WHO/EOS/96

1 WHO/ : ENGLISHP articipatoryHygiene andSanitationTransformationA new approach toworking with communitiesWorld health OrganizationGenevaUNDP- world Bank Waterand sanitation Program/ ii:, !>: I Prepared by Mayling Simpson-Hebert, Ron Sawyer and Lucy Clarkeas an information document to the water supply and sanitation cover illustration by Victoria FrancisPhotography by Mayling Simpson-HebertThe PHAST initiative is a joint project of WHO and theUNDP/ world Bank Water and sanitation institutionsBotswana: Ministry of health , Ministry of Local Government, Lands and HousingKenya: Ministry of health , CARE-Kenya, Kenya Water and health organization (KWAHO)Uganda: Ministry of health , Ministry of Natural Resources, Energy and Minerals, Rural Water andSanitation Programme (RUWASA), Katwe Urban Pilot Project (KUPP), WaterAidZimbabwe: Ministry of health , Department of Environmental health , Rural District Council (RDC),Agricultural Technical and Extension Services (Agritex), Ministry of National Affairs,Employment Creation and Cooperatives (MNAECC), Africare, PLAN International,Mvuramanzi Trust Zimbabwe, Lutheran world FederationUNICEF country offices in Botswana, Kenya, Uganda and ZimbabweNetwork for Water and sanitation (NETWAS)Institute of Water and sanitation Development (IWSD)Swedish International Development Agency (Sida)Danish International Development Agency (DANIDA)Reprinted 20000 world health organization , 1997 All rights reserved.

2 This document may be freely used, copied and translated, in whole or in part, for educational and other non-commercial purposes, but any use for commercial or promotional purposes [including distribution for a fee to third parties) is strictlyprohibited. Any other use of the document, including adaptation into electronic form, requires permission from WHO, and requestsshould be directed to Rural Environmental health , world health organization , 20 avenue Appia, CH- 1211 Geneva 27, by WHO GraphicsContentsList of acronymsivIntroductionVAcknowledgementsv i1. What is PHAST? health awareness and understanding - a basic premiseHealth-related community development principles of PHASTNew principles on hygiene and sanitation promotionSARAR - the underlying methodologyKey factors needed for effective participation2.]

3 How PHAST beganWorking principles of the partnershipThe selection of countriesTwo creative workshopsField testingMonitoring and evaluation718912133. The impact on communities15 Examples of impact15 Common achievements of the pilot phase16 The impact on extension workers174. The lessons learnedOn behaviour changeOn the requirements for successOn how to startOn how to sustainOn how to expand1818181919205. The future and the potential of PHAST21 AnnexesA. Synopses of experiences in pilot countries23B. List of collaborating institutions30C. List of persons involved in PHAST31D. Participatory approaches to water and sanitation change:the roles of PROWWESS and ..IIIList of acronymsAgritexCAREDANIDAITNIWSDKUPPKWAH OMNAECCNETWASNGOPALNETPHASTPROWWESSRDCRE HRWSG-EARUWASASARARSidaUNDP/DGIPUNICEFWH OA gricultural Technical and Extension ServicesCooperative for Assistance and Relief Everywhere, International Development AgencyInternational Training Network for Water and Waste Man-agement (Zimbabwe)Institute of Water and sanitation Development (Zimbabwe)Katwe Urban Pilot Project (Uganda)Kenya Water and health OrganizationMinistry of National Affairs, Employment Creation andCooperatives (Zimbabwe)Network for Water and sanitation (Kenya)Nongovernmental OrganizationParticipatory Learning Network (Africa)

4 Participatory Hygiene and sanitation TransformationPromotion of the Role of Women in Water and Environ-mental sanitation ServicesRural District CouncilRural Environmental health Unit/WHOU nited Nations Development Programme/ world BankRegional Water and sanitation Group - East AfricaRural Water and sanitation Project of the Government ofUgandaSelf-esteem, Associative strengths, Resourcefulness,Action-planning and ResponsibilitySwedish International Development Cooperation AgencyUnited Nations Development Programme/Division forGlobal and Interregional ProgrammesUnited Nations Children s FundWorld health OrganizationIntroductionPHAST stands for Participatory Hygiene and sanitation Transformation. Itis an innovative approach designed to promote hygiene behaviours, sani-tation improvements and community management of water and sanita-tion facilities using specifically developed participatory document describes the underlying principles of the approach, thedevelopment of the specific participatory tools, and the results of the fieldtests done in four African is unique because the underlying basis for the approach is that nolasting change in people s behaviour will occur without understandingand believing.

5 To summarize the approach, specific participatory activi-ties were developed for community groups to discover for themselves thefaecal-oral contamination routes of disease. They then analyze their ownhygiene behaviours in the light of this information and plan how to blockthe contamination approach was field tested in four African countries: Botswana, Kenya,Uganda and Zimbabwe in both rural and urban areas. The results werevery encouraging. The approach involved community groups in a waynever before possible. Groups planned ways to improve hygiene behav-iours in the community, to build or improve facilities and they made plansfor operation and maintenance of facilities. The PHAST initiative laid theground work for communities to take their own development though the approach was tried in different countries and differenttypes of communities, the results were equally inspiring.

6 The approachcan be replicated successfully provided a number of supporting condi-tions report documents:n the principles which underlie the approach;n how the methodology was developed at workshops in the African re-gion;n the impact that PHAST made on communities and extension workersthat were part of the field test;n the lessons learned during the field test;n how the approach can be adopted more widely and what the enablingfactors for this generated a ground swell of motivation and enthusiasm whichwe would like to share with others. This document is a start in that direc-tion. It will be followed by a guide for extension workers on how to im-plement the approach at community level, a sample tool kit of graphicmaterials which accompany the approach and a manager s PHAST initiative owes its success to all the people who have faith inthe capacity of all human beings to be creative and to be leaders of change,if approached in the correct manner.

7 This includes not only the mastertrainers and extension staff who promoted the methodology, but also theinstitutions that supported the effort without necessarily knowing veryprecisely the , thanks go to the UNDP/ world Bank Water and sanitation Programwho was a joint partner with WHO in this initiative, however, would not have been possible without the sup-port and participation of the Ministries of health in the four pilot coun-tries: Botswana, Kenya, Uganda and Zimbabwe, to whom we- are most ~grateful. In order not to overlook another important contribution, men-tion needs-to be made of the Environmental health Department of theMinistry of health in Ethiopia which was represented in all the thanks also go to the Regional Water and sanitation Group -East Africa (RWSG-EA) part of the UNDP/ world Bank Water and Sanita-tion Program for facilitating the adaptation of the PROWWESS/SARAR methodology for pilot testing acknowledgement for their contribution goes to all those involvedin the training workshops and in field testing of the PHAST approach in-cluding.

8 Uganda s Rural Water and sanitation (RUWASA) project, UNICEFin Kenya, Botswana and Zimbabwe, the Regional and Water SanitationGroup-East Africa, the Institute of Water and sanitation Development (IWSD)in Zimbabwe, the Network for Water and sanitation (NETWAS) in Kenya,CARE International in Kenya, the Kenya Water and health organization (KWAHO), the Katwe Urban Pilot Project (KUPP) and thanks to Gunnar Schultzberg who provided encouragement to-wards the collaboration between the world health organization /RuralEnvironmental health and the UNDP/ world Bank Water and SanitationProgram Group in Nairobi (Regional Water and sanitation Group-EastAfrica). Thanks also go to Rose Lidonde, Noma Musabayane, T. Motsemme,and Therese Dooley for gathering specific, sometimes obscure informa-tion for the country synopses; to Eric Dudley, Jose Mar-tines and HeatherMacDonald for commenting on an early draft.

9 We are also very grateful toAnna Girling for copy editing this were many donors to the PHAST initiative, including the SwedishInternational Development Cooperation Agency (Sida), the Danish Inter-national Development Agency (DANIDA), UNICEF, CARE International inKenya and the government of Norway. Their generosity and faith in theproject were crucial to its Simpson-Hebert,WHO, Geneva1, What is PHAST?P articipatoryH ygieneA ndS anitationT ransformation..is an innovative approach to promoting hygiene, sanitation andcommunity management of water and sanitation facilities. It is anadaptation of the SARAR methodology of participatory learning, whichbuilds on people s innate ability to address and resolve their ownproblems. It aims to empower communities to manage their waterand to control sanitation -related diseases, and it does so by promot-ing health awareness and understanding which, in turn, lead to en-vironmental and behavioural uses methods and materials that stimulate the participation ofwomen, men and children in the development process.

10 It relies heavilyboth on the training of extension workers and on the development ofgraphic materials (sets of which are called tool kits ) that are modifiedand adapted to reflect the actual cultural and physical characteristics ofcommunities in a particular area. The production of PHAST materials there-fore requires trained artists as well as trained extension s participating in a PHAST development workshop. SARAR stands for Self-esteem, Associative strengths, Resourcefulness, Action-planning, and Responsibility. It was developedduring the 1970s and 1980s by Dr Lyra Srinivasan and colleagues for a variety of development purposes (see Annexe D). Themajor work describing the methodology for the water and sanitation sector is entitled Tools for Community Participation, AManual for Training Trainers in Participatory Techniques. PROWWESS/UNDP Technical Series Involving Women in Water andSanitation, New York, awareness and understanding - a basic premiseAn underlying principle of the PHAST initiative is that no lasting changein people s behaviour will occur without health awareness and under-standing.