Updated: Wednesday 11 January 2006

Program Characteristics of Scale

Program Characteristics of Scale

HIP has identified key characteristics that help to achieve scale: multiples (stakeholders, levels, options and interventions), partnerships, private sector involvement, mainstreaming, sustainability and saturation. These characteristics are intertwined when working to achieve scale.

Multiples: To work at scale, HIP will ensure that a full complement of players, at different levels, uses a range of interventions and provides appropriate options to achieve sustained change.Key ways programs should be inclusive are:

Multiple Players – Achieving change at scale requires the collaboration of a wide-range of health and non-health as well as public and private sector players, to participate in a coordinated effort for hygiene improvement.Essential stakeholders include various public agencies – water, education, road and water works, agriculture and health ministries; and private sector players including PVOs, FBOs, indigenous and international NGOs, media and manufacturers.

Multiple Levels –Involving multiple players implies working with players at the international, national, regional, district, community and household/individual levels. This allows for impact at scale because working at various levels allows planners to assure the enabling environment and access to necessary products. Specifically, areas addressed by the various levels might include policy, norms, and access to information, products and services.

Multiple Interventions – A coordinated strategy for behavior change must involve a range of interventions to address hygiene improvement within a given context.Multiple interventions include 1) communication through various channels; 2) capacity building through training, supervision and other approaches; 3) service provision, infrastructure, hours and consumer-focused services; 4) increased accessibility of products such as soap, water, containers and water purification products; 5) policy and advocacy at district, national and international levels; 6) other social and organizational change interventions such as social marketing and community mobilization.

Multiple Options – Having choices is important when encouraging new practices. Often, development has overlooked the importance of offering choices to the poor. These options can be technological (different latrine models or soap sizes) or financial (different financing schemes for technology to assist in adopting or maintaining practices), or sets of practices from which to choose. Choices must all be efficacious and should consider a range of issues: urban vs. rural, socio-economic status, gender differences, and water access.

Multiple Hygiene Practices – The literature is not clear on the effect of promoting one versus multiple key hygiene practices at a time. In general, behavior change theory supports limiting the number of practices to address at one time, but promoting related cluster behaviors has been successful in the hygiene and sanitation field. Therefore, HIP will examine the implications of working simultaneously with these three key practices to achieve scale and sustained improved behavior, and document best practice with regard to the promotion of single or multiple behaviors.

Partnerships:As mentioned earlier, multiple players often work side-by-side but do not reach the same target groups. HIP’s role is helping to coordinate these efforts so that synergies can be realized and economies of scale achieved. HIP will bring together donors to ensure efforts are complementary and to maximize their results. Likewise, HIP will encourage governments to promote policies that support hygiene improvement programming, that enhance private sector partnerships, and that capitalize on donor contributions.

Private sector involvement: The private sector is not always included in health and hygiene programming, yet private-sector products are involved in most hygiene improvement efforts. HIP aims to work with a wide range of private sector partners from manufacturing and commercial entities that sell hardware and essential hygiene improvement products such as latrines, soap, and water disinfection treatment options, to non-governmental and faith-based organizations that design and deliver water, sanitation and hygiene programs for various populations.

Mainstreaming:Integrating hygiene improvement into existing programs is seen as critical to promoting sustainable improved hygiene practices. The literature discusses the failure of hardware without the accompanying promotion necessary to effect sustained behavior change. Thus, as hygiene improvement approaches are integrated into a wide variety of programs both in health and non-health areas, the approach is sustained, and the messages multiply. For example, mainstreaming hygiene into education[1] will mean integrating hygiene improvement information and activities into primary and secondary schools, relevant professional education such as teacher or health worker training, PTA programs, etc.Moreover, schools must have latrines, water and soap available to practice and reinforce proper hygiene behaviors. Mainstreaming hygiene improvement into HIV/AIDS[2] programs would get HIV counselors, PLWHA networks, health workers, home-based care educators and others involved in the system to include hygiene improvement in their activities.The purpose of mainstreaming is to transform hygiene improvement from being an isolated development objective to being a component of various health and development programs.

Sustainability: Hygiene improvement is contingent on positive changes being sustained over time. HIP’s approach to long-term sustainability in hygiene improvement will focus on several actions.

Strengthening capacity is a key component of HIP’s efforts to achieve sustained hygiene practices at scale. HIP will build the capacity of countries to design, manage and implement behavior change programs around hygiene practices so that these activities can continue long after HIP leaves the scene. The key to HIP’s capacity strengthening approach is to coordinate different actors so that the whole system is refocused and structured to reinforce the improved hygiene practices. By emphasizing the system, for example, integrating hygiene into school curricula instead of only training teachers in proper hygiene practices, HIP intends to break the cycle of training individuals, who leave little behind once they leave the system. HIP will also strengthen the capacity of PVOs/NGOs involved in water, sanitation and hygiene programming to implement hygiene improvement at scale so such an approach and accompanying tools and guidelines will spread through these organizations and be replicated around the world – even beyond HIP’s focal countries.

Policy also affects behaviors.Programs at scale must target policies that can enhance or inhibit adopting and sustaining new practices. HIP will work at both global and country levels to contribute to the evidence and knowledge base to support advocacy around hygiene improvement and to streamline policy decisions.

Mainstreaming, as mentioned above,
is vital to the long-term sustainability of hygiene improvement.It also changes social norms, which are required to ensure that good hygiene behavior becomes habit. Long-term sustainability of hygiene improvement efforts requires incorporating HI practices into ongoing programs that then become a routine part of established efforts, such as nutrition and child survival programs and agricultural extension projects.

An equally vital area of program sustainability is education.While this goes hand-in-hand with mainstreaming, it places special emphasis on ensuring that hygiene improvement becomes a standardized portion of all educational curricula, i.e. in primary and secondary schools, pre-service training, and in training in different sectors. Long-term hygiene improvement sustainability requires that hygiene improvement be an established part of generation-to-generation learning, not a one-time campaign or program.

As the HIF clearly demonstrates, hardware and infrastructure, along with hygiene promotion and enabling environment, are critical to sustainability: one without the others is ineffective and insufficient.In the 1980s and early 1990s, the global community focused almost exclusively on hardware, and the health impact on diarrheal disease incidence was limited.A recoil from this hardware emphasis led to an equally unbalanced emphasis on hygiene promotion over the last decade.And though hygiene promotion yielded some successes, it too was insufficient.As the HIF illustrates, all three components are necessary.Effective, sustainable hygiene improvement efforts necessitate an equitable, appropriate combination of access to hardware, hygiene promotion and enabling environments. Long-term sustainability of hygiene improvement efforts requires that the requisite hardware and infrastructure be in place.

Saturationis vital for changing social norms. Lasting change ultimately depends on a critical mass of people – individuals, families, groups, communities and countries – taking action and implementing new social norms. Accelerating social norm formation can occur when targeted individuals encounter the same focus on key practices at every key contact point in their lives.[3] Individuals then assume the promoted behavior as a social norm and adjust their own behavior to conform to it. And as many psychological and anthropological studies attest, individuals desire to conform to their social peer group. Peer pressure is a powerful re-enforcer of social messages. Peer pressure accompanied by enabling environments is vital to sustainability.

[1] See also the UNICEF / IRC school sanitation and hygiene education programme. http://www.irc.nl/sshe

[2] See IRC's Thematic Overview Papers HIV/AIDS and Water, Sanitation and Hygiene http://www.irc.nl/page/3462

[3]Smith et al., Philippines, 2002