developed by WASHplus on: the small doable approach to handwashing; how to make tippy taps for handwashing; making a habit of handwashing; and integrating WASH  into nutrition and HIV programs.


sda thumbnailSmall Doable Actions: A Feasible Approach to Behavior Change, Learning Brief, 2015. This brief takes a look at how WASHplus has applied the Small Doable Action approach to handwashing, water treatment, improved sanitation, menstrual hygiene management, and food hygiene.

habitHandwashing and the Science of Habit, Webinar, 2014.  This webinar emphasizes ways to apply the basic science of habit and behavior change to real world health interventions and program delivery, with a focus on behavior change for handwashing with soap.

WASH HIVIntegrating Safe Water, Sanitation, and Hygiene into HIV Programmes: A Training and Resource Pack for Uganda, 2014. This training manual teaches the four key WASH practices: safely transporting, treating, storing, and serving drinking water; safe handling and disposal of feces; safe handling and disposal of menstrual blood; and handwashing with soap (or ash) and water.

WASH nutritionIntegrating Safe Water, Sanitation, and Hygiene into Infant and Child Nutrition Programmes: A Training and Resource Pack for Uganda, 2014. This resource pack can  aid health workers in helping household and community members to overcome, or change, the many daily obstacles to improved water, sanitation, and hygiene (WASH) practices in the home.

tippy tap makingHow to Make Other Types of Tippy Taps, 2014. This pamphlet shows how to make Tippy Taps for handwashing from mineral water bottles, tin cans, and hollow tubes. The tippy tap is a hands free way to wash your hands and is especially appropriate for areas where there is no running water.

Bangladesh: Materials to Support WASH Improvement

Below are links to flipcharts, flash cards, pocket books and other materials in Bangladeshi to help improve WASH:



Behavioral Challenges and Potential Solutions to Reach Universal Sanitation Coverage


By Orlando Hernandez, USAID/WASHplus Project and Senior Monitoring and Evaluation Advisor, Global Health, Population and Nutrition (GHPN), FHI 360.

The comments below are from Dr. Hernandez’s participation at the World Water Forum 2015 and then posted to the Sanitation and Water for All website.

Behavior change specialists rely on frameworks to dissect a problem and define a strategy to address it. The Water Improvement Framework (WIF), previously named the Hygiene Improvement Framework (HIF) developed in connection to USAID WASH projects some 15 years ago, is one such framework. Given its openness and comprehensiveness, the WIF has stood the test of time. Other donors and implementation agencies are thinking along the same lines as there are other similar frameworks developed by WSP, SVN, the London School of Hygiene and Tropical Medicine, among others.

The WIF is a three-legged stool which brings together: 1) supply, 2) demand, and 3) the enabling environment. It suggests that behavior change (BC) strategies are more than mere promotion, channels and messages. They bring a human dimension to the WASH sector, and when based on the WIF’s the three elements, it guides us to design, implement and evaluate WASH activities. orlando2

Behavior change frameworks require us to segment our audiences as social groups involved in development are not monolithic. One obvious breakdown in sanitation is a split between urban, peri-urban and rural dwellers. The needs, preferences, sanitation practices and certainly resources of urban, peri-urban and rural populations may be different. With growing urbanization throughout the developing world, coverage in peri-urban areas represent a challenge, especially when we think of tenants living in crowded quarters with no services.

Addressing appropriate sanitation practices in peri-urban areas will require appropriate sanitation options that would allow peri-urban residents to dispose safely of human feces. There are recent innovations which make us think about the importance of ‘human centered design’ for identifying effective supplies and products required to carry out an action. A first step in behavior change is to have the right enabling products as well as the needed access to such a product that a targeted population needs to have in order for a promoted practice to occur.

Sanivation in Kenya, for example, has developed the Blue Box. This is a container-based toilet that is placed in any room in someone’s home and serviced regularly by Sanivation’s Toilet Service Representatives. Sanivation then transforms the collected material in high-performing charcoal briquettes, which are resold on the market. Blue Box clients get a toilet and services to remove fecal matter from their homes for US$7/month.

This approach is based on research suggesting that 50% of Kenyans were planning to invest in improved sanitation, but that many of those living in peri-urban settings may be paid monthly salaries and could have no savings to construct a toilet, may have no space to build a latrine, or be moving away to another location in the near future and do not want to make permanent home sanitation improvements that would be forced to leave if and when they do move. The Blue Box toilet relies on a subscription service, has come to be perceived as a status symbol, and has a marketing strategy that relies heavily on word of mouth. There are other similar options to – dwellers: loowatt in Madagascar, Sanergy also in Kenya, etc.

We are probably all too familiar with the experience of easy latrine in Cambodia designed also using human centered design principles by iDE to come up with a toilet that responded to sanitation needs and preferences of rural residents. Three principles guided the design of these toilets as products that will be purchased by consumers to satisfy their needs. These principles can be referred to as those that meet the three A’s of a marketable product: aspirational, accessible and affordable. Cambodia was a country with 20% rural sanitation coverage when the work of IDE started.

Formative research conducted identified the characteristics of an attractive rural sanitation option. These rural consumers were interested in having a pour flush toilet with an off-set pit and a concrete superstructure that may constructed in due time once resources become available. Such a product was baptized as the easy latrine and ended up being the appropriate technological option for rural Cambodian households. Project implementers in Cambodia resolved production and supply chain issues and more quickly than expected sales and coverage increased considerably.

Universal coverage requires eliminating open defecation as a first step, and such a goal will not be achieved if open defecation is not eradicated in large countries, including India. The Government of India has a program that subsidizes latrines so households have no economic barriers to overcome in order to have latrines at home. Subsidies resolve an important barrier helping to increase access. However, access is a necessary but not a sufficient condition for use of an installed technology to use.

Access does not mean use or correct use. The Research Institute of Compassionate Economics (RICE) at Emory University, with Gates funding, has clearly demonstrated the multiple motivational barriers have to be overcome especially in Northeast India to get people that may have latrines constructed at home at the government’ s expense to accept having them installed, and also in using them.

The research conducted by RICE at Emory has demonstrated that family members in rural settings have morning walks, leaving home to breathe clean air in the woods as they wake up, and that at the end of their walk they defecate before returning home. In addition to enjoying a morning walk, there is a preference to leave their fecal matter away from home. We will be challenged to bring human centered design to address not only the specifications of on-site sanitation, but possible the characteristics of off-site sanitation.

Perhaps we need to think about the possibility of setting up public toilets in current open defecation sites. I know that off-site defecation may not be counted as part of meeting universal coverage, but we may forced to expand our definitions to take into account special circumstances affecting millions of people.

Rural sanitation offers other challenges that we should be prepared to address, even we have detected the appropriate technology as was the case in Cambodia. CLTS has been used in many countries, supported by donors and adopted by many public and private implementing agencies. However, it is an approach that is implemented in different phases including pre-triggering, triggering, adoption, sanitation facilities construction and certification.

It is certainly an approach that requires considerable institutional implementation capacity in addition to involvement of central and local government officials, community mobilizers, masons, lenders, etc. It is also an approach that moves at its own pace, village by village. The presence of multiple villages will require multiple implementation teams. I should add that participatory approaches are likely to be more effective than top down approaches that offer cookie cutter solutions.

A review of rural sanitation programs implemented in the past few years in Latin America has demonstrated that even when institutional capacity is in place, solutions exclusively from the desk of technicians that do not incorporate community members to the process of change may backfire.

Now, let me turn to a related topics: consistent use over time for all family members. Implementers of CLTS programs in multiple countries over time are beginning to generate data that helps to see what even when there is the right technology and the right institutional support to increase coverage, we may be confronted with the problem of recidivism.

Some of these implementing agencies are indicating that in some instances up to 30% of households with sanitation coverage may come back to open defecation . So, one challenge is how to make sure that family members continue to use available sanitation over the long run. We will also be concerned with the fact that the feces of all family members should be disposed of hygienically.

And in this regard, the disposal of child feces will emerge as a larger challenge than we think. Families that have access to sanitation facilities should use them to dispose of child feces. Some studies in which I have been involved open the door suggest that this is not necessarily done. If there is recidivism among adult family members, there may not be consistent hygienic disposal of the feces of younger family members, even when latrines are available.

Habit formation concepts are beginning to offer a new way of thinking regarding consistent use of a practice over time. They suggest that to instill sticky habits we must help construct routines that are driven by external cues and are repeated over time automatically.

Settings must be stable so that external cues remain constant. In addition, habit formation principles suggest that we must try to piggyback practices onto existing habits. Studying what sequence of events occur when we engage in cleaning up a child may help identify how the appropriate disposal of these feces can be integrated to such a sequence.

Universal coverage often means on-site sanitation for households. However, there is a homeless population of over a billion individuals in the world, data that was recently shared with be by a colleague from Bangladesh attending this forum.

But if the current proposal stands, the Sustainable Development Goals will define universal sanitation including both households and institutional settings, namely schools and health facilities. The WIF can be of use when deciding how to tackle behavioral issues in school populations and clients and staff at health facilities.

The health and nutrition and nutrition benefits of WASH investments may not be reached if we ignore handwashing with soap at critical junctures, before handling food and after potential contact with fecal matter. Future handwashing promotion programs targeting households should focus on having households set up permanent handwashing stations near toilets or places where food is handled, and ensuring that these stations are duly supplied with soap and water, if no tap are available.

The challenges presented by handwashing promotion are large, but it has been done for a long time now and we have different ways of tackling them. That, nevertheless, is a different discussion that we can pursue at another time.

I hope that these remarks help us have an eagle’s view at the behavior change challenges ahead of us and some potential ways to address them. We must be open to technological innovations but also to innovative behavior change approaches and new ways of tracking our achievements. I also hope that it stimulates your thinking and generates discussion.

Expanding WASH Coverage in Bangladesh

bangladesh water pump

WASHplus mounted intensive, accelerated efforts in a new expansion subdistrict in the Khulna District in response to USAID interests in water technology innovations. It has also been working with a new local NGO partner, Shushilan, to begin installation of rainwater catchment and pond sand filtration systems. In the original four subdistricts, WASHplus continues to construct water points and latrines as well as train community members on operations and maintenance for the new WASH (water, sanitation, and hygiene) facilities.

The numbers tell the story: WASHplus is well placed to reach, and even surpass, its proposed targets for open defecation free (ODF) communities, number of new water points and latrines, and water and sanitation beneficiaries. This is happening despite the fact that flooding delayed the documentation of ODF communities, and storms damaged a number of new latrines. Fortunately, new construction standards meant that the latrines sustained primarily superficial damage, and households were resilient enough to make repairs. Also, WASHplus has surpassed the target for number of people gaining access to sanitation facilities by 691 (100.78 percent), and is 88 percent of the way toward the three-year beneficiary target for water access.