Draft Review Report of the National Open Defecation Free (ODF) and Hand Washing with Soap (HWWS) Strategies Submitted to The National ODF Taskforce Ministry of Health Headquarters, Capital Hill P.O. Box 30377 Lilongwe 3 Submitted by Dr Steven Taulo (Team Leader) Centre for Water, Sanitation, Hygiene and Appropriate Technology Development (WASHTED) University of Malawi, The Polytechnic, P/B 303, Chichiri Blantyre 3 Phone +265884588934, Email: [email protected]Authors: Steven Taulo, Christabel Kambala, Save Kumwenda, Tracy Morse January, 2018
TableofcontentsTableofcontents ........................................................................................................................ i
Summary ................................................................................................................................... iv
Introduction ........................................................................................................................... ivObjectives ............................................................................................................................. ivMethods................................................................................................................................. ivResults .................................................................................................................................... vCross cutting recommendation for future strategy development ........................................ vii
AbbreviationsandAcronyms ................................................................................................... ix
4.5.2 Cross cutting issues .............................................................................................. 594.5.2 General recommendations from stakeholders for inclusion to updated Strategy 59
Ourgratitudeisextendedtoallthosewhoguidedandparticipatedinthepreparationofthisreport from thepublic, privateand community sectors from inception to the completion.
IntroductionDiarrhoeal diseases pose significant health risks for the rural population and account for18%ofdeathseachyearinchildrenundertheageof5.Increasingaccesstobasicsanitationand hand washing with soap at critical times are key interventions to the prevention offuture diarrhea and cholera cases. The Government of Malawi with its developmentpartnersdevelopedtheOpenDefecationFree(ODF)Malawi(2011–2015)andtheNationalHandWashingCampaign2011-2012Strategies,inlinewiththeMDGstosupportattainmentofitsgoaltocreateaclean,safeandhealthyenvironment.Astheinitialstrategiescametoan end (2011-2015), the global community entered the new phase of SustainableDevelopmentGoals (SDGs 2016-2030). As such,Malawi also felt theneed to up-date theODF and theNational HandWashing Campaign strategies to be in linewith the nationalsanitationandhygienetargetsandSDGGoal6.2:by2030.ItisagainstthisbackgroundthattheNationalOpenDefecationFreeTaskForce(NOTF)commissionedthisconsultancywhoseTORsweretoprovideaframeworkforfacilitatingthereviewanddevelopmentofthenewNationalODFandHandWashingwithSoap(HWWS)strategies.Thisreportisasaresultoffielddatacollection,literaturereviewandstakeholderconsultationwhichareinformingtherevisionoftheODFandHWWSstrategiestosupportMalawiinmeetingtheSDGtargets.
ObjectivesNOTFoutlinedspecificobjectivesforthisreviewwhichhavebeenarrangedintwostagesasfollows:Stage1:• Reviewofcurrentcountrystrategieswithemphasisonoriginalassumptions.• Review the effectiveness of the scope, mechanisms and actions applied in the
Stakeholder analysis: Stakeholder analysiswas used to identify project's key peoplewithstake,interestorinfluenceinreducingopendefecationandpromotinghandwashingwithsoap. Stakeholder analysiswas a useful tool for identifying people and organizations andinstitutions that assisted in providing information regarding ODF and HWWS. TheinformationfromidentifiedstakeholderswasgatheredusingKeyInformantInterviews(KII)andFocusGroupDiscussions(FGD)duringfieldresearchandstakeholdermeetings.Deskreview:ThedeskreviewconstitutedanimportantstepintheprocessofreviewingthenationalODFandHWWSstrategies.Itprovidedtheevidencebaseforthereview.Reviewingall documentation (grey, published and peer reviewed information) relating to the issuescoveredintheexistingstrategiestodevelopascompleteapictureaspossibleofthecurrentstate of ODF and HWWS both in and outside Malawi. This involved using the followingtechniques: Internal Desk Research, External Desk Research, Online Desk Research,GovernmentpublisheddataandCustomerdeskresearch.FieldResearch:Thisinvolvedcreationandcollectionofprimarydatafromthefieldsetting.The process involved determiningwhat precise data was necessary and fromwhere thisinformationneededtobeobtained.Fieldresearchwasperformedbytheconsultancyteamin person in 6 Districts and with key stakeholders, through KIIs (n=24) and FGDs (n=38).PurposivesamplingwasusedtorecruitparticipantsforboththeKIIsandFGDs.StakeholderWorkshopwasundertakentogetprovidefeedbackandvalidationofthedeskreviewandfieldresults,aswellasreceiveinputfromfurtherDistrictsandstakeholders.Theworkshopusedpresentations,worldcaféconsultationanddirectfeedback.
ResultsKeyFindingsFindingsdemonstratethattherehavebeenpositiveresultsandprogresstowardsmeetingstrategic targets from 2011-2015. Nevertheless there are still significant barriers andchallenges to the achievement of key goals of ODF andHWWS acrossMalawi. Themaingapsidentifiedinclude:Scope• TheODFstrategyfocusesonlyontheruralpopulation,whichhaslimitedthefocusand
successofODFachievement.• TheODF strategy referredonly tohouseholdswithno requirement forODF status in
publicspacesandinstitutions.• There is no reference or integration of ODF strategy with menstrual hygiene
management.• Neither strategy has specific reference or support for vulnerable and marginalized
• ODF strategy implementationwas to be overseenby theNOTFwhich represents theMinistryofHealthand theMinistryofAgriculture, IrrigationandWaterDevelopmentwithkeydevelopmentpartnersandcivilsocietywhichdoesn’tincludeotherministries.
• ThecurrentODFstrategyislimitedtotheuseofCommunityLedTotalSanitation(CLTS)and sanitation marketing and does not take into consideration the use of otherparticipatoryapproachessuchasParticipatoryHygieneandSanitationTransformation(PHAST)andmechanismstoachieveODF.
• Althoughthereistheinclusionof2levelsofODFstatusinthestrategy(i.e.1-appraisinga community towards theattainmentof theODFstatus;2- sustenanceofODF statusafter attaining the ODF status), there is little reference to the effective use of thesanitationladdertoachievecontinuedimprovementandsustainability.
littleconcentrationonbehaviorchangecommunicationforsustainedchange.KeyrecommendationsScope• The scope of the strategies should include proper definitions of a latrine (including
• Newstrategiesmusttacklebothurbanandruralpopulations.• Support for vulnerable and marginalized populations must be more effectively
integrated.• Integrationofmenstrualhygienemanagement• CriteriaandmechanismsforbeingdeclaredODFshouldbereviewed.Mechanism• NOTF should be more multidisciplinary in its membership with the inclusion of
representatives from nutrition, disabilities and other appropriate governmentdepartmentstoensureintegrationofservices.
• Movement towards a requirement for standard systems tobe constructed shouldbeconsideredwhichwouldimprovequalityoflatrinesandcreatebusinessformasonsandentrepreneurs.
ofallowances.• Fundingmustbering-fencedforODFactivitiesfromtheDistrictbudget.• Stakeholders reported the need for integration in community structures for effective
• Vulnerable and marginalized groups should be engaged from the offset of the CLTSprogrammeandbeinvolvedinthetraining,implementationandverificationprocessestoensureappropriatesystemsareinplacetosupportthem.
• By laws should continue to be encouraged butmust be enforced consistently for allcommunitymembersandbefacilitativeratherthanpunitive,takingintoconsiderationhumanrights.
• SchoolWASHstandardsneedtobecompletedandcirculatedtoensureimprovementatfacilities. These standardsmust include a range of low cost HWF suitable for schoolsettings.
• Theconceptofusing schoolsandchildrenasagents is still awelcomeonebutneedsbetterintegrationandstructure
• Health facilities must be supported to ensure that they are modeling improvedsanitationandHWWStopromotegoodbehaviour.
• Behaviour change messaging needs to be developed based on sound principles andwith an understanding of the audience and behavioural factors which are beingtargeted.
• Theneed for, andpromotionofHWWS requires effective public privatepartnershipsandtheserequiretobeengagedonamoreregularandformalbasis.
• Strengthen CLTS and HWWS monitoring systems: There is need for more detailedmonitoringandevaluationofprogressandeffectiveness.
• Improved integration of behavior change communication to support sustainedimprovementsinODFandHWWSthroughoutMalawi.
CrosscuttingrecommendationforfuturestrategydevelopmentIt is clear fromthe feedback fromall stakeholdersanddesk review, that futurestrategiesmust address concerns regarding integration of sanitation and hygiene programmes toensuresustainedchangeacrossMalawiandachievementoftheSDGsby2030.
Withthisinmind,itistheoverallrecommendationofthisreviewthatthecurrentODFandHWWS strategies should be integrated into a more general ‘hygiene and sanitation’strategy.ThiswouldsupportnotonlytheintegrationofHWWSandODFprogrammes,butalso the inclusionof key issues raised in stakeholdermeetings suchasmenstrualhygiene
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management and solid waste management (including faecal sludge management). Thiswouldbeanallencompassingstrategywhichtargetsruralandurbanpopulations,domestichouses, commercial premises and institutions across the country. Only then canMalawitrulymeetthetargetofUniversalSanitationandHygieneforAll.
Figure 1: WHO estimates of childhood illness from environmental exposure?
Figure 2: Various transmission routes of pathogens from extra of an infected person to a healthy person (Source: Pond, 2015)
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Thesedeathscouldbepreventedinpart,byimprovingaccesstosafelymanagedsanitationandimprovedhygienepractices(Brownetal.2014).Handwashingwithsoapatcriticalmoments,suchasbeforeeatingandafterdefaecation,canalsoprevent infectiousdiseasesby interrupting the transmissionof infectiousagents.Empiricalevidencesuggeststhathandwashingwithsoapreducestheriskofdiarrheaby47%(CurtisandCairncross,2003,Cairncross,2010),acutelowerrespiratoryinfectionsbyupto34%(Lubyetal,2005),andsoil-transmittedhelminths(Strunzetal,2014),andithasbeenrecognizedasoneofthemostcost-effectivehealth interventionstoreducetheburdenofdisease(BartramandCairncross,2010).Yet,only19%oftheglobalpopulationisestimatedtowash theirhandswithsoapafterusingsanitation facilityorhandlingchildren’sexcreta(Fremanetal,2014).Good hygiene is of vital importance inMalawi due to the lack of basic sanitation in thecountry. Evidence of actual hand washing practice is scanty but studies in rural areassuggestthattheactualpracticeofHWWSatkeytimesisbetween3–18%butmorelikelyon the lowendof this scale,as responses tendtoexaggerateactualandregularpractice.Observations inMalawi show that HWWS promotion is undertaken as an ad hoc activityboth at national and local level. Current efforts to promote good hygiene and HWWS inparticular,havenotbeensufficienttobringaboutmassbehaviourchangeonthescalethatis needed. Efforts producing piecemeal village-by-village and pilot approaches have hadsomeimpactinMalawibutnothingonalargeornationalscalehasbeenattempted(MoH,2015)TheJointMonitoringProgrammeforWaterSupplyandSanitationestimatesthat2.3billionpeoplegloballylackaccesstobasicsanitation(useofimprovedsanitationfacilitiesthatarenot sharedwith other households) and that 892million people practice open defecation(WHO/UNICEF 2017). As such the control of open defaecation is a primary public healthconcern in thereductionofdiarrhoealdiseasemorbidityandmortality,andthespreadofdiseasessuchascholeraacrossvulnerablepopulations.
Inrecognitionofthispriority,theGovernmentofMalawilaunchedtheNationalSanitationPolicy in 2008. This policy emphasized the need for sanitation for all in Malawi. Itenvisionedatransformedcountrywhereallthepeoplehaveaccesstoimprovedsanitation,and where safe hygienic behaviour is the norm. This included the recycling of solid andliquidwaste, leading toabetter life forall thepeopleofMalawi, throughhealthier livingconditions,abetterenvironmentandanewwayforsustainablewealthcreation(NationalSanitationPolicy2008).
Key to thiswas the development and launch of theOpenDefecation FreeMalawi (ODF)2011-2015StrategyandtheNationalHandWashingCampaign(2012).InlinewiththeMDGsthey aimed to support attainment of its goal to create a clean, safe and healthyenvironment,whichresultsinimprovingpeople’shealthandwellbeing.Thestrategiesweredeveloped to ensure complete elimination of open defecation (OD) and promote HandWashingwithSoap(HWWS)toreducethespreadofsanitationandhygienerelateddiseasessuchasdiarrhoeaandcholera.Recognizing that increasingaccess tobasic sanitationanduseof safehygienepractices isthemain key to the prevention of future diarrhoea and cholera cases, both theNationalHandWashingCampaignandOpenDefecationFreeStrategieswereimplementedthrougharange of programmes with implementingpartners.The primary programme was the AcceleratedSanitation and Hygiene Practices Programme(ASHPP). This was a government-led nationalinitiative on sanitation and hygiene funded bythe Water Supply and Sanitation CollaborativeCouncil (WSSCC) through the Global SanitationFund(GSF).Itaimedtosupportcommunitiestoadopt and use safe hygiene practices byeliminatingopendefecationandincreasingtheiraccesstoimprovedsanitation.
Thisprogrammeprimarilyaimedtoachievetheobjectives of the Open Defaecation FreeStrategy(2011–2015)throughtheGovernmentofMalawiandarangeofdevelopmentpartners.These activities have been coordinated by theNational Sanitation and Hygiene CoordinatingUnit (NSHCU) (Government ofMalawi) and theNational Open Defaecation Free Task Force(NOTF)(Multisectoral).
As the initial strategies came to an end (2011-2015), the global community entered the new phase of Sustainable Development Goals(SDGs 2016-2030). As such, Malawi also felt the need to up-date the ODF and HWWSstrategiesforthenationalsanitationandhygienetargetsinlinewithSDGGoal6.2:by2030,achieve access to adequate and equitable sanitation and hygiene for all and end opendefecation, paying special attention to the needs of women and girls and those invulnerable situations. It is against this background that this review report has beenprepared.
Box 1: ODF Declaration Status
Level 1 • 95% of the households must have
latrines � • All available latrines must offer privacy,
good state of repair, with good roof � • All latrines must show evidence of being
used � • All households must properly dispose
baby’s feacal matter � • No sign of open defeacation in the area � • 5% sharing of latrines is allowed �
Level 2 • 100% of the households must have
latrines � • All latrines must offer privacy, good state
of repair, with good roof � • All latrines must show evidence of being
used � • All households must properly dispose
baby’s �feacal matter � • No sign of open defeacation in the area � • No sharing of latrines is allowed � • All latrines must have hand washing
facilities �
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1.2 SummaryofachievementsandlimitationsAccording to the most recent WHO/UNICEF Joint Monitoring Programme (JMP) figures(2015), between 1990-2015, the percentage of the country’s population practicing opendefecation decreased from 29% to 4% and access to improved sanitation increased from
29% to 41%.Over the period of implementation of theODF strategy (2011 – 2015), thiscoverageof latrineshas increased from66–85%ofhouseholds, anduseofa latrinehasincreased from 89 – 95% reported (Figure 3). These national figures, however, masksignificantdisparitiesbetween:
Figure 4: Map of Malawi depicting ODF status by percentage of Traditional Authorities
Figure 5: Info graphic depicting the percentage of Traditional Authorities achieving ODF by Level (Box 1)
Figure 6: Percentage of village which have been triggered for CLTS and achieved ODF
in Malawi (2017)
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theexistenceofhandwashing facilities (Figure7). This is reflected in the lowprogress inincreasingcoverageofhandwashingfacilitiesacrossMalawiwithalessthan10%increaseto34%achievedby2016.
AswithODFthiscoveragevariessignificantlyacrossthecountry(Figure8),andstatisticsarealsosubjecttodebate,asthepresenceofahandwashingunitdoesnotnecessarilyreflectconsistentuseathigh risk times.The lackof soapavailable,and the locationof thehandwashing facility by the latrine can also negate effective HWWS practice at critical timestherebyachievingtherequiredreductionindiseasetransmission.ItmustalsobeconsideredinFigure8,thatmanyoftheDistrictsshowinghighcoverageofhandwashingfacilitieshavenotachievedODFandassuchdonothavealatrineat>90%ofhouseholds.
Primary focus has been on the provision of infrastructure through CLTS andmassmediacampaigns.Althoughprogressinthisareaisstillneeded,itmustalsobeacceptedthattheseactivities require to be complementedwith appropriate health promotion and behaviourchangeprogrammes.
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2.0 Reportoutline
2.1 PurposeofthisreportThe primary purpose of this report is to support the review of the ODF Malawi (2015)StrategyandNationalHandWashingwithSoap (HWWS)CampaignStrategy;and toguidethedevelopmentofnewnational strategiesbasedon the lessons learned in linewith theSustainableDevelopmentGoal(SDG)andMalawiGrowthandDevelopmentStrategy.
2.2 SpecificobjectivesoftheReportTheobjectivescoveredwithinthisreportfallintotwoclearstages:Stage1:• Reviewofcurrentcountrystrategieswithemphasisonoriginalassumptions.• Review the effectiveness of the scope, mechanisms and actions applied in the
3.1 OverviewofMethodologyThepurposeoftheoutlinedmethodology is toachieveacriticalunderstandingofthekeyelementsoftheODFandHWWSstrategiesIt is understood that although ODF and HWWS are inextricably linked, they also requirestandingalonetoensuretheir integrationandadoptionwithothercrosscuttingareas.Assuch,wherepossiblethereportoutlinestheODFstrategyandHWWSstrategiesseparatelyalthoughtheyarelinkedandintegratedwhereappropriate.Basedonthespecificobjectives,themethodologiesoutlinedinFigure11andTable1wereutilised.Table1: Summarydatacollectionmethods
3.2.1. StakeholdersmappingandanalysisStakeholder analysis was the identification of organisations with a stake, interest orinfluence in reducing open defeacation and promoting hand washing with soap. It alsoinvolved assessing their interests and the ways in which these interests affectedimplementation, viability and sustainability. The information from identified stakeholderswasgatheredthroughDeskreview,KeyInformantInterviewsandFocusGroupDiscussions.
3.2.2DeskReviewThedeskreviewconstitutedanimportantstepintheprocessofreviewingthenationalODFand HWWS strategies. It provided the evidence base for the review. A review wasconductedonalldocumentation (grey,publishedandpeer reviewed information) relatingto current progress in Malawi and where appropriate relate to findings from othercountries.Thedeskreviewaimedtodocumentthefollowing:• Thenationalcontextofthestrategies(keysocioeconomicindicatorsanddeterminants);• Progresstowardsachievingthenationaltargetsfor impact,outcomesandoutputsfor
Keysourcesofinformationincluded:3.2.2.1NationalDataandReviewsTheteamcollatedthecurrentnationaldatapertainingtoODFandHWWS.Thisincludedthefindings and issues raised at the recent National Sanitation and Hygiene Learning Forum(May 2017, Lilongwe) andNational ODF Review (November 2017, Lilongwe). Thesewererecordedbytheteamwhentheyattendedtheevents.3.2.2.2ProjectReportsMuch of the information was generated internally within private organizations,collaborating partners, interested groups and the affected ministries (Health andAgriculture, Irrigation andWaterDevelopment). Project documents andNOTFdocuments(policies, strategies, reports, protocols, regulations and other related documents) weresourced.Where appropriate documentswere also sourced fromother relevant countriesforcomparison.3.2.2.3PeerReviewedLiteratureA literature review was conducted online to identify the most relevant peer reviewedpublicationswhichrelatedspecifically toMalawiorhadrelevant learningtobetaken intoconsiderationonthereviewoftheNationalODFandHWWSstrategies.Whereappropriatedocumentsweresourcedfromotherrelevantcountriesforcomparison.3.2.3 FieldResearch.This element of data collection allowed the collation of actual and authentic information(primarydata)fromthefieldsetting.Fieldresearchwasperformedbytheconsultancyteamin person, through Key Informant Interviews and Focus Group Discussions, as outlinedbelow.
3.2.3.1 KeyInformantInterviewsKIIsprovidedexplanationsandperspectivesfromthekeystakeholdersinODFandHWWSinMalawi. Stakeholders were targeted in 2 key areas: (1) Districts being used for fieldassessment (n=6) both government staff and development partners, and (2) CentralGovernment offices representing the gatekeepers of the strategy and policy documents(Table3).KIIs followed a semi-structured questionnaire (Appendix 1) and were conducted by amemberoftheresearchconsultancyteam.
Key Informants (n=24): These included WASH coordinators, DEHOs, SHIN coordinators,DistrictDirectorsofWater,DevelopmentalPartnersofWASHincludingthefollowing:WorldVision,FeedtheChildren,UnitedPurpose,ProjectConcernInternational,MalawiRedCross,ONSE, NAYORG, CADECOM, Participatory Rural DevelopmentOrganization (PRDO),WaterAid,PlanInternational,HygieneVillage,SynodofLivingstoniaDevelopment(SODEV).
Data from these interviews was consolidated and summarized as both qualitative andquantitative data. Saturation was achieved in responses from stakeholders in all sectors(implementingpartners,districtstaff,donors,government,etc.).
Overall 6 Districts were targeted (2 in each region) to provide an array of ODF statusincluding(1)recentlydeclaredODF,(2)achievedODFbutnowshowingslippageand,(3)notdeclaredODF.Ineachdistricttheteamattemptedtoconduct6FGDsasoutlinedinTable5.
Each FGDaimed tohave6–10participants, andpurposive samplingwasused to recruitparticipants of the FGDs. Each FGD followed a guide (Appendix 2) and addressed thefollowingkeyareas:
The informationwasconsolidatedunderspecific thematicareas relevant toeachtheODFandHWWSstrategies.InitialkeyfindingswerepresentedtotheNationalstakeholderODFreview in November 2017, where they received comment, validation and supplementaryinformation.Thishasbeenincludedwithinthisreport.
The Findings section of this report therefore represents the outcomes of all stages ofevaluation.
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4.0 FINDINGSAs described earlier, findings are outlined under specific objectives, which provide athoroughexplorationoftheODFandHWWSstrategy’ssuccesses,barriersandchallengesinthelast6years.Thesefindingsaredrawnfromacombinationofdeskreview,KIIs,FGDsandstakeholderanalysis.
Ultimatelytheeffectivenessofthescopeofthestrategiesisbasedontheimpacttheyhaveachievedsincetheirimplementationin2011.TheprevalenceofODin2011,(NationalODFMalawi 2011-2015 Strategy) was estimated at 11%; and in 2017 (JMP, 2017), is nowestimatedat6%,demonstratingsignificantreduction.IntermsofHWWS,althoughprogresshas been reported, there is still a significantway to go to ensure HWWS is possible andbeing undertaken at critical times. An increase of 10% from 24 – 34% coverage of handwashing has been reported between 2011 and 2016. However, this does not necessarilyreflectthepresenceoruseofsoap.
Scope: AchieveOpenDefecationFree (ODF) status for rural communities andschoolsinMalawiby2015
fromtheNationalOpenDefaecationTaskForceActions: Training and capacity building of HSAs, Traditional Leaders, Natural
LeadersandMasons CLTSprocess: Triggering,Verification,Certification Supportingactions: Traditional leader support, publicity, networking,
coordinationandintegration
ODF
Strategy
Scope: Accelerate the adoption of hand washing with soap behaviour in Malawi Mechanisms: Communications, pubic private partnerships, social marketing and
participatory approaches Actions: Making hand washing facilities available Using health facilities and schools as models and agents of change Behaviour change communications Supporting actions: Integration
HWWSStrategy
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The figures do demonstratethat from 2011-2017, therehavebeenpositiveresultsandprogress towards strategictargets (DeGabrile andNgwale 2017). Neverthelessthere are still significantbarriersandchallengestotheachievement of the key goalsof ODF and HWWS acrossMalawi.4.1.2 KeyfindingsScope:• BoththeODFandHWWSstrategiesdonotprovidespecificdefinitionsoflatrines,hand
schools,andnoactiontakeninotherinstitutionalsettings.Forexample,declaredareashave schools, prisons, markets and health facilities which do not have sufficientfacilities and show evidence of open defaecation. During our survey, we found thatmost schoolshadbasic latrines (i.e.withmuddy floorsandgrass thatched)andoftentimesthelatrineswereinadequatesothatthepupilsresortedtousingthebush.
• There is no reference or integration of ODF strategy with menstrual hygienemanagement.
• Neither strategy has specific reference or support for vulnerable and marginalizedgroups.
• TheODFstrategydoesnotconsiderthewholesanitationchain(capturetodisposal).MechanismsandActions:• ODF strategy implementationwas to be overseen by theNational Open Defaecation
Task Force (NOTF) which represents the Ministry of Health and the Ministry ofAgriculture,IrrigationandWaterDevelopmentwithkeydevelopmentpartnersandcivilsociety.
• The currentODF strategy is limited to the use of CLTS and sanitationmarketing anddoes not take into consideration the use of other participatory approaches such asPHASTandmechanismstoachieveODF.
• Althoughthereistheinclusionof2levelsofODFstatus,thereislittlereferencetotheeffective use of the sanitation ladder to achieve continued improvement andsustainability.
“Although steady progress has been made in triggeringcommunities - overall, 80% of villages have been triggeredand 70% have achieved level 1 ODF - many districts,particularly those struggling with co-resourcing withpartners, are still lagging behind. Besides making goodstridesinachievinglevel1ODFincommunities,sanitationislagging behind in institutions such as schools, hospitals,prisons and in public places such as markets and tradingcentreswhere pit-latrines are in short supply. Furthermore,nationwide, hand washing facilities are in short supplyand/or not available in both communities (including thosethat achieved ODF) and institutions. Consequently, thebehavior of handwashingwith soap remains a challenge”-Summary fromDistrict Environmental Health Officers andDistrictWaterOfficersfromvisiteddistricts
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• The HWWS strategy is limited in terms of integrationwith other key strategies (e.g.Nutrition, mother and child health, immunisations, school health and nutrition, etc.)andrelieslargelyonmassmediaratherthanfocusedbehaviorchangecommunication.
o Definitionofalatrine(developmentofassociatedstandards).o Considerationofthewholesanitationchain.o Bothruralandurbanareastobetargeted.o Inclusionofinstitutionsandpublicsettings,i.e.hospitals,schools,healthfacilities,
markets,prisons,offices,etc.o Specificreferencetotheinclusionofvulnerableandmarginalizedgroupso Integration of menstrual hygiene management standards and considerations
particularlyininstitutionalandpublicsettings.• The scope of the HWWS strategy is wide ranging and does not require any specific
changesMechanismsandActions:• NOTF should be more multidisciplinary in its membership with the inclusion of
representatives from Nutrition, disabilities and other appropriate governmentdepartmentstoensureintegrationofservices.
• ThemechanismsandactionsoftheODFstrategyshouldconsider:o A requirement of all settings to meet targets for ODF before an area can be
declaredODF.ThesestandardsshouldbeintegratedwiththoseofotherMinistriesand WHO/UNICEF (e.g. school standards in terms of numbers andcondition/cleanliness).
o TheinclusionofothermechanismsandparticipatoryapproachestoachieveODF.o Inclusionanduseof thesanitation ladderasa strategy forcommunities tomove
o Effectiveintegrationwithawiderrangeofstrategieso ProvisionofstandardsandspecificationstoguideODFimplementation.
• ThemechanismsandactionsoftheHWWSstrategyshouldconsidero Effectiveintegrationwithawiderrangeofstrategieso ProvisionofstandardsandspecificationstoguideHWWSimplementation.o Ensurethesitesforgoodpracticeareabletoachievethesestandards.o Improve focus on private sector engagement and public private partnerships to
4.2.1 OpenDefaecationFreeMalawiStrategy2011–2015TheODFstrategywasdevelopedwitharangeofCLTSstakeholdersinMarch2011.Atthistime they agreed on CLTS as a key strategy for Malawi to achieve ODF by 2015, butrecognised the need for the inclusion of other issues to complement CLTS includingsanitation marketing, involvement of traditional leaders, publicity of the strategy,mobilizationof resourcesandbettercoordination.AssuchthestrategycomponentswereoutlinedasdepictedinFigure12.
4.2.1.1Component1:SanitationandHygieneToolsandPracticesKeyAssumptionsDuringthedevelopmentofthestrategy,keyassumptionsweremadeontheachievementofrapidODFstatusforMalawi:• CLTS had been shown to be effective in 12 districts with 40% of triggered villages
• LessonslearnedfromCLTSintroductionsince2008indicatedthatsanitationmarketingcould support communities in the achievement of effective ODF and to climb thesanitation ladder through locally available sanitation masons, suitable low costtechnologiesandsystemsoffinancing.TheseweretobedevelopedinconjunctionwithCLTStriggering.
• ODFverificationwouldbeanopenand transparentprocesswhichwouldonly reflectthose communities which have truly achieved ODF through infrastructure andbehaviourchange
CLTSasafocalmethodologyAccordingtoChambers,participatoryruralappraisalenableslocalpeopletoshare,enhanceand analyse their knowledge of life and conditions, to plan and to act’ (Chambers 2009).CLTS applies the principles of participatory rural appraisal to facilitate the community toanalyse the problems associated with open defecation and to trigger all members of acommunitytoconstructahouseholdlatrine(Chambers2009).For example, CLTS was adopted by the Government of Kenya as a national sanitationstrategy in 2011 following successful piloting by sector players since 2007. Significantly,between2010and2011thisinitiativeregisteredimpressiveresultswithover1,000villages(571,231 people) attaining open defecation free status. Consequently, in May 2011, theGovernment and partners launched the ODF Rural Kenya 2013, campaign which aims toeradicateOpenDefecation(OD)inRuralKenyaby2013.(ODFruralKenya,2013)
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The ODF success rate, defined as the proportion of triggered communities that becomeODF, isakey indicatoroftheeffectivenessofCLTS implementation.TheODFsuccessratedoes not tell us anything about the quality or sustainability of collective sanitationoutcomes, but it is a key indicator of CLTS effectiveness that can highlight problems asprogrammesspreadandscaleup.TheCLTSapproachfocusesontriggeringruralhouseholdstouselocallyavailableresourcestobuildanduseaffordablelatrinesthatmeettheirsanitationneeds.ItshouldbenotedthattheODFsuccessratemightbeexpectedtodecreaseasprogrammesscale up due to the more difficult physical conditions and challenging social contextsencountered, and the challenges of maintaining the quality of CLTS facilitation andprocessesonalargerscale.Inpractice,mostCLTSreviewsfindsubstantialvariationsinODFsuccessrateacrossbothlargeandsmallprogrammes,andevenunderthesameconditionswithin the same programme (UNICEF, 2013). The country CLTS overviews suggest thatgovernment sanitationpolicyand technical guidelinesare important factors in the scalingupandeffectivenessofCLTSprogrammes.CLTSusesanumberofdifferentmechanismstoencourage sanitation behaviour change among the poorest and most disadvantagedhouseholds,includingdisgust,peerpressureandcollectiveaction.(UNICEF,2013)Recommendations• Improve CLTS enabling environment: Scaling up CLTS progress and improving CLTS
effectivenessandsustainabilitywillbedependentonfurtherstrengtheningofenablingenvironmentsforruralsanitation. InMalawi,governmentsordevelopmentpartners intheregionhaveyettodevelopstrategicsanitationplansthatelaboratetheroleofCLTSin creating large-scale demand for sanitation, or financed national implementationprogrammes that combine CLTS with other approaches. Realistic, costed and wellprioritized strategic sanitation plans are central to persuading governments, whichhistoricallypreferinfrastructureinvestmentsthatit is intheir interesttoallocatemorefinanceand capacity tobehaviour-changeprogrammes likeCLTSwhich can reach thepoorandreducehealthcosts(UNICEF,2013).
• StrengthenCLTSmonitoringsystems:There isneed formoredetailedmonitoringandevaluationofCLTSprogressandeffectiveness.Thereisaneedformoreregularupdatingand reporting of national CLTS and other sanitation progress data. Annual strategicreviews, ideally linked to themonitoring of CLTS progress against strategic sanitationtargets,andlocalgovernmentbenchmarkingsystemsareusefulmechanismsforpullingmonitoring data and reports up through government and programme systems. Inparticular, the strategy reviews must consider recommendations that allow thestreamliningofM&EintheODFsectorbothforinfrastructureandbehaviorchangeandshould consider guidance and recommendations of the World Bank Innovations inWASH Impact Measures: Water and Sanitation Measurement Technologies andPracticestoInformtheSustainableDevelopmentGoals(2018).ThiswillalsosupportthealignmentofindicatorswiththeSDGstoprovideabasisforprogressmeasurement.
• ODF sustainability Demand for information on ODF sustainability is essential and,
therefore, we support the recommendations on ODF sustainability highlighted inDeGabrieleandNgwalestudy(2017).Despitefrequentsuggestionsbythestakeholders
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at the annual review meetings that follow-up and long-term support after CLTStriggeringarecriticaltosustainability,therehasbeenlittlefinanceorcapacityallocatedto these areas by projects or programmes. We therefore further recommend thatgreater priority be allocated to post-triggering activities in plans, programmes andpractice,andthateffortsshouldbemadetodocumentbestpracticesforthelong-terminstitutionalsupportandmonitoringofODFandnon-ODFcommunities.Concernsaboutthe possible negative effects of institutional incentives for collective sanitationimprovementonsustainabilityshouldbeaddressed(informationgatheredduringFDGsrevealed that somechiefsmonopolized the incentives suchasplatesandbasins. Theykept these in their houses and never sharedwith the communities). Nonetheless, thebroad family of incentives available,which include numerous non-financial awards inadditiontomoreconventionalconditionalgrantsandfinancialrewards,offersausefulmechanismthroughwhichtoincreasethemonitoringandsupportprovidedtopost-ODFcommunities.
• Latrine hardware subsidies.Our desk review and field data indicate that a policy on
latrine hardware subsidies remains an emotive and important issue. More effort isrequired to understand how government and development partner policies on latrinehardwaresubsidiescanbeimproved(Thediscussionsheldattheannualreviewmeetingof November, 2017 highlighted the strong polarity of those that either support oroppose latrinehardwaresubsidies)andbetteralignedwithCLTS,sanitationmarketingandother interventionsdesigned to improve rural sanitationandhygiene.At theverysameannualreview,donoragenciesstronglyfeltthatsubsidiesshouldonlybeappliedtothevulnerableormarginalized(disabled).
SanitationmarketingasameanstoachievingODFTheuseof sanitationmarketing in conjunctionwithCLTSwasa logicalprogressionat thetimeofthestrategydevelopment,asthiswouldsupportthemovementofhouseholdsupthe sanitation ladder through the availability of local skilled labour, and would createincome opportunities for local masons, etc. However, feedback from the range ofstakeholdersindicatedthefollowingchallengesandmissedopportunities:• Focusofmanypartnerorganisationshasbeenonthetrainingofmasons.• Despitetrainingofmasonsandentrepreneurs,therehasbeenlittledemandcreatedfor
collapse. Therefore there is a need for improved construction and use of masonshoweverthisislimitedbythefinancialcapabilityofthehouseholdsandthepressuretoconstruct.
• OnceacommunityhasbeendeclaredODF, there iscurrently littleprogresstoODF++(primarily attributed to economic challenges) and as such the need for masons andentrepreneursislimited.
Sanitation marketing was intended to be working in conjunction with community basedfinancingsystems, therebyaddressing this issueofeconomicchallenge,andremoving theneed for subsidieswhichweredeemedunsustainable. This approachhas been successfulelsewhere, for exampleevidence fromCambodia shifted focus from subsidy to amarket-based approach and achieved an increase in sanitation facilities through the use of a
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market-model. In this case, families are working in groups and contribute monthly toprovidetoiletstohouseholds.Togethertheypaymonthlyinstallmentsandonrotation,onefamily receives a toilet eachmonthuntil all thehouseholds in the grouphave receivedatoilet(Phyrumetal.2012).FeedbackfromtherangeofstakeholdersindicatedthefollowingchallengeswithfinancingsystemsunderthecurrentODFMalawistrategy:• A number of partners have tried specific community financing systems with varying
ratesofsuccess.Itmustbeconsideredthatvillagebasedsavingandloansschemesarenowubiquitousinruralsettings,andthesehaveworkedverysuccessfully.However,theuse of funds from these schemes may be not being focused on the construction ofsanitation and hygiene facilities but rather school fees, etc. With this in mind, thesystemitselfmayworkeffectively,buttheuseoffundsmaybeprioritizeddifferentlyinthecommunity’sperspective.
• Numerous development partners and government implementers requestedconsiderationofthereinstatementofsubsidies.
Recommendations• Effective sanitationmarketing and financingmodels need to bemore fully integrated
intoCLTStriggeringprogrammes.• There should be an emphasis on the role of sanitation marketing and supportive
EfficacyofDistrictandTraditionalAuthorityteamsanduseofNaturalLeadersInorder toaccelerate implementation theStrategy required thedevelopmentof TA levelteamswhowouldidentifyandincorporateNaturalLeaderstoworkwithDistrictextensionstaff. This element complements the Strategy Component 2 – Involvement of TraditionalandNatural Leaders. As such full feedback on those roles is outlinedwithin that section.However it was also noted by partners that the aim of the TA team was to providemultidisciplinary support to achieving ODF. However in the majority of cases theresponsibility forCLTShad landedspecificallywiththeHSA in thearea,with limited inputfromotherextensionworkers.Recommendations• The implementation, achievement and maintenance of ODF status needs to be
now agreed and adopted through the National Community Health Strategy (2017 –
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2022). As such, community members should be involved through the PrioritisedCommunity Structures (Figure 2a) specifically the Village Health Committee andCommunityHealthActionGroupinconjunctionwiththeDistrictstaffintheCommunityHealthTeam.(Figure13)
theirCLTS/ODFactivitieswhentheybecameroutineactivities.• Datawasinconsistentlyreportedandinsomecasesvalidityiscalledintoquestion.• HSAs in a number of areaswere reported to be using village health committees and
SLTSasatooltopromoteODFDespitetheintentiontouseschoolsasaplatformtopromoteSLTSandsubsequentlyCLTS,itwasreportedthatyouthhadnotbeenactivelyinvolvedinvillagesanitationandhygiene.Nevertheless it was agreed that this should be a considerationwhenmoving forward toimproveyouthparticipationandintegrationofODFmessaging.Recommendations• Issues of sanitation and hygiene including the necessity for open defaecation free
• Leaders would interact regularly with district staff to discuss and support ODFachievement
• Leaders would identify vulnerable households and ensure community support fortheconstructionoflatrinesetc.
KeyfindingsandRecommendations• As outlined above, the TA was recognized as a key level at which teams should be
operating simultaneously to achieve accelerated implementation of CLTS andsubsequentODFstatus.Itwasreportedthattheseteamshavebeenmoreeffectiveinsome TAs than others, and where leaders and TAs were not supportive of thisprogrammetherehasbeenlittleprogress.
• Communitymembers and partners indicated that in some areas households are notmotivatedtochangeastheyseeleadershipwithnolatrines.
• Numerous TAs have utilized by-laws as a means to enforce latrine construction andhave reported success on this basis. However therewere conflicting issues raised byrespondents:o Respondentsindicatedthatby-lawshadsupportedtherapidachievementofODFin
someareas.Forexample“Strong local leadership (sanctions /by-laws)have led toachievementofODF”,(Respondent,MwanzaFGDs).
o Community members reported that they feel the sanitation improvements are‘imposed’on themanddonotnecessarily lead touseor sustainability even if thetoiletisinplace.
o Leadershiphadbeen reported to givepreferential treatment to friendsand familywhentheyimposeby-laws.
o Concernswere raised that the use of by-laws negated the real implementation ofbehaviorchangecommunicationwhichwouldaffectsustainabilityandwillingnesstoscaleuptoODF++
• Stakeholders reported the need for integration in community structures for effectiveimplementation,andthevaluableroleofNaturalLeaders.
• There was little reference from any stakeholder on the use or support of religiousleadersinachievingODF.
• With regard to the awards given, results from FGDs and KII as well as stakeholdersanalysisrevealedthatgivingwasagoodwayofincentivizingthecommunity.However,respondentsnotedthatsomeTraditionalleaderswouldkeepthegifts(especiallyplasticbasinsandcups)forpersonaluse.
support this, after theyhavebeendeclaredODFadditionalactivities shouldbeaddede.g. competitions and rewards, whereby households which are exemplary should berewarded.
• Consideration shouldbegiven to the integrationof theODFandHWWS strategies toone strategy in the future. It must be borne in mind that these strategies can alsobenefitfromstand-alonestatuswhichallowstheireasyintegrationwithotherstrategiessuchaswater,maternalhealth,nutrition,communityhealth,etc.
• EffectiveuseofWaterandEnvironmentalSanitationNetwork(WESNET)tocoordinatebetween national publicity campaigns to ensuremessage integration and best use offunds.
Keyfindings• Documentation of the success, failure, or lessons to be learned from CLTS and ODF
achievements ishaphazard.Naturally, there isan inclination for those involved in theinnovation (either through its implementation or its funding) to claim success for it.Fromthedocumentsobtained in thedistricts, ithasbeenshownthat therewas littlecomparativedocumentationofwhatworkedandwhatdidnotonaprogrammaticbasisinordertodeterminewhetherornottheprojectswereinfactreplicated,orcreativelyadapted,forexpansion(Dutton,etal,2011).Thisreviewcanhelptoidentifyingwhereandwhytheyhavefailedorsucceededandthefutureroutetobetaken.
• Results from the FDGs and KIIs indicated that ODF achievement was attributed tosupport and zeal frompartners,multi-sectoral collaboration and better coordination.OneoftheparticipantsfromtheKIIsechoedthat“Propercoordinationworkswonders”.
4.2.2 HandWashingWithSoapCampaign(Strategy)2011–2012The HWWS Campaign 2011 – 2012 for Malawi was developed in consultation with keyMinistries and partners. The overall objective was to accelerate the adoption of HWWSbehaviour in Malawi. The Campaign adopted 8 strategies to achieve this as outlined inFigureX.
KeyAssumptionsThe assumptionsmadewere that the campaignwill promote handwashingwith soap atcriticaltimeswithspecificemphasison:
a. Beforepreparingfood(particularlyforinfantsandbreastfeeding)andeatingb. Aftervisitingthetoiletandcleaningababy’sbottom
KeyfindingsRespondents indicated that themajority of households are awareof the key timeswhentheyshouldwashhandsbuttherearestillbeliefswhichaffecttheuptakeofhandwashingwithsoap.• Households wash hands with water only and do not see the value of using soap to
• The use of PHAST to promote handwashingwas contradictory to the use of disgustthrough the CLTS approach. This may have led to confusion in facilitators on theapproachtobeused.ThiswouldalsohavebeenimpactedbythegreateremphasisonODFachievementwithoutHWWS.
• The concept of using schools and children as agents is still awelcomeone but needsbetterintegrationandstructure:
o HSAs to bemore involved at schools for sanitation andhygiene advice andsupport
o School WASH guidelines to be completed and implemented to set specificstandards.
o Schools tobeprovidedwitha rangeof lowcostoptions forHWFwhichareappropriate of high number of students. This includes the use of soap andprotectionagainsttheft.
SincethelaunchoftheODFStrategyandHWWSCampaignin2011and2012,respectively,anumber of sanitation and hygiene programmes have been implemented to support theGovernment ofMalawi’s efforts tomeet its sanitation and hygiene goals both under theMDGandSDGframeworks.
4.3.1 GovernmentFrameworksTopromoteandensurethesupportofOpenDefaecationFreeandHandWashingWithSoapby all by 2015, the Government ofMalawi have a number of underpinning policies andstrategiesasoutlinedinTable5.Table1:PoliciesandstrategiesthatprovidedirectguidanceforsanitationandhygieneinMalawi
Promotion of participatory approach in sanitation and hygiene inrural,urbanandinstitutionalsettings.ThepolicyprovidesguidelinesforthedevelopmentofanInvestmentStrategythatwillbesupportedbydevelopmentPartnersunderaSectorWideApproach(SWAp)forsanitation
Provide guidance in the implementation of health promotioninterventions for all the stakeholders in health and other sectors.‘ThegoaloftheHPinMalawiis:‘toreducepreventabledeathsanddisabilitythrougheffectivehealthpromotioninterventions’.
Source:MalawiNationalHealthpolicy,2012.DeGabrieleandNgwale,2017&Stakeholdersanalysis,May2017)ThesePoliciesandStrategiesprovide thebasis for supportingODFandHWWScampaignsandprogrammes.
4.3.1 SupportingprogrammesODF and HWWS implementation have been supported by a number of programmes andagenciessince2011.Throughoutthisperiod83TraditionalAuthoritieshavebeendeclaredODFwhichwerefundedprimarilythroughtheGlobalSanitationFundandUNICEF(Table2)Table2:ODFDonors
4.3.2.1 GlobalSanitationFundOne of the main programmes is the Accelerated Sanitation and Hygiene PracticesProgramme (ASHPP) (2010 – 2017) managed in country by Plan International and its
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collaboratingpartners.Theprogramwasagovernment-lednationalinitiativeonsanitationand hygiene funded by the Water Supply and Sanitation Collaborative Council (WSSCC)throughtheGlobalSanitationFund(GSF).Theprogramsaimedtosupportcommunitiestoachievethefollowing:• Reduceopendefecation, increaseaccess to improvedsanitation,coverageanduseof
inWASH.Support the planning and implementation of sanitation and hygiene promotionactivitiesatdistrictlevel(Planinternational,June2017).
Reports from the ASHP Program (2017 outcome survey Report) established an overalllatrinecoverageof99.2%whichwashigher than64.5%and87%notedduringbaseline in2012 and Outcome survey of 2014, respectively. Respondents were asked to show theirlatrine,therewerenosignificantvariationsbetweenmales(98.8%)andfemales(99.5%).Pitlatrinewithoutslab/openpitwasthemostprevalenttypeoflatrineownedby82%oftherespondent households who owned latrines. Most of the latrines had drop-hole covers(74.7%) this was contrary to the findings of the ODF sustainability studies conducted byDeGabriele andNgwale (2017) and intact floors (84.4%) to assist in the reductionof fliesmovinginandoutofthelatrines.Overallthelatrineutilizationinallthesurveyedareaswasvery high at 99.2%. This program as explained above had an objective of increasingsanitationtocurbOD(OutcomeSurveyFinalreport,2017).Results fromtheASHPProgram (2017outcomesurveyReport) further report thatoverallself-reported attainment of ODF status of communities of the respondents in the studyconducted by Kumwenda et al. (2017) was at 82.9%. During the outcome survey, anassessment at household level was conducted to check if therewas use of latrine by allhouseholdmembersandthattherewerenofaecesinthehouseholdsurrounding.Similarly,anobservationwasmade to checkpresence/absenceof faeces in the village. Inspectionsaroundthehouseholdpremisesfoundthatmostofthehouseholds(98.3%)didnothaveanyhumanfaecesinthehouseholdareaoraroundthecompound.However,about37.8%ofthehouseholdshadanimalfaecesinthehouseholdareaoraroundthecompound.Theseresultspoint that indeed other programmes contributed to the attainment of theODF status inotherareas.
4.3.2.2 UNICEFUNICEFisaleadingdonorintheruralwatersupplyandsanitationsectorinMalawi.UNICEFiscommittedtosupportingGovernmenttodevelopcapacities,policiesandsystemsthatwillstrengthen the sanitation sector as a whole. UNICEF’s commitment to sector---wideinitiativesweredemonstratedthroughtheirsupportofCLTSprogramsin14districtsacrossMalawi.
TothisregardUNICEFsoverallgoalofthe2012-2016initsCountry(Malawi)programmeisto support national efforts to progressively realise children’s andwomen’s rights through
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improved child survival, development, protection and participation. The purpose of thesurvival component is to ensure that all children inMalawi reach their 5th birthday andthereafter grow and realize their full potential. Early childhood and adolescentdevelopment,basicqualityeducationforall,participationbychildrenandyoungpeopleinmattersofnationalinterest,andpreventionofHIV/AIDSamongadolescents.SupportingtheGovernment todevelopaNationalChildProtectionSystem.Moreover,UNICEFrecognizessocialprotectionasafundamentalrightforchildren.Promotingsocialinclusionofthemostmarginalizedhouseholds,especiallychildrenandwomen,throughevidence-basedadvocacywithknowledgegenerationonemergingissues.
Ensuringthatchildrenandwomenhaveaccesstosafewaterandappropriatesanitationandthat they learn healthy hygiene practices is a big determinant of children survival anddevelopment.UNICEFMalawihas taken slides in thepromotionofWater, Sanitation andHygiene with water-borne diseases being among the major causes of death in youngchildren in Malawi, providing safe water and improved sanitation takes on urgentdimensions.
4.3.3 ModelDistrictsItisworthnotingthatBalakadistrictisanexampledistrictrealizedbystakeholdersatboththe learning event meeting of May, 2017 and also at the annual review meeting inNovember,2017.Box1highlightstheareasthatcontributedtotheirsuccess
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Box2:PrinciplesthatfacilitatedthesuccessoftheODFInitiative:ThecaseofBalakaBalaka district achieved over 95% Open Defecation Free (ODF) status five years afterimplementationoftheCLTSinterventioninitscommunities.Meanwhile,Balakaisknownasthe district that hasmore TA’s declared ODF than any of the 28 districts inMalawi. Theissues below, drawn from the positive lessons learnt in Balaka district, are key principleswhichenhancedtheeffectiveimplementationoftheODFintervention:Effective collaboration and better coordination: In order to identify, plan and developoptions, a multi-sectoral approach was adopted. Partners were encouraged to workcollaborativelytogetherandinsodoingprovideaunifiedandseamless levelofsupporttocolleagueswithinandbetweeninstitutions(e.g.totheDEHO,WASH,SHINcoordinatorsandNGOs at the district, EHO at the health centre to HSAs, volunteers and members atcommunity level). Thisapproachoffered a joint initiativewheremembers shared tasks tomake the best use of skills and resources that were available both within and betweeninstitutions.Participationbyall: therewasactiveparticipationbyallplayers includingholdingplanningmeetingstogether(i.e.allpartners)atdistrictlevel,mappingoutactivitiestogether,holdinghousehold visits together and evaluating the program together. In addition, the teamencouragedinformationsharingatalllevels.Passion and Commitment: both implementers and communitymembers were passionateandcommittedindividualsandusedthesecapabilitiestoworktogethertoimprovetheCLTSinterventionBasic skills enhancement: although the ODF initiative did not require expert skills toimplementsinceitonlyencouragesanincreaseinlatrinecoverage(ref),stilltheawarenessonODFapproach itself includingconstructionofbasic latrinesandhandwashingfacilitiesneededsomeformoftraining.Thefollowingweredone:
• CommunityworkerswereorientedandtrainedonCLTS• Demonstrations on how to cast san-plats and hand washing facilities were done
As summarized in the review of the current strategy content there are a number ofrecommendations on content development and areas of the scope that require beingincluded.
• ODFstrategyimplementationhasfocusedonhouseholdswithlimitedimprovementsinschools,andnotactiontakeninotherinstitutionalsettings.Forexample,declaredareashave schools, prisons, markets and health facilities which do not have sufficientfacilities and show evidence of open defaecation. During our survey, we found thatmost schoolshadbasic latrines (i.e.withmuddy floorsandgrass thatched)andoftentimesthelatrineswereinadequatesothatthepupilsresortedtousingthebush.
• There is no reference or integration of ODF strategy with menstrual hygienemanagement.
• Neither strategy has specific reference or support for vulnerable and marginalizedgroups.
• TheODFstrategydoesnotconsiderthewholesanitationchain(capturetodisposal).• ODF strategy implementationwas to be overseen by theNational Open Defaecation
Task Force (NOTF), which represents the Ministry of Health and the Ministry ofAgriculture,IrrigationandWaterDevelopmentwithkeydevelopmentpartnersandcivilsociety.Thishasnottakenintoconsiderationotherministrieswhicharealsocruciali.e.MinistryofEducation,andothers
• The currentODF strategy is limited to the use of CLTS and sanitationmarketing anddoes not take into consideration the use of other participatory approaches such asPHASTandmechanismstoachieveODF.
• Althoughthereistheinclusionof2levelsofODFstatus,thereislittlereferencetotheeffective use of the sanitation ladder to achieve continued improvement andsustainability.
• ThereisalsoagapinharmonizationofdefinitionssuchastheuseofthewordODF.TheJMP report defines OD as “Disposal of human faeces in fields, forests, bushes, openbodiesofwater,beachesorotheropenspaces,orwithsolidwaste”.Thepercentageofhouseholds estimated to be OD is calculated by subtracting the percentage ofhouseholds that have access to any facility. JMP has changed the definitions of theaccesslevels:basicsanitation(i.e.useofwhatusedtobecalledimprovedfacilitiesthatarenotsharedanduseofhigherservicelevelwhichiscalledsafelymanagedservices);limitedsanitation(meaningsharingofimprovedfacilities)andunimproved(e.g.useof
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facilitieswithoutaslaborplatform).Thedefinitionandcriteriaused isdifferent fromthatofMalawiOpendefecation(OD)whichisthedisposalofhumanfaecesintoopenspacessuchasfields,forests,beachesoropenwater,includingbeingmixedwithsolidwaste and disposed of openly. The term is widely used in literature about Water,Sanitation,andHygiene(WASH)issuesindevelopingcountries,includingMalawi.OpenDefecationFree(ODF),ontheotherhand,iswhenhumanfaecesaresafelydisposedof,including into basic latrines or managed facilities. The difference is more on thecalculationandverification(DeGabrieleandNgwale,2017).
• Suitable designs for different segments of communities e.g. the elderly, disabled,childrenandpregnantwomenwerenotconsidered.Oursurvey results shows thatsomepregnantwomenfail touse toiletsas theentranceto the latrine isnormallysmall to allow them get in. Provision for latrines suitable for the marginalizedespecially thephysically challengedwasnot considered in thepreviousODF2011-2015Strategy.
• Participants further observed that there was no emphasis on behaviour change,improvement of school sanitation, HWWS activities and no activities to equipchildrenwithbehaviorchangeinformationonHWWS.
• Some tools used for triggering communitieswerenot acceptable in some culturesi.e. field work revealed that some Ngoni’s in Mwanza did not like the issues ofbringing faeces inpublicandmostparticipants leftwhile triggeringwas in session.However,duringMaleFGD,respondentspreferredtheothertoolsfortriggering
• Designing lower cost latrines through reduced input of expensive materials such ascement
• Facilitating user choice on technology by presenting both construction costs, andoperationandmaintenancecosts
• Providingaccesstosustainablecreditservicesforconstruction• Building capacity for affordable and sustainable support services such as toilet
emptying,processingofwaste,etc.• ProvisionofanenablingenvironmentforprivateenterpriseStakeholders also stated that there is a need to have a better understanding of howsanitationandhygieneanddirectlyorindirectlyimpactonhouseholdincome.
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4.4.1.3 InvolvementofLeadersAsoutlinedabove,theTAwasrecognizedasakeylevelatwhichteamsshouldbeoperatingsimultaneouslytoachieveacceleratedimplementationofCLTSandsubsequentODFstatus.Itwas reported that these teamhavebeenmore effective in someTAs thanothers, andwhere leaders and TAs were not supportive of this programme there has been littleprogress.Thegapsidentifiedinclude:• There was little integration of natural leaders into community structures i.e. village
healthcommittees.Thiswasreportedduringstakeholdermeeting.• There was little reference from any stakeholder on the use or support of religious
• With regard to the awards given, results from FGDs and KII as well as stakeholdersanalysisrevealedthatgivingwasagoodwayofincentivizingthecommunity.However,respondentsnotedthatsomeTraditionalleaderswouldkeepthegifts(especiallyplasticbasinsandcups)forpersonaluse.
4.4.1.5 Networking,CoordinationandIntegrationTherewasagapintheunderstandingonwhateachactorisdoing.ThisledtolackofpropercoordinationacceleratedbyfragmentedworkbytheWASHactorsinMalawi(WESNETDIRECTORY,2017).• Documentation of the success, failure, or lessons to be learned from CLTS and ODF
achievements ishaphazard.Naturally, there isan inclination for those involved in theinnovation (either through its implementation or its funding) to claim success for it.Thereishowever,littlecomparativedocumentationofwhatworkedandwhatdidnoton a programmatic basis, to determine whether or not the projects were in factreplicated, or creatively adapted, for expansion (Dutton, et al, 2011) This review canhelptoidentifyingwhereandwhytheyhavefailedorsucceededandthefutureroutetobetaken.
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• Results from the FDGs and KIIs indicated that ODF achievement was attributed tosupport and zeal frompartners,multi-sectoral collaboration and better coordination.OneoftheparticipantsfromtheKIIsechoedthat“Propercoordinationworkswonders”.
• TheWASHsectorinMalawihasvastactorsbutWESNETechoesthattherewasminimalcoordinationandknowledgesharingofeffortstodriveaconcertedagenda.Therewerevery minimal efforts towards networking and learning in the WASH sub sector inMalawi.
4.4.1.1 DevelopmentofKeyMessagesRespondents indicated that themajority of households are awareof the key timeswhentheyshouldwashhandsbuttherearestillbeliefswhichaffecttheuptakeofhandwashingwithsoap.• Households wash hands with water only and do not see the value of using soap to
improvethis.• Childstools (particularly those from0–6months)donotcontainbacteriawhichcan
causeillness.• Hand washing facilities are not conducive to supporting effective and easy hand
washing.• Use of soap is prioritized for other household activities such as bathing, washing
• TheODF strategy only required the presence of a handwashing facility and soap toachieveLevel2certification.TodatecommunitieshaveprimarilyachievedODFatLevel1whichdoesnothavea requirement forahandwashing facilityand therefore therehasbeenlessemphasisonthispractice.
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4.4.1.3 Ensuringavailabilityofhandwashingfacilities• There is still a significant issuewith thedevelopmentanduseof appropriateHWF in
Malawibothathouseholdatinstitutionallevel.• SchoolsdonothavesuitablefacilitiestoensureeffectiveHWorHWWSforallstudents.• Households may have facilities but lack of access to water can mean they do not
prioritiseuseforhandwashing.• HWF used at the moment are not durable or sustainable as they are damaged by
animalsanddamagedbythesunafterafewmonthsexposure.• PlacementofsoapatHWFisfrowneduponasitisoftenstolenoreatenbyanimals.• There is primarily an emphasis on HWWS for rural communities only without
• The use of PHAST to promote hand washing was contradictory to the use of disgustthrough the CLTS approach. This may have led to confusion in facilitators on theapproachtobeused.ThiswouldalsohavebeenimpactedbythegreateremphasisonODFachievementwithoutHWWS.
4.4.1.5 UseofHealthFacilitiesmodelsforhandwashingwithsoap• Most health facilities and other institutions in theODFdeclared areas had noHWWS
facilities.• Health facilities and healthworkerswere not promoting effective hygiene behaviours
duringclinicsduetolackoffacilities.
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4.4.1.6 UseofMultipleCommunicationChannelsforBehaviourChange• Behaviour change messages were generalized and were not always based on sound
researchandunderstandingofhowthesewouldinfluencepractice.• Messagesthroughdifferentchannelswerenotconsistentandassuchcausedconfusion.• Institutional settings were not using good practice and were therefore not
communicatingeffectivebehaviourchangemessages.
4.4.1.7 PublicPrivatePartnerships• Therewassomebuy in fromtheprivatesectorprimarily throughthesupportofhand
4.4.1.8Othergapsidentified• The HWWS strategy is limited in terms of integrationwith other key strategies (e.g.
Nutrition, mother and child health, immunisations, school health and nutrition, etc.)andrelieslargelyonmassmediaratherthanfocusedbehaviorchangecommunication.
4.5.1 ODFandHWWSChangingAssumptionsAs outlined in Section 4.2, there were a number of key assumptions made regarding the implementation of the ODF strategy and HWWS campaign between 2011 and 2015. These have been explored in detail in that section, however several assumptions have been identified which have directly impacted the achievement of ODF and HWWS in Malawi. These are summarized here and should be considered in conjunction with specific detail in Section 4.
4.5.1.1CLTSasaneffectivetooltoachieveODFandHWWSCLTS has taken hold across SSA since its introduction and is a very credible strategy for eliminating open defecation. Due to the speed with which it is being scaled up, its use as a primary vehicle of elimination of OD and the newness of the approach, it is essential to take note of key lessons which impact on effectiveness and sustainability. At the time of the ODF strategy development for Malawi, the key stakeholders who participated were from organisations involved in CLTS piloting in Malawi. This system was being lauded and adopted across the world in LMIC countries to accelerate achievement of ODF, and to an extent has also achieved this in Malawi since 2011. Nevertheless, use of CLTS as the sole tool for achieving sustained ODF also has its limitations, and these must be carefully considered when moving forward to ODF Strategy 2018. As outlined previously, CLTS is not without , its limitations as a tool, and the impact expected from linked CLTS with sanitation marketing has not been realized to date in rural populations. However there were also concerns raised from respondents on the challenges of harmonisations across the country when so many partners are involved in implementation. During the stakeholders’analysis,therewasaconcernaboutmovingtowardsharmonization,ifthatwasinterpretedto mean that one approach is the only approach. However it was agreed that there issignificant value in trying to synchronize key principles that allow governments andimplementerstomakedecisionsthatmatchtheneedsoftheirpopulations.Therewasalsoan agreement that other approaches should be considered and documented to supportCLTSandthatallapproachesmustemphasizeuse,equityandsustainability,andasharedcommitmenttoworkinginpartnershiptoavoidduplication,maximizeresourcesandensureimpact.TherewasalsotheassumptionthattheHWWScampaignwouldworkhandinhandwith the CLTS triggering programme.Howeverwith a primary focus on achieving Level 1ODF,therewaslittlesupportoremphasisplacedonthevalueandimportanceofHWWS.
4.5.1.2HSAsandTraditionalLeadersasImplementersThe strategy assumed the full and effective participation of HSAs and Leaders in theimplementationofCLTSandachievementofODF.TherehavebeenanumberofchallengesidentifiedinthisareawhichhavehinderedachievementofODF.Asoutlinedpreviously,HSAswereactive inmanydistricts in implementation,andutilizedtheirvillagehealthcommitteeseffectivelytosupportthisactivity.However,particularly inthosedistrictssupportedbypartners,HSAsreceivedadditionalpaymentsandallowancesto
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undertake this work, and as such this did not effectively integrate the achievement andmaintenance of ODF into their routine tasks. Once seen as a ‘project’ they were thenunwillingtoundertakesanitationrelatedactivitieswithoutthesupportofadditionalfunds.It was agreed that HSAs are key to the achievement andmaintenance of ODF, and theyshould be supporting and supervising their communities to achieve this as part of theirroutineactivities.TheproductionoftheCommunityHealthStrategy(2017–2022)andtheRole Clarity Guidelines (2017) by the Community Health Services Section has helped toclarifystructuresforhealthservicedeliveryatcommunitylevel,andthatincludestheroleofcommunityhealthteams,HSAsandcommunityhealthvolunteers.Thesedocumentsshouldbe used as a guiding tool for the ODF strategy to ensure clarity and consistency forimplementation.In the case of leadership, there were a number of areas outlined including the use oftraditional, religiousandnatural leaders. It is clear fromthis review that therehavebeenvarying degrees of success with the use of these leaders, and particular challenges withtraditional leaders where they have failed to provide support. There have also beenchallengeswhere communityhealth volunteers and leadershavenotdemonstrated goodpractice at their own households, and are therefore not the role models required topromote change. These situations have led to several concerns in ODF achievement. Forexample, leaders using by-laws to achieve ODF by refusing health services or extractingpaymentasfines.Thestrategymustconsiderwhethersomeoftheseby-lawsmay leadtolifethreateningsituationsorgoagainsthumanrights.Leadersmayalsofavourfriendsandfamily during verification processes and protect those who are not meeting the targetindicatorstherebysendingthewrongmessagetoothercommunitymembers,andleadingtoODFcertificationwherethenecessarystandardshavenotbeenmet.Itisthereforeclear,that a more detailed understanding is needed of leadership roles in achieving ODF andsupportingtheprocessandsustainedchangeofacommunity.Theremustbemechanismsthatensuretransparency,objectivityandequityacrossallcommunitiesandhouseholds.
4.5.1.3VerificationofODFwouldbeatransparentobjectiveprocessThe verification process is currently ineffective and costly. Inconsistent criteria andproceduresfordeclaring,certifyingandverifyingODFachievementhavebeenreportedascommonconstraintsinmanycountries.Inseveralcountrieswherenationalcriteriahavenotyet been agreed, different implementing agencies adopt different criteria and followdifferentprocesses,withsomereportedtobe lessrigorousthanothers,asituationwhichalsoexistsinMalawi.
Indonesia and Timor-Leste were the only countries identified where an ODF verificationprocesshasbeen finalizedat thenational level. Forexample the stringentODFcriteria inIndonesia require that every household owns and uses an improved sanitation facility,whereasinothercountries,includingTimor-Leste,theODFcriteriaallowsomehouseholdstosharelatrineswithinODFcommunities.ODF verification is important because it provides some guarantee that commonly agreedODF criteria have been reached, and that these criteria have been assessed by anindependent group sometime after the ODF status was originally declared by the
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communityorimplementingagency.WhileanODFverificationprocesswillnottellusmuchabout the sustainability of sanitation outcomes, it provides a more reliable source ofprogress data, and often encourages government involvement. Standardized ODFverification criteria are needed in order to assess the nation’s progress towardsmeetingODFandSDG6,aswellastoallowforprogresscomparisonbetweendistricts.MaintenanceoftwolevelsofODFachievementisrecommendedalthoughthecriteriawithineachshouldbereconsideredunderconsultation.
4.5.1.4MaintainingODFandclimbingthesanitationladderThe final keyassumptionmade in the2011–2015 strategywas that theachievementofODFstatuswould leadtosustainedbehaviorchange,andthathouseholdswouldbegintoclimbthesanitationladderandbegintoachieveLevel2status.Instead,thecurrentsystemhasseenthecelebrationofODFLevelStatusbefollowedbyalackofsustainedchange,andalevelofslippagebacktoopendefaecationwhichnegatestheinitialachievement.ThisalsoremovesanypressureorsupporttoputinplaceinfrastructureorchangebehaviourtowardsHWWS,asthiswasonlyanindicatorofLevel2ODFachievement.The2011–2015strategyhadaprimaryfocuson‘triggering’communitiesintoaction;whileconsiderably less resources andemphasison followingupandmentoringof communities‘post-triggering’. Thiswas also identified as a concern by Thomas and Bevan (2014)whoreviewedtheprocessesandprotocolsfordefining,reporting,declaring,certifyingODFandsustaining ODF, highlighting where the process varies between countries and potentialdeterminants of sustainability within the process itself. They identified two keydeterminants to reduce slippage which were (1) quality of facilitation, and (2) post-triggeringvisitsandmonitoring.Qualityoffacilitationhasvariedacrossthecountry,andasstated above implementation has been undertaken by a number of different agencies.Therewasanassumption that achievementofODFwould indicate that communitieshadtruly achieved ODF in terms of both infrastructure and behaviour change. However asevident from the sectionabove, thishasnotbeen the case inmanypopulations,with lipservicepaidtotheprocess,andachievementbeingaresultofpeerpressureratherthanadesiretochange.Thisiscompoundedbythefactthatmanyprogramssimplydon’tbudgetorhavethetimelinestosupportpost-triggeringfollowonandseeanODFdeclarationasthechief outcome. However, in most cases, post certification is exactly the point at whichcommunitiesarelookingforsupporttoaccesssanitationproductsandservicesandadvice.Currentprogrammingandreviewprocessesmustlookatincludinginnovationssuchaspost-ODF sustainabilityplans and linkingpost-ODFmonitoringmoreeffectivelywith SanitationMarketingefforts.Thefrequencyofpost-certificationvisitswillvarydependingonneed,butshouldideallybeatleastoncepermonthduringthefirstyear.ThisreviewprocessshouldalsoconsiderthestandardsbywhichacommunityachievesODFstatus.AtpresentMalawihas2levels(Box1).Itisrecommendedthatthesearesubjecttoreview,andthatthestrategyshouldreflectawiderscopeforcommunityhygienestandardsthan just the elimination of open defaecation. For example, the ODF protocol can beleveraged to yield enhanced health outcomes such as handwashing with soap and safedisposalofchildren’sfaeceswhichcaneasilybeincorporatedintothetriggeringprocessandwhich are key elements of the definition ofmaintaining anODF environment. This could
4.5.1.5UsingInstitutionsasmodelsitesforeducationandsupportBoth the HWWS and ODF strategies required the use of schools, health facilities andhospitals asmodel sites for education and training onHWWS and promotion ofODF. Allstakeholdersindicatedthatthelackofspecificrequirementsandtargetsforthesefacilitiesmeant that these supposed ‘model’ institutionswere in fact demonstrated poor practicerather thanpromoting the ideal.ODFandHWWStargetsmust includepublic spaces (e.g.markets) and institutions to ensure that standards aremaintained across a population toensureeffectivebehaviourchangeisachievedandsustained.
4.5.1.6EffectiveBehaviourChangeCommunicationIntegraltothesuccessofalltheseareasistheneedforsustainedbehaviourchangeacrossthe population. As such, there needs to be a well-trained quorum of community healthteams volunteers who understand the key principles behind CLTS and HWWS behaviorchangepractices.Onlythenwilltriggering,supportandeducationbetargetedeffectivelytoachievesustainedbehaviourchange.
4.5.2 Cross cutt ing issues
If we are to achieve the SDG 6 targets by 2030, then the ODF and HWWS with soapstrategiesmust consider emerging principles and recommendations,whichwork towardsequitable and adequate sanitation for all by 2030. (Myers and Gnilo 2017). Key to thisprocess iseffectivelearningfromthelast7years.This isdifficultasdocumentationofthesuccess,failure,orlessonstobelearnedfromtheseexperimentsarehaphazard.Naturally,there is an inclination for those involved in the innovation (either through itsimplementationor itsfunding)toclaimsuccessfor it.Thereishowever, littlecomparativedocumentationofwhatworkedandwhatdidnotonaprogrammaticbasis, todeterminewhetherornottheprojectswereinfactreplicated,orcreativelyadapted,forexpansion.Byrevisitingthesesanitationprogrammesthroughthisprojectandidentifyingwhereandwhytheyhavefailedorsucceeded,muchcanbelearnt(MinistryofHealth,Kenya,2016)
4.5.2 General recommendations from stakeholders for inclusion to updated Strategy
• Revisit the no subsidy notion on building of toilets in communities inrelationtosustainability.
Sustainability • DevelopstructuredpostODFactivities• Specificallyrecognizenaturalleaders,superviseandsupportthem• Clearly define toilet standards to be used in CLTS – encourage the
• SLTSguidelinestobedevelopedanddisseminatedeffectively.• Schooltoiletstandardstobefinalizedanddisseminatedeffectively.• Ensure adequate toilets in schools. Furthermore, cleanliness of toilets in
schools needs to be emphasized in order to encourage usage. Somestudentsresorttousingthebushduetoinadequatetoilets.However,somepupilsdon’tusethefewavailabletoiletsforlackofcleanliness.
Innovation • Showavisiblelinkbetweennonwashingofhandsanddiseases• DevelopmoreBehaviourChangetechniquesinthenewstrategies.• Develop and introduce better sanitation technologies that can withstand
badweather• Developlatrinessuitableforthemarginalized.• Improveprivacyinthetoiletsespeciallyforwomen.• Include the whole shit flow diagram in the new ODF strategies, what
happenswhen the toilets are full, especially in schools?Wemay need todevelopemptyingstrategiesamongothers.
4.6 HowthestrategieslinkinwithotherWASHrelatedstrategiesandapproachesThenowoutdatedODFMalawiStrategy (2011–2015)andHWWSCampaign (2011-2012)was developed in line with one of the provisions within National Sanitation Policy 2006,whichstatesthat“OpendefecationshallnotbetoleratedinMalawi”.ItwasalsodevelopedinlinewiththeNational10YearSanitation,HygieneInvestmentPlanandtheSanitationandHygiene Master Plan for Low income areas and the Health Sector Strategic Plan. TheSanitation Policy stresses the need to create public awareness on improved sanitation,create effective linkages between all relevant sanitation stakeholders and promoteintegrated and holistic planning, development and design of sanitation and hygienepromotions initiatives and programmes. The policy also emphasises the need forundertaking relevant training and capacity building of government staff, school children,teachersandcommunitymembersinsanitationandhygienepromotionrelatedissues.
At the time, the strategy and campaign were aimed at aligning, synchronizing andharmonizingsanitationandhygieneinitiativesandinterventionstowardsmeetingthegoalsof the Malawi Growth and Development Strategy (MGDS) II (2012 – 2016) and theassociated Millennium Development Goals (MDG) 1, 3, 4, 5, 6 and 7 by the year 2015.PreventionofdiarrhoeaandpneumoniawouldthereforecontributesignificantlyinmeetingMillennium Development Goal (MDG) number four which is aimed to reduce deaths inunderfivechildrenbytwothirdsby2015.
Theoutdatedstrategyneedstonowbealignedwiththecoreupdatednationalpolicieswitha specific focus on Sustainable Development Goals 6 which requires universal access toimprovedsanitationandhygienebytheyear2030.These includetheMalawiGrowthandDevelopment Strategy III, Health Sector Strategic Plan II, Sanitation Policy and theCommunity Health Strategy (2017 – 2022). Any revisions and changes to the ODF andHWWSstrategieswillrequireintegratingwiththerequirementsofthesefocaldocuments.
5.0 CONCLUSIONOverall,findingsfromthedeskreview,fieldresearchandstakeholderconsultationmeetingsuggest that Malawi has made strides in increasing latrine coverage. Still there arechallenges,weaknessesandgapsthatneedtobeconsidered inrevisingthenewODFandHWWSstrategies.
InrelationtoODFandlatrinecoverage,thecountryhasonlymanagedtoreachlevelone(1)ofODFwherecloseto80%ofcommunitieshavebeentriggeredandapproximately40%ofTAshavebeendeclaredODF.SpecificallyfortheTAsdeclaredODF,therearenovisiblesignsofhumanexcretasignalingthatcommunitymembersdisposeoftheirfaecalmatterinapit-latrine.However, theavailablepit-latrines (i.e. traditionalpit-latrines)areofpoorquality,weakandcannotwithstandextremeweathers (e.g.heavyrainsandwinds)andoftenendupcollapsing.Thecountry isyettoattain level2ofODFwheremoredurable latrines(i.e.improvedpit-latrines)shouldbeconstructedsoastosustaintheODFstatus.Theevidencegeneratedbythisassignmentsupportsthepromotionofconstructionanduseofimprovedpit latrines for scaling-up the latrine coverage in both households and institutions (e.g.schools)withintheTAs.ApartfromthepoorqualityoflatrinesintheTAsthatweredeclaredODF,institutions(e.g.schools,hospitals,prisons,marketplacesandtradingcentres)withinthe TAs have inadequate pit-latrine coverage. The evidence generated through thisassignment suggests that policy makers and/or NOTF should ensure that for a TA to bedeclaredODF,anyinstitutionswithintheTAshouldalsodemonstratethatithasadequatesanitation.
WithregardstoHWWS,asignificantfindingwasthatcoverageofHWFisextremelylowataround30%andinselectedTAsnationwide.AkeychallengeistheabsenceofdurableHWFwhich can withstand extreme weathers (especially heat from the sun) and cannot bevandalized. This then calls for efforts to come up with hand washing facilities that areconstructednotonlyusinglocallyavailablematerialsbutthattheyshouldbedurable.Thelow coverage of HWF has also affected hand washing behavior where only a handful ofcommunitymembersreportedthattheywashtheirhandsafterusingthetoilet.ObviouslywiththelowcoverageofHWF,improperorineffectivehandwashingisexpected.Ourreviewrevealed that the practice of hand washing is a challenge even to households that haveHWF.Whilesomeparticipantsexpressedthatscarcityofwaterrestrictsthemfromhavingwaterinthehandwashingfacilityandsubsequentlyaffectingtheirwashingofhandsafterusingthetoilet,someparticipantsexpressedthattheirHWFareoftenvandalizedbyanimalsandchildren.Fromthereview,italsoemergedthatHWWSisnotcommonlypracticedandthatsoapisconsideredasascarceand/orexpensiveandvaluedcommoditythatisusuallyprioritizedforotherimportantusese.g.forwashingclothesandnotforhandwashing.Formany,washing theirhandswithplainwater isenough.This finding illuminatesa rangeofcontextualfactorsthathinderhandwashingandshowsthatHWWSisnotprimarilyvalued.ThisthencallsfordemonstrableinnovationsbeyondtheskillofmakingHWFthatwillmakepeoplechangetheirbehavior,valueandprioritizeHWWS.
It is clear fromthe feedback fromall stakeholdersanddesk review, that futurestrategiesmust address concerns regarding integration of sanitation and hygiene programmes toensuresustainedchangeacrossMalawiandachievementoftheSDGsby2030.
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Withthisinmind,itistheoverallrecommendationofthisreviewthatthecurrentODFandHWWS strategies should be integrated into a more general ‘hygiene and sanitation’strategy.ThiswouldsupportnotonlytheintegrationofHWWSandODFprogrammes,butalso the inclusionof key issues raised in stakeholdermeetings suchasmenstrualhygienemanagement and solid waste management (including faecal sludge management). Thiswouldbeanallencompassingstrategywhichtargetsruralandurbanpopulations,domestichouses, commercial premises and institutions across the country. Only then canMalawitrulymeetthetargetofUniversalSanitationandHygieneforAll.
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