From Raj Kumar Bhattrai, WASH Sector, SNV Bhutan, Thimphu, Bhutan
Posted 23 November 2010
During the Solution Exchange Bhutan Visioning Workshop on 18 August 2010, I shared a concept paper, which outlined the behaviour change challenges and limitations in the Ministry of Health’s (MoH) Rural Sanitation and Hygiene Programme (RSAHP). To read the concept paper click here http://www.solutionexchange-un.net.bt/Docs/res18081007.pdf. At the workshop, a group of participants discussed/explored ways to take on this issue. One suggestion was to develop a behaviour change communication strategy. The group (action group) decided to post a query to seek members’ inputs on preparing this strategy.
Although Bhutan achieved the MDG targets for water and sanitation in 2003-2004, it is still short of meeting its own goals of 100% access to safe drinking water and sanitation before the end of the Tenth Five Year Plan (in June 2013). According to the MoH Annual Health Bulletin 2010, 83% of households had access to safe drinking water in 2009 and 91% had access to safe excreta disposal. However, when issues of reliability, equitability, quantity and quality are taken into consideration, these construction coverage figures fall substantially. A survey of the functionality of rural piped-water schemes carried out by the Public Health Engineering Department (PHED) of the MoH in 2008 found that at least one-thirds of the schemes were performing sub-optimally. For rural sanitation, if sanitary construction and hygienic use is taken into consideration, the coverage figures fall drastically.
Despite the impressive figures for water and sanitation construction coverage, the incidence of WASH-related diseases remains stubbornly high and the under-fives mortality rate which dropped from 84 per 1,000 live births in the year 2000 to 62 in 2005 is still among one of the worst in South Asia. This is thought to be due to continued poor hygiene practices (e.g... some latrines have been built but never used) and the poor condition of many latrines (i.e. their unhygienic state) and lack of associated facilities such as hand-washing and bathing.
The approach now being adopted by PHED in the RSAHP programme is an adaptation of the earlier PHED Community Development for Health (CDH) workshop that incorporates ideas from the increasingly popular Community-Led Total Sanitation (CLTS) approach now being implemented in over 30 countries.
The key elements of the approach in Bhutan are:
- The outcome is measured in terms of achieving a complete end to open defecation (including unsanitary latrines) rather than simply in terms of latrine construction coverage. The process is achieved through a well documented participatory process of developing individual and group responsibilities and fully involving existing traditional leadership as well as local government structures
- It discourages government subsidies for sanitary hardware and materials provision
- It provides information on a variety of sanitary toilet solutions and allows families to select an affordable solution that best meets their particular needs and aspirations
- It encourages the maximum use of local materials and the same construction skills used for local house building
- It encourages the use of traditional community mechanisms for helping the poorest of the poor so that they are not excluded
The RSAHP began in June 2008 with a 2-year pilot phase in four Gewogs (Jarey in Lhuentse; Nanong in Pemagatsel; Laya in Gasa and Hilley in Sarpang). In June 2010, the pilot was expanded to all of Lhuentse Dzongkhag. This expansion will allow RSAHP to gain more experience before scaling-up countrywide.
The RSAHP is being implemented by PHED with technical support from SNV (Netherlands Development Organisation). One of the biggest challenges is to discover the motivating factors and ‘tipping points’ for achieving sustainable sanitation and hygiene behaviour for all. As part of the programme, we are in the process of developing a behaviour change communication strategy at the Dzongkhag (district) level and we would like to get some expert recommendations, suggestions, advice and opinions from the SE members. The main behaviour change challenges’ questions we have are divided into three themes:
- Awareness and correct messages – From your experience, what could be/have been the best approaches (methods and tools) to reach the rural population for bringing about sustainable hygiene behaviour change?
- Measuring and monitoring changes – From your experience, what have proved to be the most effective ways of measuring and monitoring hygiene behaviour changes?
- Sustainability and institutional issues – What suggestions can you give on how we can ensure that the hygiene behaviour change strategy is integrated and sustained into the existing health institutions/systems?
We look forward to your ideas and suggestions on this important issue. Your inputs will help PHED, SNV and members of the Action Group to develop an effective behaviour change communication strategy.
Please see attachment below for the responses.