2nd Africa San Conference 2008: African Ministers Endorse a Plan of Action for Sanitation
Sanitation was still just a dirty word at the 1stAfrica San Conference five Years ago in 2002. Although the MDGs had been articulated, the message had not filtered down to national level, and it was rare for top African leadership to even tag Sanitation onto the end of Water supply projects, let along designate a budget for building latrines. So great progress in the fight for safe sanitation was made visible when we saw 32 Ministers from across Africa, standing side-by-side on stage in Durban, looking slightly coy, holding their Africa San balloons, like happy children with their party bags. As they simultaneously let go of the balloons to end the Conference, the Action Plan for Sanitation in Africa was launched and over 500 delegates ululated and cheered the new commitment to forge ahead and meet the MDG targets for Africa to halve the number without safe sanitation by 2015.
At present there are an estimated 234 million open defecators (ODs) across the Africa continent, and only a handful of countries in Africa are on track to meet these ambitious MDG targets. However it is encouraging that one of the first stumbling blocks is being addressed, the lack of political will. To reverse this dire record of disinterest in the subject of open defecation, these 32 Ministers have pledged to return to their countries and produce Action Plans of their own by the end of July 2008. Given the cost-effectiveness of our approach, we hope that many of these plans will include the recommendation to start Community Health Clubs in their countries.
It is one thing to pledge support and provide the political will, but it is another thing altogether to find a successful plan of implementation which can convert these simple undertakings into reality. One key undertaking in this international Action Plan that is critical is the commitment to provide an enabling environment to ensure that the methodologies that can stimulate demand-led sanitation are given support. There were a few main strategies cited to operationalise the scaling up of sanitation, two of which were discussed at some length at the Conference in the smaller groups. As not everyone had the chance to follow the debate which was focused on how best to trigger behaviour change, our perspective is summarised below.
Community Led Total Sanitation (CLTS)received a high profile at the Conference with the presence of the initiator, Kamal Khar, as well as the much acclaimed author on participatory approaches, Robert Chambers, in person. These two strong advocates provided a persuasive team for CLTS, a quick-fix system for ensuring ODF (open defecation free) villages by shaming villages into compliance by disgust for excreta pollution of water. This ingenious method has caught on in Asia on a large scale; however, the question remains whether this method is culturally suitable for much of Africa, where political correctness often ensures that public criticism is swept under the carpet in favour of overt politeness. CLTS does provide a ‘sticking plaster’ to cover the open sore of faecal contamination but it does nothing to address the underlying cause of diarrhoea disease, poor understanding that leads to risk practice. People can be made to clean up the village for a time when the warden is on patrol, but is this a sustainable approach? The authoritarianism reinforces existing village elites, mainly men, and may do little to provide women with a structure to challenge the status quo. Another question is important: what happens next after ODF? Can CLTS capitalise on the mobilisation achieved to clean up the village to move onto other initiatives? Is a structure created that provides organisation on the ground to support ongoing ‘projects’ across a wide spectrum of behaviours related to prevention of other communicable diseases such as malaria, bilharzias, or water washed diseases such as scabies, ringworm, Trachoma, and parasitic worms that infect children due to poor hygiene. This is perhaps where CLTS could combine with the CHC (Community Health Club) Approach – community health clubs could be formed to achieve CLTS, and them move onto other projects, so providing ongoing monitoring and management of all diseases at community level.
Public Private Partnerships (PPPs)were given extensive time to explain a novel approach in which ‘strange bedfellows’ i.e. large multinationals (Unilever and Rentokil) and local implementing partners (community) link in a ‘win-win’ situation, in the effort to minimise diarrhoea. Hand-washing with soap is encouraged by subliminal appeal to smartness, using established commercial advertising techniques. The funding available from large companies of course is attractive as a means to an end, but one may question whether the method of broadcasting a few simple key messages provides real understanding of the reasons for this smart new hand-washing practice. Again, does this simplistic approach give the poor adequate respect, by empowering them to control their own health though knowledge. The term ‘Social Marketing’ was conspicuous by its absence, possibly indicating that the buzz may have gone out of the claims of a few years ago, that with massive spending on media, this is a cost-effective approach. Although it is now widely claimed that hand-washing can reduce diarrhoea by 47%, diarrhoea is caused by multiple hygiene malpractice and so the use of soap, as laudable as it is, is just another vertical and very shallow intervention to achieve limited behaviour change. If it is linked to philanthropic handouts from soap companies it is likely to endure as long as the goodies continue and no longer. For PPP to succeed the multinationals who wish to improve their ‘street credibility’ should rather support robust community development programmes with the human resources necessary to train communities in safe hygiene. The overt market-orientated could be tempered with the use of ‘pc’ label of some sort that would indicate that a certain percent of sales were used to support community projects. This may increase up market sales as is the case with the ‘fair trade’ label.
Africa AHEAD has little issue with involvement of the Private Sector in the Public Good in a hand washing programme, provided there is a strong element of community empowerment and sustainability. An example of this is an innovative programme in the Informal Settlements of Western Province, South Africa, were health clusters (mini health clubs) were supported for a year before any products were distributed and no branding was allowed. The intervention was a research project where Brigham Young University (BYU) partnered with the makers of Dettol (Rickett Benkisser) to provide a case study that aims to establish whether the use of anti-septic products in shanty towns can decrease communicable diseases such as diarrhoea and acute respiratory illnesses (ARI). Africa AHEAD provided the training in health promotion for the health clusters, which involved 70 facilitators holding a meeting each week with ten households for a year to discuss hygiene issues. This provides a good example of combining strategies to achieve long term sustainable behaviour change based on assumptions which are core to the CHC approach.
Both CLTS and PPP focus on a very limited target, the reduction of diarrhoea; they are vertical programmes with a narrow spotlight on a small aspect of one disease. Both seek no further than to achieve more than one direct change: either safe faecal disposal or the practice of hand washing with soap. As laudable as these outputs may be, neither strategy as it stands can address the fundamental issues of poverty and ignorance that underpin the high prevalence of killer, preventable diseases.
Whilst we saw strategies that could contribute to reducing diarrhoea, we found no new methodologies on display at Africa San 2008 to rival the CHC Approach, in terms of cost-effective behaviour change to ensure demand driven sanitation. Not enough time was allowed for us to showcase our achievements in any detail, but many delegates sensitive to ‘horizontal’ broad development, understood our message and there were many new ‘converts’. Those who were interested in the deeper and more sustainable version of hygiene behaviour change, based on a ‘culture of health’ rather than a ‘sticking plaster on the wounds, gravitated to our organisation. Africa AHEAD has received many serious enquiries to start up health clubs in a number of new countries, notably Rwanda, Ethiopia, Namibia and Mozambique, whilst a large programme is soon to be launched in South Africa.
