208706 Expanding Ethiopian partnerships for at-scale water, hygiene and sanitation behavior change

Wednesday, November 11, 2009: 11:24 AM

Julia Rosenbaum, ScM , Hygiene Improvement Project, Academy for Educational Development, Washington, DC
Renuka Bery, MPH , Global Health Population and Nutrition, Academy for Educational Development, Washington, DC
Kebede Faris, MS , Water & Sanitation Programme/World Bank - USAID/HIP, Bahir Dar, Ethiopia
Asrat Genet, MD , Amhara Regional Health Bureau, Bahir Dar, Ethiopia
Belete Muluneh , Water & Sanitation Programme/World Bank - USAID/HIP, Bahir Dar, Ethiopia

Scale approaches draw from systems and chaos theories to focus on enhanced linkages among familiar and uncommon development partners, committed to a common action agenda. Scale approaches focus on activating the “multiples” --multiple partners working at multiple levels promoting multiple options to reach agreed upon goals. These approaches were combined with the best of community mobilization and behavior change approaches to address safe water, sanitation and hygiene improvement (WASH) in Ethiopia, with a focus on handwashing, safe water and safe feces management since these practices can each reduce diarrheal disease by 25-47%.

Design and Implementation

Eager to implement the new National Hygiene and Sanitation Strategy with the ambitious goal of universal hygiene and sanitation coverage by 2012, the Government of Ethiopia's Ministry of Health and Regional Bureaus boldly agreed to pioneer At Scale Hygiene and Sanitation Improvement in the Amhara Region of 20 million. Tremendous effort went to strengthening the “enabling environment,” building partnerships, forging unprecedented alliances between line ministries, and building regional and district staff capacity. Nearly 100 key stakeholders came together and agreed on a common action agenda. Extensive investment was made in building capacity in negotiating behavior change and total sanitation. The approach is applied at the district level within the context of the national maternal and child health program (the Health Extension Program) and outreach activities of development agents, leaving sustainable services and committed and competent communities and government personnel.

The scale effort is being evaluated on several dimensions: measuring changes in policies, organizational structures, financial commitments; increased and enhanced partnerships; increased organizational and professional competencies; and changes in household access and practice of WASH behaviors.

Results/Outcome and Challenges/Solutions

Results are promising. Partners have increased competencies to plan and implement programs; are collaborating for enhanced reach and outcomes; and are progressing towards ambitious district-level WASH improvement.


Scale methodology offers an alternative to traditional scale-up approaches by beginning at scale. Intensive time is required to lay the foundation for scale approaches; a tipping point must be reached to ignite at scale change.

Learning Objectives:
By the end of my presentation, the participants will be able to: • Describe basics elements of a systems approach to start interventions “at scale.” • Describe the elements of total sanitation approaches to hygiene and sanitation improvement. • Review the application of a systems approach to at-scale sanitation and hygiene improvement in Amhara, Ethiopia. • Reflect on the impact of this approach in translating political commitments into concrete action.

Keywords: Community Collaboration, Environmental Health

Presenting author's disclosure statement:

Qualified on the content I am responsible for because: I have provided technical and managerial guidance to this activity for the past 4 years.
Any relevant financial relationships? No

I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.

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