-~ IN BANGLADESH · 2014. 3. 7. · Iv Hygiene Education in Bangladesh 3. Hygiene education in...

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822 B1395

-~ ~HGIENEEDUCATION

INBANGLADESH

MARIEKE BOOTINTERNATIONALWATER ANDSANITATIONCENTRE

- 822—BD95—116041-

Hygiene Educationin Bangladesh

Marieke BootInternationalWaterandSanitationCentre

LIBRARY IROP0 Box 93190, 2509 AD ThE HAGUE

Tel.: +31 70 30 689 80Fax: +31 703589964

BARCODE: L bc’LO:

UNICEFNew York, N.Y., USA

Copyright© 1995UnitedNationsChildren’sFundProgrammePublications3 UN PlazaNew York, N.Y. 10017USA

ISBN: 92-806-3155-9

January1995

The designationsemployedin this publicationandthe pre-sentationof the material do not imply on the part of theUnitedNationsChildren’sFundtheexpressionof anyopin-ion whatsoeverconcerningthe legal statusof anycountryorterritory,or its authorities,or the delimitationsof its borders.

Coverphoto:UNICEF/90-203/JorgenSchytte

Contents

Foreword v

Introduction viiHygieneeducationplus viiPopulation,healthand hygiene ix

I. From physical implementation to socialmobilization

Needfor anew approach 1The IntegratedApproach 2Intensivepromotionof sanitation 7Socialmobilizationfor sanitation 12

2. Overview of hygiene education activities 19Summaryof activities 20Striking features 25Hygieneeducationduringemergencies 33

Iv HygieneEducationin Bangladesh

3. Hygiene education in schools andnon-formal education settings 35

Formalprimaryand secondaryeducation 36Non-formalprimaryeducation 42

4. Policy, organization and collaboration for hygieneeducation 51

Policy 51Organizationandcooperation 53Collaborationwith otherprogrammesand agencies 63

5. Training for hygiene education and socialmobilization 65

6. In-depth review of a hygiene educationactivity: The Ramgoti experience 69

Set-upandorganization 70Activities 73Progressandachievements 76Financialcostsandlessonslearned 79

7. Learning points 83

Abbreviations 89

Glossary 91

List of references and bibliography 93

Annex: List of persons met and field visits 103

Foreword

To maximizethe health and socio-economicbene-fits from water and sanitationprogrammesthe29th sessionof the UNICEF—WHOJoint Com-

mitteeon Health Policy, held in Genevain February1992, recommendedthat the two organizationsworktowardsa joint strategyfor hygieneeducationin watersupplyand sanitationfor the 1990s.This wasapprovedin November1992.

A work plan developedfor 1993—1994covers a numberofcollaborativeactivities, including thepreparationandanalysisofsevenhygieneeducationcase-studiesunder-taken in Bangladesh,Turkey, Honduras, Indonesia,Mozambique,VietNamandZambia.

The case-studieswill provide backgroundinformationfor thejoint strategydocument.In addition, the case-

vi HygieneEducationin Bangladesh

studieswill beusedby UNICEF to assistin the develop-mentof hygieneeducationguidelinesfor in-countryUNICEF programming.It is intendedthat the UNICEFguidelineswill contributetowardsdevelopmentof thejoint strategy(UNICEF—WHO,1993).

It is widely recognizedthat hygiene educationandhygienebehaviourchangeare essentialif watersupplyand sanitationprogrammesare to achievemaximumhealth benefits.However, the inclusion ofhygieneedu-cation and communicationactivities within water andsanitation hasfrequently beenuncoordinatedandpoorly documented.To date, therehasbeenno consis-tent hygieneeducationpolicy amongdonorsor imple-mentingorganizations.

In preparing the case-studyon hygieneeducationinBangladesh,the International Water and SanitationCentrewascontractedby UNICEF to actasfacilitatorin a six-day skills workshopfor health and hygieneeducation in Bangladesh,in October1993. Followingthis workshop,this case-studywaspreparedthrough20 daysof interviewsand documentationresearchamongten differentorganizationsin Dhakaand infor-mal individual and group discussionsduring twofieldvisits in Bangladeshand 8 days of writing at theInternationalWaterandSanitationCentre.

GOURISANKARGHOSHChief~

WaterandEnvironmentalSanitation,UNICEF, NewYork,HQ

Introduction

Hygiene educationplus“Is thereany good hygiene education in Bangladesh?” I wasasked several times while I was collecting the informationfor this paper.* Clearly, some doubts were voiced in thequestion.This paper looks into the current hygiene educa-tion activities and experiences, their strengths and weak-nesses. But before starting, it is necessaryto define whatwe aretalking about.What is hygieneeducation?

Hygiene educationis that part of health educationwhich isconcernedwith the preventionof diseasesrelatedto waterandsanitation.A common definition of health educationis

*Many thanks are due to the kind and fruitful contributions of UNICEF,

Government and NGO stafl~and local women and men in the areas visited. Aspecial word of thanks to Mr. Philip Wan, Chief Water and EnvironmentalSanitation Section, UNICEF Bangladesh, who coordinated my visit and reviewedthe draft write-up. It is hoped that this case-study serves its purpose and willcontribute to the development of hygiene education guidelines and the jointUNICEF—WHO strategy.

vilI HygieneEducationin Bangladesh

from Greenet al. (1980): “Health educationis anycombinationof learningopportunitiesdesignedto facilitate voluntaryadap-tation of behaviourwhich will improveor maintainhealth.”

This definition implies that:

• Hygieneeducationis not teaching,but learning.

• Hygiene educationis planned,with clear points ofdepartureand objectivesto reach.

• Hygiene educationhelps peopleto make decisionsfor themselvesand to acquireconfidenceand skillsto put thesedecisionsinto practice.

However, if we restrict ourselvesto this definition ofhygieneeducationin Bangladesh,we missout on a challeng-ing experimentthat starteda few years ago and concernscreating mass support for sanitationthroughsocial mobi-lization. Therefore,this paperwill cover both hygieneedu-cationand social mobilizationexperienceand actions.

The remainderof this Introduction provides basic back-ground information about the population, health andhygienesituation in Bangladesh.Chapter I describesthenational Rural Water Supplyand SanitationProgrammeandits processof changefrom pure technical implementationof water supply improvementsto a broad movementforimproved sanitationand healththrough hygiene educationand socialmobilization.

Chapter2 presentsan overview of hygieneeducationactiv-ities in Bangladesh;the striking featuresemergingfrom theoverview are summarized.Hygiene educationin schoolsand non-formal educationsettingsreceive attention in

Introduction Ix

Chapter3. Chapter4 discussesorganization,collaborationand policy issues.Training is coveredin Chapter5, andChapter6 providesan in-depth review of one of thehygieneeducation/socialmobilization activities.

The major learning points from this case-studyon hygieneeducationand social mobilization are summarizedinChapter7. Finally, the sourcesof informationfor this paperare found in the bibliography and the annex. Informationwas collectedthrough individual andgroup discussionswithgovernmentand project staff, NGO5, donor organizationsand consultants,local authorities,and men and women invillages. In addition,all relevantdocumentsthat I could putmy handson were reviewed. Becausean overviewof rele-vanthygiene educationin Bangladeshwas not readily avail-able, it was necessaryto follow an incrementalapproach,moving from onecontactto anotherand from one reportreferenceto the next. This may haveled to imbalancesinthis write-up.

Population,health and hygiene

Population

Bangladeshhas a population of about 120 million people.Populationdensity is oneof the highestin the world, withover8,000 peopleper 1,000 hecraresof land. Over half ofthe population is below 16 yearsof age. Even if strict lawsenforcingone- or two-child families were to be introduced,the populationof the countrywould still doublein thenext30 years. Over 60% of the country’s population is belowthe povertyline.

x HygieneEducationin Bangladesh

HealthAccording to the UNICEF situation analysisof children andwomen in Bangladesh(1992), half of all deathsin 1991 werechildren under five years of age. Diarrhoeais oneof themajor causesof thesedeaths.Eachyear thereare over 65million episodesof diarrhoeain children under five years ofage, resultingin 260,000deaths—onethird of all child deaths.

Over90% of children aremalnourishedby the time theyarebetween l2 and l8 months old. This is not only due topovertyand lack of food, but also to increasedexposuretodisease.

The poorest I 0% of families in Bangladeshspendbetween75% and80% of their total householdincome on food,gen-erally consumeless than 80% of the minimum calorierequirementsand are acutely malnourished.The middle70% of the populationspend60% to 75% on food and arechronicallymalnourished.

Other common health problems are acute respiratoryinfections,iodinedeficiencydisordersand nutritional blind-nessdueto vitamin A deficiency.

Pregnanciesthatareearly andclosely spaced,apoor nutri-tional statusand poor healthcare lead to Bangladesh’shav-ing one of the highestmaternal mortality rates in theworld: 600 per 100,000live births (UNICEF, 1992).

Education

Although about77% of children enrol in school,only abouthalf of them attendregularly and almost half of them dropout altogether,especiallyin the first two years.Accessto

Introduction xi

educationis unequal.Peoplewho live in urban areashavegreateraccessthan those in rural areas,boys havegreateraccessthangirls, and the urban poor arethe least likely ofall to getany education.

Girls enrol in schoolat a lower rate and drop out earlierthan boys. However, their enrolmentis steadily increasingand the boy-girl ratio in primaryschools is currently 56 to44. Nevertheless,only 22% of adult Bangladeshiwomenareliterate comparedto 43% of men.The Governmenthaslegislatedcompulsoryprimaryeducation(UNICEF, 1992).

WaterandsanitationBangladeshhas achievedconsiderabletube-well water supplycoverage.It is estimatedthat therearesome2.5 million tube-well handpumpsin the rural areas,out of which onethird aregovernmentand two thirds are private tube-wells.A recentnational survey (Mitra, I 992) showedthat 85% of the ruralpopulationand 98% of the householdsin urban slums andfringes have accessto tube-well water within I 50 meters.Accessibilityto tube-wellwaterincreaseswith socio-econom-ic status.About 90% of the public tube-wellsare in operatingcondition;of the privatetube-wells,96% are.

Improvementsin sanitationare lagging behindimprovementsin water supply. According to the above-mentionedsurveyby Mitra (1992), sanitarylatrine coveragewas estimatedat6% in l987, rising to 10% in 1989,and26% in 1991.Theesti-mateis 33% coveragefor 1993. But this meansthat 67% ofthe rural population either are using unsanitarylatrines orpractisingopendefecation(assumingthat all family membersof householdswith a sanitarylatrine use it regularly). About60%of the sanitarylatrinesareof the homemadetype, while

xli HygieneEducationin Bangladesh

the remainderare water-seallatrines. In the urban areas,48% of the populationhaveaccessto sanitarylatrines.

HygienebehaviourandbeliefsVarious studieshave beencarried out in supportof thewater, sanitation and hygieneeducationactivities inBangladesh.Someof thesestudiesincludedaspectsrelatedto hygienebehaviourand beliefs; a brief summaryof theirfindings is given below.

The national survey by Mitra (1992) indicatedthat 96% ofthe population usetube-well water for drinking. Butdespite relatively generalaccessto tube-well water, onlyI 6% of the householdsin rural areasand 55% in urbanareasuse this safewater for all personaland domesticneeds.Other main water sourcesare ponds and rivers.Other studiesconfirm the picture of ageneraland exclu-sive useof tube-well waterfor drinking, while waterfromponds and rivers is preferredfor cooking, dish-washing,bathing, clothes-washingand other domesticpurposes(Kamal and Chowdhury, 1993; Bateman, 1993). Reasonscited for not usingtube-wellwaterfor purposesother thandrinking include: ‘tube-well is too far away’ (68%), ‘tube-well water turns cookeditems black and is distasteful’,‘boiling requiresmore time andspots utensils’ (32%) andwashingutensils in the pond is more convenient’(22%)(KamalandChowdhury,l993).

The nationalsurvey by Mitra also indicatedthat althoughover 90% of families with a sanitarylatrine use it regularly,only 10% of children under five and 50% of the older chil-dren use the latrine. A recentWHO studyfound that 25%of the latrines were used by all membersof the family

Introduction xiii

(WHO, I 993). Latrine useis higherand moreregularamongwomenand girls than men and boys. Also, peoplein urbanslums and fringes are more likely to use the latrine thanpeople in rural areas(Mitra, 1992). The needsassessmentby Kamal and Chowdhury(1993) reports that 24% of menandwomendo not usethe samehouseholdlatrine. Usuallyan infant defecatesin a bed, napkin, cradle or its mother’slap. In mostcases,napkinsand clothesarecleanedin ponds,canalsand rivers. Peoplehaving little or no accessto thesewater sourceswash theseclothes with tube-well water,mostly on the platform. Children one to four yearsof agedefecateon the verandahor in the courtyard or openspacenear the house. Sometimessmall pits are speciallymadefor them. Fecesarecleanedawaywith strawanddis-posedof in the bush,canal, river or latrine. Fecesare alsocleanedaway with spadesand disposedof in ditches. Inmany cases,feces remainat the defecationsite (Kama) andChowdhury, I 993).

Hand-washingafter defecationand before preparingor tak-ing food is a generalpractice,but is not always followed,especiallyby children (Abdullah and Boot, 1989). Hand-washing is done with water only, soap,mud (soil) or ash.The survey by Mitra (1992) found that the frequencyofhand-washingwith only water is very low after defecation(<5%) andvery high beforeservingor taking food (>95%).The explanationseemsto be that after defecationa lot ofpeople usemud for hand-washing,whereasbeforetouchingfood nobody usesmud. Bateman(1993) askedthemothersto demonstratehow theywashtheir hands.Most mothersused water (99%), washedboth hands(92%) and rubbedhandsat leastthreetimes (57%). Fewermothersusedsoap,ash or mud (21%) or used a clean rag or air-dried theirhands(only 7%).

xiv HygieneEducationin Bangladesh

Several studiesshow that knowledgeabout the relationsamongwater, sanitation,hygieneand healthis generallylow,although mostpeopleare awarethat drinking unsafewatercan causediarrhoea.Use of a sanitary latrine and washinghandswith soap or ash are not often mentionedas mea-suresfor protectinghealth.There is a generalbelief thatworm infestationis causedby eatingsugar(Mitra, 1992; 18District Towns Project, 1991). Bateman (1993) also con-cludes that knowledgeabout diarrhoeaand the meanstopreventdiarrhoeais low. Some22% of the mothersinter-viewed could not nameany causeof diarrhoea,while 36%gaveat least oneof five traditional causes,such as bad air,evil eye, breastmilk,indigestionand hot temperature.Only3% of the motherscould namemore than two ‘medicallycorrect’ causesof diarrhoea.Most commonly mentionedbyfar were the food hygiene—relatedcauses.Almost threequarters(71%) of the motherscould not nameeven onemeansof preventingdiarrhoea.Thosemothersthat couldnameameansof preventingdiarrhoeagenerallyknewfew.

The resultsof the study by Kamal and Chowdhury(1993)areabit more positiveaboutpeople’sunderstandingof dis-easetransmission.Some 76% of the in-depth interviewrespondentsdescribeda sanitary latrine as: ‘flies/mos-quitoes/poultrycannotspreadbacteria’ or ‘environment isnot polluted’. Someof the perceivedadvantagesof a sani-tary latrine were statedto be: ‘[user] does not becomesick’ (78%), ‘bacteria cannotspreadout’ (67%) and ‘envi-ronmentis not polluted’ (55%). Reasonsfor diarrhoealdis-easeswere mentionedto be: ‘eating rotten/contaminatedfood’ (77%); ‘drinking polluted water and using pollutedwaterfor cooking’ (54%); ‘flies on food’ (44%); ‘open defe-cation’ (44%); ‘not washing handsafter defecationandbeforetaking food’ (39%).

lntroduction xv

Mitra’s studyreports that some7% of the rural populationand 11% of the urban population had receivedsomehealthinformationrelatedto water, sanitationand hygienein thepreviousthree months.The main sourcesof informationwere the health system(health and family planningwork-ers, doctors) and the school system (teachers,male andfemale students).Neighboursand relativesare also impor-tant informationproviders(Nlitra, 1992).

In Kamal andChowdhury’sstudy, a more specific questionwas askedas to whetherpeoplehad receivedanyinforma-tion aboutsanitary latrines. Disseminationwas highestinBanaripara(90%), NGO areas(69%) and IntegratedAp-proach areaswith three or more yearsof intervention(61%), as discussedfurther in ChaptersI and2. The sourcesof information were primarily the tube-well mechanics(TWMs) andsub-assistantengineers(SAEs) of the Departmentof Public Health Engineering(OPHE) (40%), NGO workers(18%), healthand family planning workers (16%), teachers/students(10%) andfriends/relatives/neighbours(9%).

HygienebehaviourandpreventionofdiarrhoeaAlthough not strictly relatedto the subjectof this paper,itwould be a pity not to mention some striking informationrevealedby three recentstudiesIn Bangladeshabout therelation betweenhygiene behaviourand the prevention ofdiarrhoea.

The baselinestudyby Bateman (1993) did not find anincreasedrisk of diarrhoeato be associatedwith usingpond water for non-drinking purposes.This may suggestthat the commonmessage‘Use tube-well waterfor all pur-poses’ hasa low priority from a healthprotectionpoint of

xvi HygieneEducationin Bangladesh

view (apartfrom the fact that such a generalmessageusu-ally does not work from an educationalpoint of view).Batemanunexpectedlyfound that householdsliving furthestfrom the tube-wells did suffer less from diarrhoeathanhouseholdsclose to a tube-well. A qualitative follow-upstudy revealedthat those who live nearestthe tube-wellfrequently usedtheir unwashed,cuppedhands to drinkdirectly from the handpump.Peoplenearestto the tube-well alsowere more carelessabout safe water storage,often using an open jug, whereasthoseliving farther awaywere more likely to use a traditional kolosh or earthen-ware pot with a lid or cover. A more generalfinding wasthat people sometimesmix tube-well water with pondwater becausethey believetube-well water to havea puri-fying effect (Zeitlyn, 1993).

Another clear outcomeof the baselinestudy by Bateman(1993) is that latrine use is the key measurefor diarrhoeaprevention.Not surprisingly, it is much moreimportantthanlatrine access.The risk of diarrhoeais relatedto the numberof family membersthat usually use latrines and to exclusivelatrine use.In addition, contaminationinside andaroundlatrines is an importantrisk factor for diarrhoea.Anotherfinding of the samestudyis thatdiarrhoearateswere lowerin householdswherethe mother knows ‘correct’ causesofdiarrhoea.And inversely,attributing diarrhoeato oneormore traditional causeswas associatedwith increasedratesof diarrhoea.The studyalsoindicatedthatusing soap,ashormud for hand-washingand using a clean rag or air-dryinghandsis associatedwith decreasedratesof diarrhoea.

Hoque and Briend (1990) madea comparisonof localhand-washingagentsin Bangladesh.The study showedthatmud and ashwereas efficientas soapin reducinghand con-

Introduction xvii

tamination.Washinghandswith plain waterwas apparentlyless effective than washingwith agents,but neverthelessreducedcontamination.The results of this study are con-sistentwith earlier studiesthat suggestthat the effective-nessof hand-washingis determinedmore by its thorough-nessand by the time takento clean the handsthan by thetype of soapor waterused(Spruntet al., I 973).

I.From physical implementation tosocial mobilization

This chapterfocuseson the majordevelopmentsandaspectsof hygieneeducationandsocial mobilization under thenationalRural WaterSupply arid SanitationProgramme.Achronologicaloverview was chosento be able to discussandhighlight major issuesin the mostinsightful manner.

Needfor a newapproachSinceindependencein 1971,the Governmentof BangladeshhasbeenimplementingaRural WaterSupplyandSanitationProgramme.The programmeis implementedby theDepartmentof Public Health Engineeringunder theMinistry of Local Government,Rural Developmentand

2 HygieneEducationin Bangladesh

Cooperatives(MLGRDC). The programmereceivessupportfrom UNICEF, with funds from variousdonors—mainly,DenmarkandSwitzerland.

In the early yearsof the Rural WaterSupply andSanitationProgramme,all the programme’sefforts were concentratedon the provision of safewater through the installationoftube-wellswith handpumps.Latrine constructionreceivedmuch lessattention. It was not aneedthe populationfeltstrongly.

Althoughthe numberof tube-wellsincreasedtremendously,the expectedhealthbenefitsdid not materialize(seealsoIntroduction). It was realizedthat provision of handpumpsalonewas not enoughto meet the challenge.Safe water,safeexcretadisposalandimprovedhygienehaveto go handin hand. For that reason,the IntegratedApproach wasdeveloped.It was startedin 1986 on an experimentalbasisin two thanas(previouslycalledupazilas)andis now beingexpandedto coverthe wholecountryby 1995.

The Integrated ApproachThe IntegratedApproachcombineswater supply, sanitationandhygieneeducationin thegroupof householdsthat appliesfor atube-wellhandpump.Theimmediateobjectivesare:

• To motivatethe membersof the tube-well applicantgroupsto practisesafeexcretadisposalby installingandusinghygienicpit latrines;

• To motivatethe groupmembersto adopt importanthygienic practicessuch as hand-washingafter

From implementationto socialmobilization 3

defecationandbefore eating, servingor preparingfood;

• To provide tube-wellsto the applicantgroupswhobestrealize the first two objectives(GovernmentofBangladesh—UNICEF,1988).

During the first yearsof the IntegratedApproach,construc-tion of latrinesand improvementof hygienepracticeswereapreconditionfor tube-well installation. But this rule wasnever forcefully applied,and hasrecently beenformallyeliminated,althoughthe practicepersists.The reasonforthe ‘mixed signals’ regardinglatrine constructionas apre-condition for tube-well installationis thatalthoughrequir-ing constructionof latrines was intendedas a lessonin theinterrelationof watersupply, sanitationandhygieneeduca-tion, the point of the lessonwas often lost as latrineswerebuilt with no thoughtin mind but thatof obtaininga tube-well.

Characteristicof the IntegratedApproachis the involve-ment of thana-and union-levelauthorities,governmentstafffrom health, educationand agriculture,schoolteachers,NGOs,political leadersandothers.Through thana-andunion-level seminars,they are invited to helpwith distribu-tion of tube-well applicationforms, educationandmotiva-tion of applicantgroups,andto continuepromotinghygieneeducationand sanitationonce the tube-well hasbeeninstalled. Recently,separatewomen’s seminarswere addedto facilitate the active participationof women.Thesesemi-narsareheldonce,at the startof the IntegratedApproachina new thana.Sectoralmeetingsare held to brief NGO,Health Departmentandother organizations’anddepart-ments’ field staff. Finally, the SAE maintainsregularcon-


tact with all interestedparties to further encouragetheirinvolvementandto keepthem informedof progress.

After a three-yearpilot phase,the IntegratedApproachwasreviewedin 1989. The threemost successfulthanaswereselectedin order to get an idea of the potential of theIntegratedApproach.The reviewdocumentedthe followingpoints regardingthe hygieneeducationcomponentof theIntegratedApproach.

• Just over 60% of the applicantgroup householdsrememberedhaving receivedhygieneeducation,eitheronceor severaltimes,on oneor more healthtopicsrelatedto waterand sanitation.

• The hygieneeducationprovided is very rudimen-tary, and mainly consistsof impartingbroad mes-sagessuchas ‘constructanduseahygieniclatrine’,‘wash your handswith soapor ash’, and ‘use tube-well waterfor all domesticpurposes’.

• Generalhealthmessagesdo not work, evenwhentheyare disseminatedthroughperson-to-personcontact.Forexample,peopledo not acton thegeneralmessageto usetube-wellwaterfor all purposes.More specificandrelevantmessagesandactivities are neededtomakehygieneeducationeffective.

• In most thanas,the TWMs andSAEs are the mainhygienepromoters.Attempts to interestother par-ties in filling this role appearto fail becauseothersdo not like ‘doing DPHE work’ since ‘DPHE prefersto be in full command’.

Fromimplementationto socialmobilization 5

• The involvementof the healthassistants(HAs) neverdevelopedbeyond individual casesof cooperation,althoughboth DPHE and the Ministry of Health andFamily Welfare(MOHFW) acknowledgedthe needforcooperation.DPHE wished to cooperatein order totake advantageof MOHFW’s comparativelylargereservoirof field staff; MOHFW soughtto cooperatebecausecontrol of diarrhoealdiseasesis one of its pri-ority concernsandhygieneeducationpart of the regu-lar dutiesof its staff. However, in practice,cooperationbetweenDPHEandMOHFW was neverseriouslytried.

• Monitoring, supervisionand training of thoseresponsiblefor providing hygieneeducationis mini-mal. If SAEs andTWMs areto be successfulhygieneeducators,they will needtraining in motivationalandpedagogicskills. Higher-levelDPHE levels willneedtraining in hygieneeducationplanning, man-agementandorganization.

• The successof the IntegratedApproachdependsonthe personalcommitmentof the SAEs andTWMs,andon the activesupportof the thananirbahi officer(TNO) (Abdullah andBoot, 1989).

The study alsorecordedthe widespreadopinion that TWM5cannotbe good hygienemotivators becauseof their lowlevel of education(most haveonly asecondaryschoolcer-tificate), their low status,and, thus, their lack of credibilityandpower to convince people. But the pilot IntegratedApproachshowedthatwith the day-to-dayguidanceof theSAE, TWMs can be good motivatorswhentheyfeel person-ally committedto the aims of the IntegratedApproach,whenthey feel comfortabletalking with men and womenat

6 HygieneEducation in Bangladesh

the tube-well site andwhen they haveconfidencein per-forming motivationaltasks.A TWM who meetsthesecondi-tions can evenfind ways to involve womenwho observepurdah.The problem,however,seemsto be that there arenot manyTWMs of that sort. While someoptimistically esti-matethat50% or so of the TWMs, giventhe right guidance,cando somemotivationalwork, othersbelievethata TWMwhois alsoagoodmotivatoris the exceptionratherthantherule.

Overthe years,the IntegratedApproach hasbeenimple-mentedin more andmore thanas.Although no evaluationhasbeencarriedout up till now, it seemssafeto say thatthehygieneeducationcomponenthasnot risen abovethe rudi-mentarylevel of attemptingto motivatelatrineconstruction.Training in hygieneeducationremainsminimal, as dosupervisionandmonitoringof hygieneeducationactivities.

A recentstudyby Kamal andChowdhury(1993)comparedthanasin which the IntegratedApproachhadnot yet beenimplementedwith thosewhereit hasbeenin placefor morethanthreeyearsandthoseto which it was introducedmorerecently. The study concludedthat in thanaswheretheIntegratedApproachhasbeenimplementedfor more thanthreeyears,although disseminationof knowledgeof per-sonal hygieneremainslimited, therehasbeenprogressinprovidinginformationregardingsanitarylatrines.The studyfoundthat so far as concernsthe impactof thehygieneedu-cationcomponenton thanas,less thanthreeyears of theIntegratedApproach andnoneat all were the same.Thisstudyalsodocumentedthe fact thatwhenathana’sSAE andfour TWMs areactive, the programmegetspromoted.

Sanitationpromotionunderthe IntegratedApproachtarget-ed only householdsin groupsapplying for tube-wells,but


duting the 1990s,efforts to promotesanitationincreasedsignificantly andvariousstrategiesfor intensivepromotionof sanitationandseveralschool sanitationprogrammeswereimplementedin anumberof thanas.

Intensive promotion of sanitation

In BanariparaThana,intensivepromotionof sanitationtookplace from April 1990 to December1991.The activitiesinvolved in this intensivepromotiondiffered in threewaysfrom thosepursuedin connectionwith the sanitationcom-ponentof theIntegratedApproach:

1. Therewas activeparticipationof thana-andunion-level authorities;fieldworkersfrom family planning,socialservices,agriculture,public healthandeduca-tion departments;NGO5; Ansar—VillageDefenceParties;and, especially,teachersandstudentsfromsecondaryschoolsandmadrashas.

2. All householdswere targetedfor latrine promotion,notjust thosein tube-wellapplicantgroups.

3. There was lessemphasison hygiene issuesandbe-havioursnot directly connectedto sanitation.

The intensivepromotionof sanitationin Banaripararesultedfrom a numberof interrelatedfactors. Banaripara’sSAE,havingtakenaseriousinterestin sanitation,togetherwith asimilarly mindedTNO, initiated aseriesof activitiesbackingup their decision to do something‘different from the otherthanas’.Forexample,theydivided eachunion into 20 areas.On aparticularday, 20 groups,eachconsistingof some 12


field staff from the variousdepartments,went to adesignat-ed areaand organized‘courtyardmeetings’with 20—25 fam-ilies to discusssanitationand otherhealth issues.In thisway, Banipara’spopulationwas coveredin asingleday.

Banaripara’sSAE and TNO also organizeda large marchpromotingsanitationon amarketdayanddistributedto allsecondaryschoolsa leaflet with instructionsfor building ahomemadelatrine. An accompanyingletter suggestedcon-structingademonstrationlatrine on schoolgrounds.

Banaripara’sdeputycommissionercontributedto the successof the intensivesanitationpromotionwith the promiseof anawardfor the schooldoing the most to destroy unsanitarylatrinesandconstructsanitarylatrines.The studentswere tobuild sanitarylatrines for their own homesandmotivateatleastone neighbourto do the same.The deputycommission-er alsoaddressedan openletter to individualsandinstitutesrequestingthat they help each otherbuild sanitarylatrines.The letter included a reminderthat ownersof unsanitarylatrineswere subject to fines. Accordingto the SAE, the let-ter was very helpful in convincingpeopleto constructsani-tary latrines.Unfortunately,unwise useof the letter by somepromotersled to needlessdestructionof hanginglatrinesandto relianceon fear ratherthanenthusiasmfor sanitationas amotivationfor latrine construction.

At the endof the campaignperiod, sanitationcoveragewasestimatedto be around 80%. Local staff report that raindamageand improperconstructionmakeit impossibletomaintainthislevel of coverage,however.

Two quick evaluationshave beencarriedout to learn fromthis mass mobilization experience(Hoqueet al., 1992;


UBINIG, 1993). Theseevaluationsrevealthe needto learnmore aboutavoiding the appearanceof coercingcoopera-tion in latrine-buildingactivities,ensuringthe sustainabilityof achievements,and involving healthworkers, imams andotherlocal leadersin promotingsanitation.

GournadiThana’s intensepromotionof sanitationdid notemploy dramaticstrategieslike Banaripara’sone-daycam-paignor its march.Gournadi is oneof the successfulpilotsof the IntegratedApproach, and intensesanitationpromo-tion in Gournadidifferedfrom the IntegratedApproachonlyin targetingthe thana’spopulationas a wholefor sanitationpromotionrather thanjust householdsapplying for tube-wells. As in Banaripara,competitionamonghigh schoolsfor a latrine-building awardproved to be a successfulstra-tegy. The winning schooldivided itself into teacher-ledgroupsof 20 students,whosemotivational visits to areahouseholdsresultedin the constructionof 1,200 sanitarylatrines, raisingcoverageto an estimated60%.

Gournadi’sSAE andTWM5 hadmaintainedthe commitmentand enthusiasminspired by the thana’sbeing chosenfor apilot IntegratedApproachprogramme,but on the whole,participationby local authoritiesand field workersof otherdepartmentsin intensesanitationpromotionwas much lessthan in Banaripara.

Ramgoti Thana’s intensivesanitationpromotion (discussedin detail in Chapter6) was carried out by an NGO as wasKushuraUnion’s in DhamraiThana.In Ramgoti, the wholethanawas coveredat the sametime; in KushuraUnion theNGO used an incrementalapproach,using meetingsfol-lowed by group discussionsand thenhouse-to-housevisitsas the main methodsof communicationin its one-village-at-

lO HygieneEducationin Bangladesh

a-timestrategy.Kushura’sprogrammeis notablefor its spe-cial effort to involve women as activecontributors.It is theonly exampleamongRural Water Supply andSanitationProgrammeactivities where hygieneeducationhasbeengiven serious,creativeattention.Little storiesandexampleswere usedto discussthe healthandsocial benefits fromimproved sanitation.Not only diarrhoea,but also othercommondiseases,such as worm diseases,causedby poorsanitation,receivedattention.Non-usersof sanitarylatrineswerebroughtinto contactwith usersof sanitarylatrinesforadirect exchangeabout the useand benefitsof sanitarylatrines (UNICEF BangladeshandDepartmentof PublicHealthEngineering,1993b;UNICEFBangladesh,l993a).

In addition to thesethana-andunion-levelactivities, DPHEand UNICEF togetherorganizednational-levelworkshopsandmeetingsto createbroadpolitical andsocialsupportforsanitation.The inaugurationof a nationalconferenceon‘Social Mobilization for Sanitation’ by the Prime Ministerin February 1992 showedthat sanitationhad becomeanissueof nationalimportance.

Figure I. This sanitation logo was launched by the Prime Minister at thenational conference on ‘Social Mobilization for Sanitation’ inFebruary1992.

From implementationto socialmobilization II

The increasingefforts towardsandexperienceswith sanita-tion promotionculminatedin the Social Mobilization forSanitationProject. CostingUS$3,962,652,this project ispart of the Rural WaterSupply andSanitationProgrammewith a total budgetof US$61,278,652for 1992—1995.Theobjectivesof the programmearestatedin Box 1.

Box 1Objectives of the national Rural Water Supply andSanitation Programme carried out by DPHE with supportfrom UNICEF

The general objectives of the present phase (1992—1995) of theUNICEF—assisted water supply and environmental sanitation pro-gramme are to help the Government:1) Reduce the incidence of diarrhoeal diseases and parasitic infec-

tions in children by further expanding clean water facilities Inte-grated with improved sanitation and promotion of personalhygiene; and

2) Strengthen its national capacity to provide water supply and san-itation facilities for rural areas and urban slums and fringes in away that will achieve the maximum possible health impact, andwith particular emphasis in the underserved coastal and low-water-table areas, and on behavioural change in sanitation andhygiene practices.

The specific objectives linked to general objective 1) are:a) Increase use of tube-well water for all domestic purposes;b) Increase regular and sustained use of sanitary latrines by all

family members;c) Improve domestic hygiene habits practised by all family members

The specific objectives linked to general objective 2) are:d) Enhance long-term financial sustainability of the programme by

the Government of Bangladesh;e) Strengthen the capability of DPHEand allies, particularly in the

‘software’ component of the programme;f) Promote the growth of the private sector;g) Increase community participation.

(Department of Public Health Engineering and UNICEF, 1992)


Socialmobilization for sanitationThe Social Mobilization for SanitationProject involvesmorethanits nameindicates.In fact, it concernsacommu-nication strategyincluding advocacy,social mobilizationandprogrammecommunicationasshownin Figure2.

Figure 2. Communication strategy for sanitation for all in Bangladesh

McKee (1992)definesthesethreecommunicationprocessesas follows:

Advocacyconsistsof the organizationof information intoargumentsto be communicatedthroughvariousinterpersonal

Source. McKee, 1992.


andmediachannelswith aview to gainingacceptancefrompolitical andsocialleadersandpreparingasocietyfor apar-ticulardevelopmentprogramme.

Social mobilization is the processof bringing togetherallfeasibleandpracticalintersectoralsocialallies to raisepeo-pie’s awarenessof anddemandfor aparticulardevelopmentprogramme,to assistin the delivery of resourcesandser-vices and to strengthencommunity participationin order toincreasesustainabilityandself-reliance.

Programmecommunicationis the processof identifying, seg-mentingandtargetingspecificgroups/audienceswith particu-lar strategies,messagesor training programmesthroughvari-ousmassmediaand interpersonalchannels,traditional andnon-traditional.

Advocacyconsistsof alargenumberof what aretradition-ally knownas informationandpublicaffairs activities,suchas lobbying with decisionmakersthroughpersonalcontactsanddirect mail; holding seminars,rallies and news-makingevents;ensuringregular newspaper,magazine,televisionandradio coverageandobtainingendorsementsfrom popu-lar people.The goal of advocacyis to makethe programmeapolitical or nationalpriority thatcannotbe sweptasidewith achangein administration.

Social mobilizationinvolvesthe creationof asocial move-ment for aparticularprogrammeby mobilizing all kinds ofallies at the national, regional andcommunity level. It islessconcernedthanadvocacywith direct behaviouralchange.Rather,the aim is to createademand,in this case,for sanitationimprovements,and thus a favourableclimatefor behaviouralchange.Socialmobilizationis the glue that

14 HygieneEducationinBangladesh

binds advocacyactivities to more plannedandbehaviour-orientedcommunicationactivities.

Programmecommunicationcomesclosestof the threecom-municationprocessesto beingexemplifiedby whatwe havedefinedas hygieneeducation.Programmecommunicationisthe processof facilitating behaviouralchange,usingallavailablecommunicationchannels.Successfulinstancesofprogrammecommunicationare thosethatare well plannedandbasedon asoundbaselineandassessmentof needs,arespecificandrelevantto their target groupsandrely heavilyon interpersonalcommunicationandmotivationaleffortsbycommunity-basedworkersandvolunteers.

The communicationstrategyof advocacy,social mobiliza-tion and programmecommunicationhas beenemployeduntil now mainly for the UNICEF—supportedexpandedpro-grammeon immunization.Thus,usingthis strategyfor san-itation is quite achallengeand will providevaluableexperi-encefor programmesin othercountries.McKee warns thatchanginghygienepracticesis more difficult thanconvinc-ing parentsto havetheir children immunizedandthus maytakemoretime. It is essentialthat we establishpolitical willthrough advocacy,that we mobilize a wide spectrumofallies in order to makeadifferenceand that we havefield-workers at community level well-trained to motivatebehaviouralchanges(McKee, 1992; 162—173).

The name‘Social Mobilization for SanitationProject’ maythus be abit misleading.The project coversadvocacy,socialmobilizationandprogrammecommunicationwith theobjective of improving excretadisposaland personalhygienepracticesandof promotingthe useof safewaterfordomesticpurposesin order to reducediarrhoealdiseaseand


improvethe quality of life of the rural communities(Gover-nmentof Bangladesh—UNICEF,1993a).

Activities aimed at meetingtheseproject objectiveshavebeendevelopedon the basisof a seriesof planning work-shopsby DPHE/UNICEF with participationof NGOs,UNagenciesandconsultants.The MOHFW did not take part inthis process.Nearly onehundredactivities have beenplanned,andthe complexoverall strategymay be somewhatdifficult to appreciatefor personswho havenot beenpart ofthe planningprocess.Basiccomponentsof the projectare:

• Needsassessmentsand other research.Under thisheading,severalstudieshavebeencarriedout andotherswill follow to supportthe developmentof theproject. Examplesare the ‘Needs Assessmentforthe Sanitation Programme’ by Kamal andChowdhury(1993), the ‘SanitationTraining Cur-ricula ReviewfNeedsAssessment’by DevelopmentPlannersandConsultants(1993), and forthcomingstudieson hand-washingand on water contamina-tion occurringbetweencollectionandingestion.

• Programmecommunicationdevelopment.Basedonliterature reviews,small village studiesand smallcommunicationdevelopmentprojects,a corecom-municationpackagewill be preparedfor usebyfield staff, primarily TWMs but also all other inter-estedallies. The project proposalstates:“Clear andspecific messagesandmaterialswill be developed,prioritized andstandardized,focusingon positivebehaviourchange”(Governmentof Bangladesh—UNICEF, l993a; 19). In addition to interpersonalcommunicationthrough field staff, massmediawillbe usedfor the promotionof sanitation.


• Advocacyand support to allies. Advocacyand thecultivation of allianceswill continueto play animportantrole, basedon the experiencegained inpreviousyears.Workshopsandorientationswill beorganizedin order to interestpolitical leadersat alllevels in actively supportingsanitationpromotion.Personnelfrom health andeducation,NGOs,reli-gious leaders,schoolteachers,serviceclubs (e.g.,Lions), andBoy ScoutsandGirl Guides will bemobilized to join promotion andeducationactivi-ties. The mostimportantallies maydiffer from areato area,but it is envisagedthat schoolteachersandNGOs will usually bethe majorones.

• DPHE capacity-building. A numberof activities willbe carriedout to strengthenDPHE’s capacityin non-engineeringaspects.A Social Mobilization Divisionanda CommunicationTrainingDivision will beestab-lished (seeChapter4). Emphasiswill be on increasingthe motivationand communicationskills of field staffas well as on increasingtheir levels of informationregardingsanitationandhygieneand their sensitivityto community andgenderissues(GovernmentofBangladesh—UNICEF,1993a;23).

The project is still in its early stages,and it is difficult topredict the natureandresultsof the hygieneeducationactivities.Thereare indications,however,thatwe shouldbemodestin ourexpectations.The projectis to be implement-ed by an engineeringdepartment,and TWM5 will be thebackbonein implementation.Their training will consistofonly two sessionsof sevendayseach,andtheir involvementwill be subjectto the samedifficulties discussedearlier.(The project documentmentionsthe appointmentof 50

Fromimplementationto socialmobilization 17

femalecommunity sanitationpromotersby DPHE, but theirrole remainsunclear.)Underthe circumstances,it is under-standablethat the communicationpackageis focusedondisseminationof messagesratherthan on a learningap-proachthat emphasizesproblem-solving,decision-makingand action. It will be interestingto seeto what extentthisapproachsucceeds.

Under the umbrella of the Social Mobilization for Sani-tation Project,andas afollow-up to the intensivepromotionof sanitationinitiatives, UNICEF hasgranteda contracttothe NGO Forum for Drinking WaterSupply andSanitationto carry out “social mobilisationand intensivehygieneandsanitationeducationthrough interpersonalcommunicationwith hundredpercentpopulationin 20 thanas(1,217,000households)”(NGO Forum, 1992). The hygieneeducationpart looks very bleak andcomparableto the one in theIntegratedApproach, and the main objectiveseemsto be100% sanitationcoveragethrough the promotionof home-madeandwater-seallatrines.How activities are to be co-ordinatedwith local DPHE staff remainsunclear.The esti-matedcostsareremarkablylow, justoverUS$300,000.

2.Overview of hygiene educationactivities

Whathygieneeducationis therein Bangladesh?Finding outwas not always easy,and what was found was not alwaysencouraging.This chapterpresentsan overviewof currenthygieneeducationactivities,exceptfor hygieneeducationactivities in formal andnon-formal education.Thesearecoveredin Chapter3. This overview is basedon an unsys-tematic investigation,starting from UNICEF—supportedactivities,and the degreeto which it can claim to be com-prehensiveis problematic.

A totalof eighthygieneeducationactivities,including thosediscussedin Chapter1, havebeenexamined.The first sec-tion below presentsa summaryof the main aspectsin astructuredformat to allow for a quick overview and to


permit somemeasureof comparison.Striking featuresthatemergedin preparingthisoverviewarediscussedin the sec-ond sectionof this chapter.

Summary of activitiesThe Governmentof Bangladeshadoptedthe primary healthcare(PHC) strategyfor achievingthe goalof ‘Health for Allby the Year2000’. Healtheducationis an importantcompo-nentof PHC and healthassistants(HAs), family welfareassistants(FWAs), andassistanthealthinspectors(AHIs) arethe staff directly engagedin healtheducationfor individu-als, families andcommunity groups.Health educationincludessubjectslike immunization,family planning,diar-rhoeatreatmentandpreventionof waterandsanitation-relateddiseases.Recently,the MOHFW initiated a strategyof intensifiedPHC in order to developa sustainableandintegratedhealth care systemwith active communityinvolvementat the grass-rootslevel. Village health volun-teers,preferablywomen,are selectedby clustersof 30—50householdsand trainedfor four days to carry out minorhealthcare services,including hygieneeducationfor thepreventionof diarrhoea(Governmentof Bangladesh,n.d.).

In addition to theseregularhealth educationactivities (al-thoughthe word ‘regular’ maybe abit misleading,as we willbediscussingin the following sectionandin Chapter4), thereare anumberof specific hygieneeducationactivities byMOHFW,MLGRDC, andNGOs.Theseactivitiesarefinanciallysupportedby foreigndonorsin degreesrangingfrom 100%forNGO activitiesto 14% foreignsupport for the activitiesof theBureauof HealthEducation(BHE). Table I presentsasummaryof somemajor aspectsof the hygieneeducationactivities

Tab!e I. Summary of major aspects of hygiene education activities

A~eAlkOO- Pom,oLjeafc.flcliocaedDecember tao of SLM7 laLontee SoughI?~I mobloaeaaeaadpnlpaxeof

Sa-asn-S S~Sr.man aid vaden S aSia S— aotiooh as~i~Sçpers by Am x S the ree

Prof

steal cornfor htegnlS*cFOOch

çl’.~,:~ ‘as ~.�— iç~~

INTEGRATED mae -,nah son meetly aoteeAPPROACH, Liççva m 355 Llamas

W* mA Sat-U Pops~—I)

mIm~asAkprapoaul

~atg Li Ithacom I~fS,

I.e pan of the-moO lindaSagh lam-the am-

en ada s e~jmn~aS maof S-mS taLe hr I Almah~eee.aife thapioi if humsmat ad — — —Doeqee moWS ad —

INTEGRATE

SANITATION.Sin

ad Isa-

t~Oa

naithen lSrmIa,-aifeooxtEe.ample cakeeInn Oman-psi IS S

(eotaaLa~a a—a

• hgufr mm oat eopeaap siLoad aim (nly S tie).

• ISi ~t ~4E~1hum Ia-

eal sits Gemas —met, ad eAten

lqánoalmthSaeoe-Ssmo ham proco meaduuedaim

• 133 kaciy masS mu (10%female, 30% mole);1 holy roasted ma (A mit,Ikeit);

.1 aS asarnami oairdluaaaocmale),

• L*ab-basod aafln pea-gnaminm coordinaaor (So)

INTENSIVE rimWOTA11ON area-basedNCNY~IE eeo)-viPROMOTION aippora kernPROGRAMME, nonnfl

ma Pmpnm(Lee Oa4rer~)

I Aiim lulv lt~2—~amg4 September51,540 house- l~3KIds

Ames hr UI—IllS.• ths~Ssr II• inn-S seaumi Ill• sealed stein 230.msa~smnIII• tuNer of henna suaa*d F

thhe-motI(oasam)

Meets 00% laIn coturage asthe eel of the rampage.

• ~ buSS ~a tie .eetagt lUll;• aclm&neainoba meesagt ~&a aO~eesmoemege 10~. keith ceanetteeo 145;•huNnwesgzl~• ‘Air meetmge 2501,.laaairiecoeesige ll’h am WA• sal/soap wtkmr 4% am 14%,• Se-mS user hr I çnuumi

frampeeneti coennunaaoe mAn(conk members of aidnedealheeaehokdi Heeongo erA miehousehold members ad ,dmrmore general meamgL Emphaassan hanue promooon

0-CCt

Ct

lS$l00,544

Table I. Summary of major aspects of hygiene education activities (continued)i-sp-a

FAMILYHEkTHEDUCATiON

lussaufleil (orattry-Se ~yIfll-Sc- Decomher

weaflamiuf 5001Keith Seeinces

Romduurg (melts with healthmessages related to the iso Ssafe nor ad weary (stems,— ad bane byguen, pee-eerboo ad cootrel of connoteSorts, home pderrg Ssri-nasa

1 hr mproeed thee,laareily plaouirg. and sac ofhealth care systom EmphausSi reeewenmg tslermeco, 051 elheawi messages mad mass uSais SItar to metre berm su-es erA easeS matenals by tu.

C, ~stw-

SOCML MOBIUZATIONFOR SANI-~PONerdeRural Waterw* SSa-

(me Daipter I)

me S sr Ceautry-made (alp III]—mpport siAn him ii len 5005

emSama

hen educatsoar sa part elpeagramo coanemcatno hrSb cern cmarwmeaan pack-agewl be peepand. SinewSnon speck nn~mSmatraM woO he desehped, board umhteratere aid loW atidiesItmpenri ceensocabum admass miii moO he used. Em-— ml peuheb% hem hrhaprison

Ii field hoot5040 rents (nasly dl mit);

• SOn cone~sastassemrem.tm (S krie)

umsrestodlSolhemother~neem20 thatThese fleW knelt•mgtnstlpim S star

csnoncatsou seed fraselegt, S as~ fa-il eIleen ad S uSingcoesihat

Prefect a au toe early a phasehr met ether tIn cerspktedroods-asoeoaesoes stidies. Tiepe~eadecemeet atarsa sheenI~eapectsd .etpwta ntISam-• nods maoosmeees ad ether

• mr~~I — S euppiet• me capaatØeAie~

U553,U2,1Sl(iucludluglS$200~leepreparatiryphaso( TAn a1.1% sI thehodget hr the

ISil100stsri Il’eaocssl

•raglarSba*thisegh*e breoltropirtetuntag health Srasumcton.

Table I. Summary of major aspects of hygiene education activities (continued)

~fr#4’* ~- ts~~‘

INTEGMIflUflMBASICSERYKES

isou$usGtyCuepwsbuu~rg~ vISe-palsy (sit~jmiep.pwteeme

*memm4bgS215-

er tam en-1g31,441Se-huldaActisrbeam5wma~~aet

lOIS—umgng

Deutsrimufhoecmoaaagmrsbosdtorim,oatam,dea-ices, 1 — —srobin aid beas of suerSeotathrieghhieedtiadpeep loSers am hegn bygumghemduerlSadpee-~bnhradomewW

McessumtyfeetuSUase(ee~ma,I~e,I

r 54-IN SthUh~,— by2 esasy wgaeass ~in4

at~

•reu .~IemSstau simmer-tesoPwSoatoliemhe*SdgpSu~el-athu,.rm,urcadPumarharaSm~

•NwetsaSSInS•maeniuerefehe-ett,

Satires, SW, srrserflghts,fl~kitpfl,semma.

•mmo~áan~~eppirgeeceimpeetacoeldea-k~

k5$l3S$dhrIPOS-fHt2l%Sir Wgrt Ihrotw$~motsoasen ofthe-moBs adfles~

adpeM~hrcmus,esae-baldregsad— at~s

I8D6T~CTTONI~P~.grhr~zSepply audSaaratiom

wnhr(Pua-s.shies WaterSupply SecsaeaadPsmaSokeith —math Rether-lads seppoet

IRinaspeadrot the came-by,~eueegmulem*INw 54(1KG pup-Stem

IORO-IKOS.bit ezteoaoiupiiulhrameyeas

GeempmeoeagsershmosfBpSL ClSauea ad heuodadpnrimeaaapa,achanlseaafewsshrldumesrkpnp.soa’; ‘Wash yew heedsS asp wash’; ‘Rae aa*ay(starer’; Sfl jabage impsmiraawhole’ Peematmoflatin caaatrectaum Ia aoparatsfrom hygsoee edocatiom.

•PanaAa’akoMsocbm—aSsay mapectue (1 mpumo-ea~adeacSacies

tnorçmarlyhmie);• I prefect-booed liii hygmn

educatoe (female);u I prepuce-laid hrsigu hyymn

educatsr~mle);u uccaeami ipet foam rind

omo al tIns hefl csmplea.

ellOaeifsrmoedkr2-3~

•sao nicstemm slat caferaolsmedhrldmmesszpmepusea rocept biehiug adeasing clothes.

Periem%-10% ii theh fir

bypeer educe-aiiM eambserelormaut.Espeeditmouptilt uom hasieee meuuret(Eatarsasod by-gate S~tsem coats mRogers Tsarme ~$2O~)

0

Ip-a“a

U ~illageo,CONlailiogfl,141 hoot-Mlii, choomhUINSSObol.igi.g to

it 3ottag.i~

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— ~t heIk•240 cxetohn ad opw~o

bated it kyglote edaioç• 1,1S matasacelSe-at aid latoaeo it projed

.50 coai~Soottoadit Wrooteds

•l3~Snooj.i.-koiaed,

• N1IO*IIIhyflIOM-Seed ochi comcofl

.MS. el to1w cnmty-bzedkweooe

ot o~knot-dngaderaSog~per

adbSooiSdagt

Table I. Summaryof major aspects of hygiene education activities(continued)

SANIUTOONurn MNUEDUCATION

Pilot

*t$t#ts Swith rootoocioqport Ire,

Jaaoylfl3 Pm.oaoud~oçotZ~’gne-jo~~~1 rn.oatot&cbw,

reflcablo pizu~paterymoth-a s~tnot speck Sfl ppo*eScot mOO-oar ad xflvebeo r°,1loS Sole ad— ~Sg.1 Setsc.maeiczdaoS-n~— Se-wa oat-Swn, 1, caa.tyspate-oiapeoiadoclelo

At field kwt• 131mW extostaott (II5*, 2

.1~

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At CW KQ kitE.1• I pregamedoeehp.nt

ii ~ ~SS s~w

p.)a

F

Overviewofhygieneeducationactivities 25

examined.The NGO Forumactivities havenot beenaddedtothe overview,as theydo not addmuch to the generalpictureofhygieneeducationactivities under the Rural Water andSanitationProgramme.It shouldbe notedthatunderthe head-ing ‘Reportedresults’ only immediatereportedresultsorexpectedresultsare mentioned,not verified results,impact oroutcome.

Striking features

Whereis theMinistry ofHealth?One would expectthe MOHFW to play amajor role in anyhygieneeducationactivity, but nothing appearsto be lesstrue. Instead,the TWMs (whoseeffectivenessis generallyquestioned),NGO staff, trainedvolunteers,and otherinter-estedpartiesare relied on as major actorsin interpersonalcommunicationandmotivationfor behaviouralchange.Theonly exceptionis the Family Health EducationProgrammeof theBureauof HealthEducation,andthis doesnot havealink to watersupply andsanitation.

The generalassumption,supportedby studiesand personalcommunication,is that healthandhygieneeducationis not apriority within MOHFW Thereis, in fact, no directive fromhigher levelsto carry out hygieneeducation,andmanymem-bersof the field-level staffsimply do not considerit as oneoftheir duties. It is little wonder,then, that so few field-levelstaff feel committedto carrying out their educationaltasks.Their attemptsto do so would, in anycase,facesuchobsta-clesas alack of initial training (especiallyin communicationskills), refreshercoursesand in-servicetraining, or super-


vision andmonitoringto improve performance.In addition,both field allowancesandprovisionsfor transportationtowork sitesareinsufficient.

A study by the BangladeshRural AdvancementCommittee(BRAC, 1990) providesavivid accountof the thana-levelob-staclesfacedby healthprogrammes,including thosein hy-gieneeducation.For example,it was found that HAs do notdevoteevenone hour aweek to healtheducation.And, thereportnotes,“What is morefrustratingis the way healthedu-cationis delivered.WhatHAs deliveredwas very superficialandtoo often given in a very haphazardway. They nevertried to makemothersparticipate: it was one-waycom-munication. HAs did not seemto care whethermotherslearned.In turn, the motherswerenot interestedin what theHAs were saying” (BRAC, 1990; 12). On the samepageanexampleis given of how HAs work: “The HAS only havetoseean adult in the house ... they would start saying: ‘keepyour houseneatandclean,it is very important’, ‘includeenoughvegetablesin your diet’, ‘use latrines—theyare easyto build’, andso on. This healtheducationis given as if theyarereciting from a verse.”

Healtheducationgiven by healthfield-level staff focusesonthe expandedprogrammeon immunization(EPI) and familyplanning.As one staff memberpointed out: “the action iswherethe moneygoes”.But, then, why doesn’t moneygo tohygieneeducation?The EPI and family planningprogrammesareconsidereda success,so lack of cost-effectivenesscannotbe the reason.And diarrhoea,worm andskin diseasesareseriousproblems,so lackof needcannotbe the reasoneither.

This case-studydid not allow for a thoroughinvestigationof the underlying reasonsfor the striking absenceof


MOHFW participationin hygieneeducationactivitiesrelatedto water supplyandsanitation.Onething is clear, however:nobody seemsto be interestedin giving it a serioustry. NotMOHFW, becauseit doesnot considerhygieneeducationapriority activity. Not DPHE, becauseit considersMOHFW tobe “busy with their own things”. Even donorsand NGOs,who agreethat the MOHFW should play a key role inhygieneeducation,do not pressthe issue(seeChapter4).

Howplannedandparticipatory is thehygieneeducation?

Disregardingsocial mobilization activities for the moment,most hygieneeducationactivities do not seemto meet therequirementsof good or effective hygieneeducation.Asdiscussedin the Introduction, good hygieneeducationisplannedand involves the participationof those being edu-cated. Good hygieneeducationinvolves the creationoflearning opportunitiesdesignedto facilitate decisionsandchoicesanddesignedto promotethe acquisitionof skills forbehavingin ways thatwill protectone’shealth.

Whenit is saidthat good hygieneeducationis planned,partof what is meantis that hygieneeducationshouldstartwitha baselinestudy andan assessmentof needs,with an under-standingof local perceptions,practicesandproblems,andwith a list of feasibleand relevantoptions for improvinghygienepractices.Although most of the hygieneeducationactivities consideredin Chapter1 did startwith somekindof baselinestudy, the data collectedseemscarcelyto havebeen usedin designinga practicalplan for hygieneeduca-tion. This is not uniquefor Bangladesh.It is, unfortunately,a commonproblem. In part,the unfortunatelack of connec-tion betweenbaselinestudiesand the designof practical


plans for hygieneeducationmay result from the fact thatsuch studiesusually take the form of questionnairesand,like all questionnaires,provideinformationonly aboutmat-tersthe investigatoralreadyknowsenoughto askabout.Butit is probablethat thereis adeeperproblem:the lack of im-agination,skills and institutional will to translatefindingsand insights into a meaningfulcombinationof learningopportunities.

As aresult, mosthygieneeducationactivitiesjust consistoftelling peoplewhat to do, with or without the helpof aflipchartor othervisual materials.Messagesare generallynon-specific,for a non-specificaudience,andit is commonprac-tice to emphasizethe importanceof reachingwomenwithoutacritical analysisof whatis neededanddesirable.Within itslimited framework, the IntensiveSanitationandHygienePromotionProgramme(ISHPP) tried to deal with someoftheseproblems.Thus, the fieldworkersdid not promote theuseof tube-well waterfor all domesticpurposes,but ratherdiscussedpracticaloptions, suchas rinsing cupsandutensilswith sufficient tube-well waterafter washingthem in pondwater. Also, realizing the importanceof male involvement,theystartedto organizemen’smeetings(seeChapter6).

Usually, though,hygieneeducationmessagesandmaterialsare to agreatdegreefocusedon the promotionof latrineconstructionanduse,hand-washingwith ashor soapandonthe use of tube-well water for all domesticpurposes,inorder to preventdiarrhoea.Food and personalhygienereceivemuch lessattention,andalthoughskin diseasesanddiseasescausedby worms seemto be a realproblem, theyare seldombroughtinto the discussion.


Figure 3. Promotion of tube-well water for all domestic purposes

The messagesdo not appearto havebeen tested.Althoughall the visual materialswere reportedto havebeentested,not all were testedthoroughly,andmostweretestedonly inorder to determinewhetherthey were understoodandcul-turally acceptable.They are not testedto determinetheirsuitability as educationaltools.


Flip chartsappearto be very popularin Bangladesh.But thenumberof themin use—i0 differentflip chartswerecollectedin one week—maysignify a lack of ideasfor alternatives.Inaddition,therearesomeposters,leaflets,stickers,etc. Althoughno systematicinvestigationhasbeenmadeon the subject,itseemssafeto saythat such materialsare designedto conveyinformationratherthan to inspireaction. Thus,thesematerialsreinforcethe ‘telling’ or ‘teaching’ wayof hygieneeducation.

An additionaldrawbackof flip chartsis their tendencyto beusedin amechanisticand inflexible way. Startingfrom thefirst picture, the educator/motivatorcontinuesto the last,irrespectiveof the interestandquestionsof the audience.Oneof the drawbacksof using leafletsis the fact thatmanypeoplecannotread.An exampleof auseful leaflet is pro-vided by abooklet linking hygieneandreligious issuesthatNGO Forumpreparedfor imamsto be usedas asourceformaterialfor their speeches.

With not muchplanningandnot much hygieneeducationthat goesbeyondmerely imparting information, it is notsurprising that mosthygieneeducationactivities do nothavespecific objectivesor clearplansof action.Whenthisis addedto the minimal training (seeChapter5) andprofes-sional supervisionfieldworkers receive,doubtsabout theeffectivenessof mostof the hygieneeducationactivitiesareinevitable. Indeed,it is likely that hygieneeducationactivi-ties, flawed by the drawbacksdiscussed,areeffective onlyfor promotingthe constructionand (to a lesserextent)useof latrines in areaswhere,becauseof local conditionsandpreferencesor social pressurecreatedby fieldworkers orlocal authorities,peopleare predisposedto be receptive.Itwas learnedfrom interviewsthat small amountsof socialpressurewereaquite commonform of motivation.


The SanitationandFamily Education(SAFE)pilot projectisaprominentexceptionto the above picture. This projectmakesa seriouseffort to put the principles of ‘good’hygieneeducationinto practice.First, informationwascol-lectedon currentbeliefsandpracticesthroughsmallquanti-tative and qualitative participatory researchactivities(Bateman,1993; Zeitlyn, 1993). Basedon currentbeliefsandpractices,hygieneeducationmessagesandactivitieswere developed.A limited numberof behaviourscloselylinked to diseasetransmissionandreadily modified by pro-viding better informationandstimulatingcommunityprob-leni-solving activities were selectedfor intervention.Hygieneeducationactivitiesarepresentlybeingcarriedoutin three overlappingcyclesof threemonths each.Duringthe first month, the emphasisis on sanitationandhygiene,during the secondmonth on safewater useandduring thethird, on diarrhoeapreventionand treatment.The cycle isgonethroughthreetimes,for atotal of ninemonthsof inter-vention. The hygieneeducationactivities are supportedbythe use of visual materialsdirectedto actionand problem-solving thatmakethe activities interestingandinvite partic-ipation. A behaviour-basedmonitoring systemto assesstheeffectivenessof the projectand to learnfrom experiencewasdesignedandtested(Jahanetal., n.d.).

Other interestingelementsof the activitiesreviewedare themore participatoryhygieneeducationinitiatives in DhamraiThanaand the attempt at a more systematicwork planapproachin RamgotiThana(seeChapter6). Whetherthenew Social Mobilization for SanitationProgrammewillreachthe levelof plannedandparticipatoryhygieneeduca-tion remainsto be seen.Someof the ingredientsare there,but the right mix needsto be foundandimplemented,whileat the sametime solutions haveto be found for the weak-


nessesat the level of humanresourcesand institutionalorganization(seealsoChapter4).

How effectiveis thehygieneeducation?

Except in the SAFE and ISHPPprojects,remarkablylittle isdone to monitor hygieneeducationactivities and results.The 18 District Towns Project(18DTP) hadsetup apracti-cal monitoringsystem,but the hygieneeducationprojectwas sufferingfrom problemshaving to do with designofthe hygieneeducationcomponentas well asoneshavingtodo with humanresourcesandbuilding institutionalcapacity,andthe monitoringsystemdid not work out. At present,theproject is being re-establishedon a new footing, with amore elaboratemonitoringandsupervisionsystem(1 8DTP,1993a).

Most of the activitiesexaminedlack specificobjectives,andit is difficult to get clear answersto questionsaboutwhoprovidesthe hygieneeducation,to whom it is ‘provided,with whatfrequency,methodsandresults. As aresult, it isvery difficult to assessthe effectivenessof the materialresourcesandhumanenergiesexpendedin their implemen-tation. This lack of information hamperspractical evalua-tion of the sort that could be used for systematiclearningandprojectdevelopmentandimprovement.

How sustainableare thehygieneeducationactivities?A last questionemergingfrom the review of currenthygieneeducationactivities is how sustainablethey are.Regularhealthstaff who are working at community levelandhavehealth educationas one of their dutiesare hardly


involved. Instead,useis madeof technicalstaff, volunteers,NGOs andprojectstaff/consultantswith donormoney.Howmuch in the way of hygieneeducationactivities would bepossiblewithout moneyfrom donors?And how muchatten-tion will be paidto hygieneeducationoncethe donorswith-drawtheir support?(SeealsoChapter4.)

Hygieneeducationduring emergenciesBangladeshis one of the unfortunatecountriesthat oftensuffernaturaldisasterssuchasfloodsandcyclones.DPHE isknown for its immediate responseto emergencies(MatrixlAssociatedConsultingEngineers[ACE], 1993).It ishard to judgethe extentto which hygieneeducationis partof emergencyactivities.DPHE central-levelstaff indicatedthat thereis just no time for hygieneeducationduringemer-gencies.Staff membersof other organizationsindicatedthatbecauseit is especiallyimportantfor peopleto know howtobestprotecttheir healthduringhigh-risk situations,hygieneeducationis a naturalpart of emergencyactivities. And, infact, togetherwith UNICEF, the Governmenthaspreparedleaflets on what to do whenwater supply andsanitationfacilities arefloodedor damaged.

Hoque et al. (l993a)did a briefpost-disasterstudysoonafterthe 1991 cyclone.They foundthat “water scarcity was acute,especiallywaterusedfor washingandpersonalhygiene.Thesituation was madeworse by the fact that the surfacewatersources(ponds)which were commonly used for domesticpurposesotherthan drinking were flooded, highly contami-natedand regardedas unusable.The user load on existingtube-wellsdoubled, indicating a significantly increaseddemandfor the tube-well water which is commonly usedfor


drinking purposesonly. The majority (63%) of the waterpurifying tabletswere found to havelostpotency.Sanitationwas very poor in householdsas well as in field clinics andshelters.Mostpeople,includingrelief personnel,lackedenvi-ronmentalhealthknowledge”.As aresult, the studyteamrec-ommendedhealth training coursesfor relief personnelandpromotionof appropriatewateruseandtreatment.

Interestingly, the SAFE project is a follow-up to the post-cyclonerelief effort including water,sanitationandhygieneeducation.However, the softwarecomponentwas limitedandcould not accomplishmuch in the short time-frameallotted to it. As a result, the decisionwas madeto continueefforts on the softwareaspectsthrough the SAFE initiative(Jahanet al., n.d.)

3.Hygiene education in schools andnon-formal education settings

This chapteroutlineshealthand hygieneeducationactivitiesin the formal and non-formaleducationsystems.Emphasisisplacedon describingexamplesof activitiesorientedtowardsactive learning,sincetheseactivities show greaterpromisefor protectinghealthasaresultof behaviouralchange.Suchactivitiesare found mainly in the non-formaleducationpro-grammesand generallysupportedby donors,which provideboth technicalandfinancial supportto governmentactivitiesand financial support to activities undertakenby NGOs. Asindicatedin the Introductionandin Chapter2, the overviewof hygieneeducationactivitieswasbasedon an unsystemat-ic investigationandthereforemay not provide afully com-prehensivepicture. Therewas, for example,no time to lookinto the part played by hygieneeducationin functionaledu-cationfor adults.


A discussionof the healthandhygieneeducationactivitiesthroughthe formal andnon-formaleducationsystemsis notpossiblewithout paying attentionto issuesand develop-mentsin generaleducation.Therefore,thesearealsobrieflycoveredin the following text.

Formal primary and secondaryeducationBangladesh’sformaleducationsystemconsistsof five yearsof primary schoolandsevenyearsof secondaryeducation,followed by two to four yearsof highereducation.Thereisalsoa parallel religious systemof madrashas(Islamicschools)with similar levels. Health andhygieneeducationin the madrashasare not coveredin this overviewdue totime limitations.

Theeducationsystemdoesnot yethavethe capacityto edu-cateall the children in the country.Not only is therea lackof schools,but the quality of educationitself is low becauseof the insufficient training and supervisionof teachers,thehigh ratesof teacherabsenteeism,acurriculum that is notrelevantto the needsof the studentsand the smallpropor-tion of time that teachersactually spendon teachingandlearning.As a result of theseproblems,only about35% ofthosewho enterthe systemin first gradecompleteprimaryschool,andamere5% areableto passthe HigherSecondaryCertificateexaminationin twelfth grade(UNICEF, 1992).Thesituationfor girls is evenworsethanfor boys.

The Governmentof Bangladeshadoptedthe declaration‘Educationfor All by the Year 2000’ and, in January1992,startedto phasein compulsoryprimary educationfor allchildrenandfree educationfor rural girls until eighthgrade.

In schoolsandnon-fonnaleducationsettings 37

Recently,with the aim of acceleratingdevelopments,thePrime Minister becameminister of what was formerlyknown as the Primary andMass EducationDivision of theMinistry of Education.The Governmentrecognizestheimportant role of non-formalprimary education(NFPE) inachievinguniversalprimaryeducationin Bangladesh.

Primaryeducation

The National Curriculum and TextbookBoard (NCTB) isresponsiblefor curriculum developmentandchanges.Arevisedcurriculumthatputs more emphasison the practicalapplicationof what is taughtwas introducedin 1992,andanattempt is being madeto makeschooling morerelevanttothe lives of the majority of Bangladesh’speople,who arepoor. The new curriculum for first and secondgrade isready,and recentlya massivetraining programmefor allfirst andsecondgrade teacherswas completed.In thecourseof a one-weektraining workshop,first andsecondgradeteacherswere familiarized with the new materials.The curriculumfor the pre-servicetraining of primary edu-cationteachersis alsobeingimproved.

Therearenew teachersguideswith units on healthandhy-gienefor the first andsecondgrades.Revisionsin the curri-culumfor the third, fourth andfifth gradesarein progress.In thosegrades,healthandhygienewill bepart of the socialstudiesandsciencecurriculum.Water,sanitation,healthandhygienesubjectsarealso coveredin the Bangla-or Bengali-andEnglish-languagetextbooks.Health inspectorsare sup-posedto visit the schools regularly to offer instruction aswell as to carryout healthinspections,but their visits are, infact, very infrequent.


Although aseriousattemptis beingmadeto makethe edu-cationmore learner-centred,it is realizedthatthereis still along way to go beforethis aim is attained.The new curricu-lum is still ratherdidactic andconcentrateson memoriza-tion rather thanproblem-solving.In addition, it will taketime to changethe teachers’current teachingmethods.Difficulties are compoundedby the fact that due to theintroduction of compulsoryeducation,the numberof chil-drenin schoolhasincreasedconsiderably(60 to 70 childrenler class),making it difficult for the teachersto maintainorder.As aresult, teachersareless inclined to attemptnewmethods,finding it easierto retainexistingmethods.

TheChild-to-Childexperiment

With supportfrom the EducationSectionof UNICEF, theNCTB is interestedin introducing the Child-to-Childapproachfor health andhygieneeducationin the thirdthroughfifth grades.This approachis meantto complementandreinforcethe new NCTB curriculum.

The Child-to-Child experimentis achild-centredapproachto healtheducationin primary schools.The approachisbasedon threeassumptions.

1. Primary educationbecomesmore effective if it islinked closely to things thatmatterto children, theirfamiliesandcommunities.

2. Educationin schoolandout of school should belinked as closely as possible so that learningbecomespartof life.

In schoolsandnon-formaleducationsettings 39

3. Childrenhavethe will, the skill and the motivationto help educateeachother, and they can be trustedto do so.

The Child-to-Child approachaims to haveknowledge leadto action. This involves the acquisition of skills as well aschangesin attitudesandbehaviour.With the helpof activitysheetsand the guidanceof the teacher,the children discussandshareviews on healthtopics andapply their skills andexperiencesin practicalactivities. Thus, knowledgeandpracticeare linked, not only in the classroom,but alsoathomeandin the community.

The NCTB aimsto usethe Child-to-Child approachto attainthe following objectives:

• to makeeducationeffective, meaningfulandlife-ori-ented;

• to help preparechildren for solving day-to-dayproblemsthroughpracticalapplicationof knowl-edgeand understanding;

• to createopportunitiesfor individual andgroupactivities that help develophealth-promotingskills,behaviourandattitudes;

• to help children to studyandunderstandtheir envi-ronmentandto increaseawarenessof why andhowto protectthe environment;

• to inspirechildren with a senseof self-reliance,responsibilityand fellow-feeling and therebypre-parethemfor their future tasks in life (NCTB, n.d.).


A first experimentwith the Child-to-Childapproachis underway. Threeactivity sheetshavebeendevelopedon water,personalhygieneandnightblindness.Teachersin 30 schoolswere trained in the approachandtried it out with their stu-dents.The first feedbackshowedthat the children reallyliked it, but that teacherssometimesfound it hardto changetheir role from oneof teachingto oneof facilitating learning.

Secondaryeducation

Water,sanitation,hygieneandhealthissuesarenot adequate-ly coveredin the secondaryeducationcurriculum, althoughwatercontaminationcausedby industry,agricultureandover-populationis discussedin scienceclasses.The presentcur-riculumwas introducedin 1974,but the total revisionthat isurgentlyneededstill awaitsa governmentdecision.

Sanitationsupport

Many schoolsdo not have any latrine facilities, althoughlatrines are important not only for protectinghealth, butalso for the schoolattendanceof the girl child. Under thesponsorshipof the WaterSupplyandSanitationProgrammeof DPHE/UNICEF, primary schoolsanitationactivitiesbeganwith headmasters’orientationin RajshahiDivisionin 1990.Schoollatrineswereconstructed,andusingsanita-tion education,teacherspromotedlatrine constructionatthe students’ homes.A study by WHO sponsoredbyUNICEF in 1992 showedthat the overall sanitary latrinecoveragefor householdsof studentsin the third throughthefifth gradeswas 62%; 20% of the students’householdsusedhanging latrines.Over 90% of the latrines hadbeenbuilt prior to the headmasters’orientation.Although the


usagelevel was almost total, over50% of the latrineswerenot maintainedproperly(WHO, 1993).

Another sanitationproject supportedby UNICEF waslaunchedin late 1992 and covered1,090primary schoolsin16 thanas.The project includedthe provision of a sanitarylatrine-cum-urinalcomplexandwater supply, where need-ed, and an orientationsessionfor teachers,studentsandschooladministratorsto ensureproperuse of the facilities.The teacherswerealsoencouragedto give more attentiontosanitationeducationin their classes.The project is nowbeing extendedto another440 schools in 32 thanas.Ateachersmanualhas beendevelopedon the construction,useandmaintenanceof the latrineandon relatedhealthandhygienetopics (UNICEF Bangladeshand DPHE, 1993c).Oneof the advantagesof this manualis thataclearpictureis given of how to usethe latrine properly. This is an issuethat is often forgotten,but one that is everso importantwhen childrenare not familiar with, or fearor dislike usinga latrine. It should be noted,however,that the manualrelieson traditionaleducationalmethods.

A small researchproject that covers five schoolswas car-ried out by the InternationalCentrefor Diarrhoea! DiseaseResearch,Bangladesh(ICDDR,B) with the aim of learningmoreaboutthe feasibility of promotingsafewaterandsani-tation practicesthrough the formal primary educationsys-tem. The projectstartedwith a baselinestudy, followed by aone-dayteachers’orientationon healthand hygiene.As-sistancewas provided in constructingsanitaryschool la-trines,and, afterfour months,afinal survey was conducted.The preliminaryresultsof the survey were:

• School textbookscontainenvironmentalhealthtop-ics,but their treatmentis not on a level comprehen-sible to the studentsandso is not effective.


• One of five schoolshad a sanitarylatrine at thebeginningof the project.

• Of the eight newly constructedlatrines, five hadfilled up within two monthsandthreeweredamaged.The reasonthe latrineswere filled so quickly wasthattheywereusedby passers-byafter schoolhours.

• It is difficult to changethe attitudesand teachinghabitsof teachers.

• Action-orientededucationis more effective thanpassiveknowledgetransfer. It was discoveredthatchildren could provide the right answersabouthealthandhygieneif askedin the way they weretaught,but could not utilize their knowledgein anindependentway. This indicates that the presentteachingresultsin memorization,not in accurateconceptualization,andwill not leadto the initiationof appropriateactions.

• Some hygienepracticesrequire clearinstructionsanddemonstration—forexample,how to washhandsproperly (Hoque,personalcommunication,1993).

Non-formal primaryeducation

IntegratedNon-FormalEducationProgramme(INFEP)

The non-formalprimaryeducationactivitiesof the Ministryof Educationare mainly carriedout through INFEP withfinancial supportfrom UNICEF andUNDP. INFEP is akind

In schoolsandnon-fonnaleducationsettings 43

of umbrellaorganization,comprising33 NGO5 that togetherrun 525 centresfor pre-schoolchildren (four andfive yearso(age),1,000centresfor children six to ten years old and2,000centresfor children elevento fourteenyearsold. Eachcentrehandles30 children.

INFEP is intendedfor children of disadvantagedfamilies inrural areaswho have neverattendedschoolor who havedroppedout at an early stage.Most teachersare from thecommunities where the centresare established.Theyreceivetraining andregularsupervision.Thereis onesuper-visor for every 15 centres.

The EducationSectionof UNICEF providessupport toINFEP’s effortsat improvingcurriculum.Oneof the compo-nentsof the curriculumdealswith mattersrelatingto healthand hygiene.Nineteenplay-basedactivities have beendevelopedfor pre-schoolchildren. Theseactivities aim todevelopthe children’s sensory,linguistic, cognitive andphysicalabilities andto foster the children’s emotionalandsocial development.Mattersrelating to health andhygieneare treatedas physicalabilities. They include washinghandsbefore andafter eating,washinghandsafter comingfrom the toilet, brushing teeth,cutting andcleaningnails,andcombingand washinghair.

A teachersmanualhasbeencompletedfor the first grade.The manualdevelopsa problem-solvingapproachto per-sonalhygiene,food andwater,cleanlinessof the closeenvi-ronment(at schoolandat home),how to safelydisposeofhumanexcreta(becausemany childrendo not havealatrineat home, variouspossibilities are discussed).Stories,playlets,question-and-answergames,competitions,self-checks,role-plays,practical individual andgroup tasks(for


example,cleaningthe classroom,helping mother withhouseholdchores), interviewing mothersandobservationsat homeare amongthe strategiesusedto make learningattractive,activeandeffective.

A teachersmanualanda studentsguidearebeingdevelopedfor second-gradeclasses.Thesematerialscover the samesubjectsas are coveredin first gradebut presentthemthrougha story about two families—onedoing well, theother with problems.Each topic beginswith a pictureaccompaniedby text andby spacefor studentsto addtheirown writing—for example,adescriptionof their householdchores.

INFEP hopesthat thesenew educationaltools employing aproblem-solvingapproachwill gradually be integratedintothe formal primaryeducationsystem.Despitemanysimilar-ities in concepts,methodsand subjectsbetweenthe twoapproaches,INFEP’s work and the Child-to-Child experi-ment remainunlinked, and neitheris formally linked to theeducationalactivities of otherNGOs, though thereis someexchangeof informationandexperienceatan informal, per-sonallevel.

BangladeshRuralAdvancementCommittee(BRAC)

BRAC is running a non-formal life-orientedprimaryeduca-tion programmefor childrenof poorerhouseholdswhohaveneverbeento schoolor who droppedout during first grade.Thereis athree-yearprogrammefor children8—10 yearsoldanda two-year programme,plus an additional year ofschoolingwith a more functional curriculum focusingonhealth,nutrition andsocialenvironment,for children 11—16.


More than70% of the studentsarefemale.Regularlysched-uled parent-teachermeetingsensureactive communityinvolvementin the project.

At the end of 1992, there were 11,108 BRAC schoolsinoperation.Most are in rural areas,but an experimentinextendingsuch schoolsto urban slumsis in progress.EachBRAC schoolhas30 studentsand I teacher,who mustbe amarriedpersonfrom the community who has completedmorethannineyearsof schooling.The teachers—over80%of whom are women—attendan initial 15-day trainingsession;thereafter,they attendmonthly teacher-trainingmeetings.

The curriculum is divided into four subjectareas:Bangla,English, arithmeticandsocial studies.Nutrition, hygiene,sanitation,safety and first aid, ecosystems,community, thecountry, the world andbasicscienceare consideredpart ofthe social studiessubjectarea. The teachingmethod,employing such tools as rhymes, poems,games,cards,mimes and role-plays,is learner-centredandparticipatory.One of the pedagogicaltools is an illustrated story aboutagirl who doesnot wantto eatathomeunlesshygienicmea-suresshehas learnedaboutin schoolare applied.Her moth-er does not believe what her daughtertells her abouthygienic food handlingandpreparationand complains to aneighbourabouther daughter’sconduct.As theydiscussthedaughter’srefusal to eat, mother andneighbourgrow lessskeptical about the information the daughterhasbroughtbackfrom school.Togetherthey ask the daughterto repeatwhat shehas learnedandthen seekconfirmation from thehealth centre.In the end, the adult womenbecomeactivepromotersof hygiene,not only in their own households,butalso in the community (seeFigure 4). This story grapples


with the difficulties childrenencounterwhenthey try to putinto practiceat homewhat they learnedat school.The storyalso dealswith cultural obstaclesto children’seducatingtheir parents.

Figure4. Illustrations from a story about a schoolgirl who teaches hermother to apply hygienic practices


The educationalmethodsusedin the BRAC schoolshaveprovedto be effective. BRAC studentsachieveas much asor more than formal school students.During a three-yearperiod,BRAC studentscompletedthe NFPE programmeandenteredthe fourth grade of formal school at a greaterratethandid studentsin the formal system(Ahmedet al., 1993).BRAC is taking an active role in assistingother NGOsinvolved in non-formalprimary educationand is sharingexperienceswith them. One of these other NGO5 isGonoshahajyaSangstha(GSS) (BRAC, l993a; BRAC,l993b).

GonoshahajyaSangstha(GSS)

The GSSPrimaryEducationProgramme(PEP)offers educa-tion to childrenup to age 12 who haveneverbeento schoolor who havedroppedout. The programmestartedin 1986andcurrentlycovers some 100 schools in urban slumsandrural areas.About 45% of the studentsare girls, 55% areboys.Monthly meetingsareheldwith parents,teachersandschool supervisorsto strengthenthe links betweentheschoolandthe community.

PEPteachersin ruralareashaveat leastcompletedsecondaryschool; in urban areas,teachersmust have a bachelor’sde-gree. Preferenceis given to femaleteachers.Teachersre-ceive an initial training lasting 12 days,andthis is followedby monthly one-daytraining meetings.Once teachersstartwork at their schools,they are given constantsupportby aschoolsupervisor,who visits eachschoolat leastthreetimesaweek. After oneyearon the job, teachersparticipatein afive-dayrefreshercourse.This intensivetrainingandsupportsystemis consideredto be the keyto PEP’S success.


PEP’seducationalmethodsarelearner-centredanddesignedto encouragethe developmentof creativethinking andproblem-solvingabilities(seeFigure5).

Figure5. Creativeand problem-solving groupwork with teacher’s support

The children work in groups,eachgroup doing differentactivities.For healthandhygieneeducationPEPusestheChild-to-Child approach.Subjectscoveredinclude: diar-rhoea,water andsanitation,measles,skin diseases,acci-dentsandnight blindness.In first and secondgrades,onetopic is discussedeach week. In the third, fourth and fifthgrades,the discussionof eachtopic lastssix weeks,andnomatter what the topic, the discussionfollows the same


sequence.For example,the topic ‘cleanliness’startswith aquestionby the teacher:“What do you do whenyou getoutof bedin the morning?” Answersto this questionlead to adiscussionaboutcleanlinessand health.Next, the childrenmake drawings about the topic, and questionsare askedabout the drawings.Then, the classdividesitself into threegroups.Eachgroupcarriesout acommunity survey, reportsback to school, returns to the community to discussthetopic with peoplein the neighbourhood,and onceagainreportsbackto school. At the conclusionof eachtopic, thechildren write a play demonstratingtheir newly acquiredunderstandingandperformthe play for theotherschoolchil-drenandfor the communityatlarge.

Recently,a two-yearprogrammefor children 10—16 yearsof age was initiated. This adolescents’programmecoversthe samesubjectsandemploysthe samemethodologyas theprimary educationprogramme,but it emphasizes,in addi-tion, income-generatingactivities andhome gardening(GSS, 1992; OSS,1993).

4.Policy, organization andcollaboration for hygiene education

This chapterexploresissuesof policy, organizationandcol-laborationamongthe majoractorsconcerningmattersrelat-ed to hygieneeducation.The issuesare complicatedbut cru-cial for achievingeffectiveinteractionand thereforedeservestudy in greaterdepthwith aview to making practical rec-ommendationsandstimulatingrealistic progress.Sometop-ics treatedherewill be consideredoncemorein Chapter7.

PolicyThe Governmentof Bangladeshis committedto achievinguniversalcoverageof rural andurban watersupplyandsan-itation. The FourthFive-YearPlan (1991—1995)allocatesa


greaterproportionof resourcesto this sectorandstates:“Inorder to developan effective water and sanitationpro-gramme,the level of awarenessof the local populationregardingsafedrinking water and its use, sanitationandhygieneas preconditionsto good health and longer lifeexpectancyis to be graduallypromotedfrom its presentlowlevel. Therefore,the packageprogrammeof water supply,sanitation,drainageand healtheducationwill be pursuedduring the plan period” (Governmentof Bangladesh—UNICEF, 1990; xiv—7). However, the programmebasedonthe plan fails to mention any sanitationplans above thelevel of production and installation of water-seallatrines.(Governmentof Bangladesh—UNICEF,1990; xiv—9). Follow-ing sectionsconcernedwith tourism and financial alloca-tions for the implementationof the plan,hygieneeducationis coveredunder the heading‘women’srole andcommunityparticipation’.The planstates:

The provisionof clean water, improved sanitationand hygieneare the basic elementsof primaryhealth careand are essentialpreconditionsforimprovementof public health....The hardwarepartof the ongoing programmeis mostly engineeringand the softwarepart relatesto healthand hygieneeducation.Thesetwo shouldbe integratedduringtheFourthFive YearPlan....During the planperiod,efforts will be madeto employ femalehealthwork-erson the water supply and sanitationprojectsfortransferof knowledgeon healthand hygieneto theusersof waterandsanitarylatrines.Apart from per-sonal contact,knowledgeof this type of informaleducationcanbedisseminatedthroughthemediaofradio, TV, video, movies, leaflets, stickers,etc.This policy will eventuallygeneratepublic aware-nesson healthand hygieneandwill give rise to anapproachof women’sparticipationin operationandmaintenanceof tube-wells, the water supply andthe sanitationsystem....During theplan penod,it is

Policy, organizationandcollaboration 53

envisagedthat the Departmentof Public HealthEngineeringwill not only be responsiblefor imple-mentationof water supply, sanitationand drainageprojects,but will also motivate beneficiaries/userson healthand hygieneeducationand sharinga partof the cost of installation and maintenance.Thiswill eventuallytransformit into a peoples’orientedorganization(Governmentof Bangladesh;UNICEF,1990;xiv—13).

Discussionof the view of hygieneeducation(and women’srole in hygiene education)expressedin the plan is beyondthe scopeof this paper.What is important to note is thathygieneeducationis given attention in the plan, that it isseenas a part of primary healthcareandthat DPHE will beresponsiblefor both the ‘hardware’ and ‘software’ compo-nentsof hygieneeducation.

Organization and cooperation

DepartmentofPublic HealthEngineering(DPHE)

As statedearlier, the Departmentof Public Health En-gineering(DPHE) underthe Ministry of Local Government,Rural DevelopmentandCooperatives(MLGRDC) is respon-sible for the implementationof water supply, sanitationanddrainagein all areasexcept for the cities of Dhaka andChittagong.

The organogramof DPHE is presentedin Figure 6. It showsthat DPHE is madeup of professionalengineersand tech-nicians.Six of the TWM5 and one executiveengineer(EE)are female. In addition, there are 20 health educators,20sanitaryassistantsand 20 projectionistsunder the project


director of village sanitation,and their roles and positionsrequirea bit more explanation.

Figure 6. Organogram or DPHE

The first health educatorwas appointedin 1963, whenhealth educationactivities beganin DPHE in the context of


apilot village SanitationProject. Sixty postswere createdin the 1970s,but only eight healtheducators(with master’sdegreesin non-engineering,public health subjects),fourprojectworkers andsix assistantswere actually hired upuntil 1989, when all vacanthealtheducationpostswerefilled by appointees(whosesuitability to their respectivepostsis opento question).Most of the appointeeswereinternally recruited,apparentlyattractedby the prospectofpromotionfrom clerical gradesrather than by the distinctchallengesof working in the field of health education.Allappointeesreceivedthree-monthcertificatetraining in theNational Institute of Preventiveand SocialMedicine (Matrix!ACE, 1993).

In 1992,64 districts—eachheadedby an EE—werecreatedandeachmemberof the healtheducationstaff was requiredto work underthe directionof theEE headingthe district towhich heor shewasassigned.TheEE5 receiveprogrammat-ic supportfrom the chief healtheducator,but the natureoftheir work remainsobscure.When lower-level DPHE staffmembers,in particular SAE5, were questionedabout theduties of the healtheducatorassignedto their district, theyansweredthat the healtheducatorwas hardly seenandthatactivitiesof asinglehealtheducatorcouldhardly beexpect-ed to have an impact over so largean areaas a district.When staff membersat the central level were askedaboutthe healtheducators’work, no definite objectives,plans orevaluationswere cited, anddiscussionof the link betweenthe work of healtheducatorsand social mobilization wasminimal (Kabirushan,1993). In Governmentof Bangla-desh—UNICEFand UNICEF waterandsanitationdocuments,healtheducatorsarerarely referredto. The projectproposalon SocialMobilization for Sanitationstatesthat the role ofhealtheducatorsneedsto be defined more precisely


(Governmentof Bangladesh—UNICEF,l993a). In sum, oneis left with an impressionof organizationalweakness.Thereasonsfor this situationrequiremoreresearch,but it seemsevident thatdeficienciesin the organizationalset-upandinthe qualificationsand experienceof the healtheducationstaffplay animportantrole.

DPHE’s organizingfor socialmobilization

The recently approvedSocial Mobilization for SanitationProgrammeindicates that DPHE, assistedby UNICEF,will havethe overall responsibilityfor implementingthe pro-gramme.Two new divisions will be establishedand staffedunderthe projectdirectorof village sanitation(seeFigure7):

PROJECT DIRECTOR (YJUAGE SANITATION AND SOCIAL MOIIUZATION)

SOCiAl. MOSILIZA11ONDlvii ION I I TRAINING DIVISiON

EXECUTiVE ENGINEER (I)SOCIAL HORIUZATION OVflC~S(2)

ASSISTANT ENGINEER (I)

SENIOR COMMUNICATION + SENIOR TRAININGTRAINING OVRCER (EdO) CONSUL1AI(T

COMMUNICATION TRAINING + TRAININGOFFiCERS (CTO) (5) CONSULTANTS (5)

Source: Government of Bangladesh—UNICEF,1993a.

Figure 7. Social Mobilization Organogram—DPIIE


• a SocialMobilizationDivision, whichwill coordinatethe overallsanitationactivitiesrelatedto the softwareaspects.The division will be headedby an executiveengineer(EE), who will be responsiblefor imple-mentation and monitoring of the project. An assis-tant engineer(AE) will assistthe EE in technicalandadministrativeissues,and two social mobilizationofficers, with social science/communicationback-grounds,will assistthe EE in ‘software’ issues.

• aCommunicationTrainingDivision responsiblefortraining all levelsof DPHE staff. This division will beheadedby asenior communicationandtraining offi-cer (SCT0) with a social sciencebackground.Fivecommunicationtraining officers (CTO5) with socialsciencebackgroundswill be placedunder the SCTOandpostedto the offices of the superintendingengi-neers(SE5) in the five Governmentof Bangladeshad-ministrative divisions. The SCTO and five CTO5 willeachbe supportedby a training consultant.In eachofthe five SE’soffices, the CTO andthe training consul-tant will form thecore training teamandbe responsi-

ble for organizingandimplementingall training acti-vities relatedto the socialmobilizationprogramme.

Social Mobilization Programmeactivities will be carriedoutby regular DPHE staff with support from allies that the pro-grammeis mandatedto identify and cultivate. The SE willcoordinateall the activities in his or hercircle and report tothe project director. The EE/sub-divisionalengineerwill co-ordinateall activitiesat the district level; the SAE will coordi-nateall activities at the thanalevel. The TWMs will work atthe community level in conjunctionwith otherinterestedpar-ties. All personnelwill receive orientation coursesand two


roundsof week-longtraining in communicationtechniquesaswell as in the ‘hardware’ and ‘software’ aspectsof hygieneandsanitation(Governmentof Bangladesh—UNICEF,1993).

Thesenew developmentsraisequestionsaboutthe appropri-atenessof DPHE’s beingthe focal organizationfor the non-engineeringaspectsof watersupply andsanitation.Duringarecentorganizationalstudy of DPHE, severaldevelopmentscenarioswerediscussed.DPHE itself focusedon ascenarioin which its effectivenessas an engineeringorganizationwas increased,while in relationto the ‘software’ aspectsofhygieneandsanitationit was ‘downgraded’ to playing anenablingfunction for other actors—inparticular,localauthoritiesandNOOs who would take on the actual imple-mentationof thosefunctions (Matrix/ACE, 1993). Whatimplicationsthischoicewill haveon the proposedorganiza-tional structureof the Social Mobilization for SanitationProgrammeremainsto be seen.

The questionof whetherDPHE is the appropriateorganiza-tion for implementingthe ‘software’ aspectsof hygieneandsanitationis to someextentanacademicone.If onelooksatthe division of responsibilitiesfor the activities under theSocial Mobilization for SanitationProgramme,it appearsthatto a largeextentUNICEF is taking the lead(Governmentof Bangladesh—UNICEF,1993a).This is in line with earlierwork in EPI, or as MatrixJACE (1993;Appendix17, 2) put it:“No centralgovernmentDepartmenthaseverimplementedamassSocial Mobilization Campaign.Bangladesh’sworld-renownedEPI programme—amongstothers—wasthe resultof nationalpolitical pressureandcommitment,andthe har-nessingof a very wide range of actors. However, UNICEFplayed a major role in day-to-daycoordination,under thesupervisionof the Ministry of Health,usingNGOs and localauthoritiesextensively.”


The organizationalproblemswith respectto the ‘software’aspectsare to someextent a manifestationof the complexi-ties of donor views and interests on the one hand andGovernmentpriorities and DPHE interestson the otherhand.And, as usual,money dictatesthe compromise.Thedonorsput increasingemphasison ‘software’ aspects.Thecountry is not—or not yet—on the sameline. From reportsanddiscussions,the impressionis gainedthat sanitationisgradually advancingas a priority, but it is sanitationcover-agethat is in question.Hygieneeducationdoesnot appearto be a priority with politicians, generalGovernmentorDPHE staff.

The standof DPHE seemsto be clear.It takesresponsibility

for hygieneeducationaspart of the deal. If hygieneeduca-tion has to be done, DPHE itself should be in controlbecauseit is responsiblefor implementing water supply,sanitationanddrainage.Therefore,it feels strongly thatmotivationalstaff shouldbe underits control, with account-ability and continuity being the reasonsmentionedmostoften. However, DPHE indicated its acceptanceof theinvolvementof NGOsbecausethe donorswant this involve-ment. Acceptanceof the involvementof NGO5 is seenas theway to safeguarddonormoney.

Acceptanceof the involvement of NGO5 in the implementa-tion of the ‘software’ aspectsalso has a practicalrationale:DPHE field staff—in the personsof TWMs—aresufficientlynumerousandcompetent.They arealreadyin place and incommunicationwith men and women in the communities.On the otherhand,as noted in Chapter2, thereareseriousdoubtsaboutthe degreeto which TWMs canfulfil the roleof motivatorsandeducators.Thesedoubts are also voicedin the organizationalstudyof DPHEby Matrix/ACE (1993).


Apart from questionsaboutthe suitability of TWM5 asmoti-vatorsandeducators,it is unclearwhetherfour TWMs—thenumberassignedto eachthana—will be ableto ensurethatevery memberof the community receivesintensivedirectcommunication.Moreover,becausenearly all TWM5 aremen(andahiring freezemakesit unlikely that this situationwill changein the nearfuture), effective communicationwith womenwould be difficult (Alam, 1993).

Non-governmentalorganizations(NGOs)

The involvement of NGO5 brings with it many advantages.Such organizationsare generallypeople-orientedandplacegreat emphasison women’s participation.Matrix/ACE(1993) presentsan overviewof characteristicsof NGOs inBangladesh(comparedto those of DPHE). The overviewnotesthat:

• NGO water, sanitationandhygieneeducationinter-ventionsoccur as acomponentof a muchbroaderdevelopmentstrategyaimedat overcomingpoverty.

• NGO5 are more flexible in accommodatingwomenwhen it comes to making arrangementsfor travelandrelocation.

a

• NGOs recognizethat effective hygieneeducationisa long-term,continuouscommunicationprocess.Inconsequence,they havea high staff-to-populationratio,andtheir staff is often recruitedfrom andcon-tinues to reside in the communitieswheretheywork. -


• NGOs emphasizepracticaltraining andsupervisionof field staff. The training focus is on social atti-tudes(towardspoverty), technicalskills (includingpedagogyandcommunication),organizationalandmotivationalskills.

• SeniorNGO staff keepabreastof the actual func-tioning of their organizationsby regularlyjoiningworkersin the field.

Despitethe overall accuracyof theseobservations,experi-enceswith the involvement of NGOs in the ‘software’aspectsof water supply andsanitationhavenot beenuni-formly encouraging.The degreeto which the NGO is depen-denton donor funding andthe amountof experienceit hasin providing healtheducationseemto makethe differencebetweensuccessfuland less-than-successfulexperiences.Where activities of an NGO are ongoing,the organizationseemsto be ableto continueapplyingits principlesandwayof working whenit is invited by UNICEF/DPFIE to take upadditionalmotivationalroles in the field of sanitation.Thiswas the case,for example, in KushuraUnion of DhamraiThana.However, if NGO involvement is basedonly on aconsultancycontract,as in the caseof NGOForum, compli-anceseemsto shift in favour of the wishesof the client.Thus,NGO Forumis awareof the fact thatmore is neededfor effective hygieneeducationthan it hasbeencontractedto offer, but neverthelessit acceptedthe contract.

Donor dependencyis not the only constrainton an NGO’seffectivenessas an educatorandmotivator in the field ofhygiene.The types of NGOs alsoseemto be an influencingfactor.Although thiscase-studyonly allows for preliminaryconclusions,it wasstriking that NGO5 involved in education


displayedfar more imaginationandamuch more sensitive‘feel’ for the developmentof hygieneeducationthanNGOsoriginally involved in ‘hardware’-orientedwatersupplyandsanitationactivities.

Ministry ofHealthandFamily Welfare(MOHFW)

Mention of MOHFW is conspicuouslyabsentfrom discus-sionsanddocumentsthatexamineoptions for creatingthebestorganizationalset-upanddivision of responsibilitiesfor the ‘software’ componentsof water supply and sanita-tion programmes.The Bureauof Health Education(BHE)under the DirectorateGeneralof Health Serviceswould bethe mostappropriateagencyto takea leadcoordinatingrolefor hygieneeducation,andBHE staff indicatedthat they arereadyif theyareaskedandif theyareprovidedthe meanstodo so (Mia, 1992). However, it is unlikely that they will beasked,becauseBHE is consideredanon-functioningbody.There is a hint of a vicious circle here: BHE may havebecomeanon-functioningbody becauseit is nevergiventhe opportunityto developandprove itself. This true situa-tion may cometo light if the Netherlands-supported1 8DTPcarriesout its intention to startworking throughBHE.

Interministerialcooperation

Thereseemsto be a consensusthat cooperationamongthevariousministriesatfield level will succeedonly whenthereis an official body for interministerialcooperationat thenationallevel. The maintaskof thisbody would be to directthe lower levels to engagein coordinatedefforts in the fieldof hygieneeducationand motivation. However, because


hygieneeducationdoesnot figure in any list of priorities, itis unlikely that suchabody will be createdin the foreseeablefuture. Becausesanitationissueshavehigher visibility thanthosehaving to do with hygieneeducation,the possibilityfor interministerialcooperationon sanitationis somewhatgreater,but thereis ageneralsensethat it would be difficultto induce the ministries to cooperatein implementingthe‘software’ componentsof sanitationpromotion.

Collaboration with other programmes andagenciesCollaborationwith other programmesand agenciesonhygieneeducationand social mobilization is asomewhattricky issue.On the one hand,optimismaboutthe possibili-ties for such collaboration is rare becauseit is well knownthat the organizationalstructureof Bangladesh’spro-grammestends towardsextremeverticality. Even pro-grammesoriginatingwithin the sameministry find it nearlyimpossibleto arrive at amodestlevel of collaboration.Onthe other hand, as part of its social mobilization drive, thenational Rural WaterSupply andSanitation Programmeexpectsto collaborateclosely with allies in the promotionof sanitation.It should be noted,however,that collaborationwith thoseprogrammes(e.g., in CDD or PHC) andagenciesthat are the most obviouscandidates,or with other waterand sanitationprogrammes,is not anticipated.Instead,majorallies areexpectedto be the primary-andhigh-schoolschoolmastersand the NGOs. In fact, their cooperationisconsiderednecessaryfor acceleratingsanitationcoverageand improvinghealthin the community.


On paper,collaboration—albeitin generaltermsonly—withother programmesand agenciesis given dueattention.Forexample,theRural WaterSupplyandSanitationProgrammefor 1992—1995statesthatit “will exploitall opportunitiesforconvergenceand interlinkageswith other child survivalactivities,particularly CDD” (Governmentof Bangladesh—UNICEF, 1992). However,making this happenis quite adif-ferent matter and doesnot seemto havea high priorityamongthe many tasksawaiting accomplishment.The con-straintsdiscussedearlier play importantrolesin this situa-tion. In addition, the CDD andPHC programmeshavetheirown problems.CDD has beenmainly focusedon diarrhoeatreatmentratherthanhygieneeducation,anduntil recentlydid not involve the privatesector,althoughthe privatesectorprovides80% of the healthservices.The PHC programmeisstill very small and powerless.And while CDD andEPI aswell as water supply, sanitationandhygieneeducationshould bepart of PHC, this is still far from beingthe case.

The result is that collaborationremainsat a rudimentarylevel andis extremelylimited. For example,the 110 diar-rhoea-pronethanasidentified by the Ministry of Healthwillbe given highpriority for sanitationactivitiesby the nation-al Rural WaterSupplyand SanitationProgramme.In addi-tion, promotionalmaterials/posterswill be madeavailableat theoral rehydrationtherapy(ORT) centres,andORT mes-sageswill becomepartof the sanitationandhygienepromo-tion messages.

Collaborationbetweendonoragenciesdoesexist, atleasttoacertainextent,but doesnot seemto coverhygieneeduca-tion activities.

5.Training for hygiene education andsocial mobilization

The hugetaskof achievinguniversalwatersupplyandsani-tation that the Governmentof Bangladeshhasset for itselfdemandsa lot from TWM5, togetherwith their SAEs, as wellas from NGO field staff, since in the presentset-upthey aregiven prime responsibilityfor community motivation andeducation.But what training do they receivethat wouldenablethem to carry out thesetasks?This chapterprovidesabrief review.

TWMsandSAEs

It is not necessaryto repeatthe limitations (discussedinChapters1 and4) of TWMs as motivatorsandeducators,but


it is importantto review how their capabilitiesare maxi-mizedthroughtrainingopportunities.

Training of TWM5 and SAEs for the IntegratedApproachdoesnot seemto havegrown beyondthe level of the yearlyfour-day refreshercoursesrequiredof all SAE and TWMstaff. Theserefreshercoursesare given by DPHE staff andcovereveryaspectof their daily work. It is rathersurprisingthat the IntegratedApproachutilizes technically trainedstaff that have neverreceivedsupplementarytraining incommunication,motivation andeducation.Such trainingwas originally envisagedbut never implemented,althoughthe needfor such training was emphasizedin the review oftheIntegratedApproach(Abdullah andBoot, 1989).

The new Social Mobilization for SanitationProgrammeincludestwo week-long training sessionsthat will covercommunicationandmotivation skills (for all TWM5 andSAE5). The plannedCommunicationTraining Division ofDPHE will developand implementthesetraining courses.How this training will work andhow it will helpthe TWM5and SAE5 to carry out their ‘software’ tasksremain to beseen,sincedevelopmentsare still in the planning phaseonly.

NGOfieldstaff

NOOs appearto havea better training record thanDPHE.Trainingcoursesare amongthe formsof supportoffered byNGOForum(establishedin 1982)to watersupply andsani-tationprojectsinitiated by grass-rootsNGOs in Bangladesh.Accordingto NGO Forum’s information,their 10-day train-ing coursesincludetraining designedto developskills in

Trainingforhygieneeducationandsocialmobilization 67

the areasof communication,community participationandsocial mobilization. Using methodssuch as brainstorming,smallgroupdiscussions,role-plays,simulationgames,case-studies,practicalgroup and individual exercises,demon-strationsandquestion-and-answersessions,their trainingmethodsemphasizeparticipatory learning.NGO Forumalsooffersa26-daycourseon the samesubjects,using the samemethods,to instructorsof the 10-day training courses(KanchwaleandRizwan,1993).

In addition to providing an overview of its own trainingactivities, NGO Forumhasprepareda list of the coursesoffered by 61 NGO5 involved in water, sanitationandhygieneeducationtraining. Typically, theseNGO trainingcourses—usuallylasting between1 and 15 days,with a 3-month coursebeingthe longest—arefor internaluseonly:few NGOs conductcoursesopento staff from other organi-zations.A numberof the coursesdeal with issuessuch aspreventing waterandsanitation-relateddiseases,personalhygiene,safewater, safehumanexcretadisposalandotherhygienic practices.Coursesoffering instruction in hygieneeducationarerare.Reportedly,teachingmethodsaregener-ally participatory,utilizing pedagogicstrategiessuch asthose mentioned in connection with NGO Forum(KanchwaleandRizwan, 1993).

Becauseneithercoursecurricula, training materialsnorevaluationsof training courseswere receivedandno train-ing courseswere observed,it is not possibleto presentaproperreviewof theseNGO training activitiesin this study.However, mindful of the increasingemphasison socialmobilization andhygieneeducation,UNICEF/DPHEcom-missionedatraining reviewandneedsassessmentin 1993.


Training reviewandneedsassessment

The training review andneedsassessmentby DevelopmentPlannersandConsultants(DPC) (1993) coversbothGovern-ment of Bangladeshand NGO training programmes.Thestudyindicatesthatinternal training andstaffdevelopmentatDPHE arenot yet institutionalized.Of the 5 Governmentagen-cies and 13 NGOs coveredby the study,only S (all NOOs)pro-vided their sanitationtraining curricula,andthesewereonlycourseoutlines,most of which were still in the draft stage.Trainingprogrammes—particularlythoseassociatedwith theDPHE/UNICEFIntegratedApproach—werenot always welldesigned,often failing to allot sufficient timeto the courses.

The DPC study found that while NGO instructorsreceivesometraining in communicationand in the participatoryapproach,DPHE trainersfailed to receiveanytrainingof thiskind. The study teamconcludedthat the training of trainersshouldbe strengthened,especiallywith respectto ‘software’issues.In addition, the training of field staff in communica-tion,motivationandeducationmethodsshould beintensifiedandmakegreateruseof participatoryapproaches.

The studyalsofound that the pre-servicetrainingof engineersrequiresreconsideration.The BangladeshUniversity ofEngineeringandTechnology,the four RegionalInstitutesofTechnology,and the 18 PolytechnicInstitutes are the maintraining institutes for engineersworking in the water supplyand sanitationsector.The curricula of thesetechnicalinsti-tutesare‘hardware’-oriented,employinga conventionalWest-ern approachto sanitation.‘Software’ aspectsarevirtually un-covered,but, the reportnoted, should be given increasinglygreaterattentionin view of the newtasks of engineersandre-quirementsfor successfulwaterandsanitationdevelopments.

6~In-depth review of a hygieneeducation activity:The Ramgoti experience

Becauseof an opportunity to visit the project areain thecompanyof project staff, the Ramgoti experiencewasselectedas an examplefor a review in greaterdepth of ahygieneeducationactivity. In addition to discussionsandobservationsin the field, this descriptionof the Ramgotiexperienceis basedon the following documents:Project inAgriculture, Rural Industry andMedicine (PRISM) Bangla-desh, 1992; PRISM Bangladesh,1993a;PRISM Bangladesh,1993b.One advantageof usingRamgotias an exampleof ahygieneeducationactivity is that in addition to its hygieneeducationcomponent,it alsopossessesasocialmobilizationcomponent.


Set-up and organization

Theprogramme

The RamgotiIntensiveSanitationandHygienePromotionPro-grammeran from July 1992 to September1993. It was sup-portedby UNICEFwith fundsfrom the AustralianGovernmentand implementedby PRISM Bangladesh.PRISM is ayoungNGO with activitiesin agricultureandruralcredit in six thanasof ChittagongDivision—Ramgotiin LaxmipurDistrict,amongthem.Following the 1991 cyclone,PRISM becameactivelyinvolvedin watersupply,sanitationandhygieneeducation.

TheRamgotiprogrammehadthreemain objectives:

1. Socialmobilizationandintensivehygieneandsani-tation educationthroughinterpersonalcommunica-tion with the entirepopulationof RamgotiThana.

2. Bettersanitationpracticesandbehaviouralchanges:

• increaseduseof tube-well waterfor all domesticpurposes;

• properhand-washingpracticeswith soap/ashbeforehandlingfood andafterdefecation;

• constructionof sanitarylatrinesto be usedby allfamily members;

• improvedpersonalhygienepractices.

3. Building an effective grass-rootsorganizationandfinding allies in the local administration,DPHE,schools,madrashasandmosques.

In-depthreview:TheRamgoti experience 71

ThepopulationRamgotiThanacontains85 villagesand56,549households.The Moslem majority observesstrict purdah,the traditionalsystemof sequesteringwomento guardtheirhonourandthehonour of their families. In contrast,womenof Ramgoti’sHindu minority face no religious obstaclesto participatingin public life, if theypossessthe self-confidenceto do so.

Organizationandstaffing

Village sanitationmotivators (VSMs) formed the backboneof the programme.EachVSM wasresponsiblefor communi-catingwith about425 individualhouseholds.

The 133 VSMs were selectedfrom more than3,000appli-cants.Selectioncriteria includedliteracy, statusin the com-munity, communicationskills and enthusiasticcommitmentto improvedsanitationand hygienepractices.VSM5 wererequiredto devotesix hoursdaily, six days aweekto moti-vationalwork andto travel throughoutthe village usinganyavailablemeans.Given the cultural contextin which VSMswere to function, it was decidedto recruit as many femaleVSMs as possible.Ultimately, the female-to-maleratioamongVSM5 was7 to 3.

TheVSMs weresupervisedby onefemaleandsix malefieldsanitationsupervisors(FSSs),who were responsibleforthe day-to-dayguidance,on-the-job training and qualitycontrol of the motivation andeducationactivities. FSS5’duties alsoincludedmanagement,financial control and liai-son with governmentagenciesand other NGOs in the area.They were responsibleto the thanasanitationcoordinator,who carriedoverall responsibilityfor the programmeactivi-


ties, including training of FSSsandVSMs, monitoringof theprocessandthe performanceof the programme,andliaisonandcoordinationwith governmentagencies,especiallyDPHE. Overallcoordinationwas in the handsof the sanita-tion programmecoordinatorbasedat PRISM Headquartersin Dhaka.

Immediatelyafter recruitment,the thanasanitationcoordina-tor and the seven FSSsreceived18 days of basic training,coveringprogrammeorientation,promotionanduseof safewater, sanitationandhygienepractices,techniquesof inter-personalcommunication,communitymobilization,planning,supervisionandmonitoring.

The VSM5 received11 days of pre-servicetraining on thepromotionof safewater, sanitationandhygiene,interper-sonal communicationand community mobilization. Twodays of refreshertraining were given after the first month’sfieldwork, followed by oneday of refreshertraining afterthethird monthandagaintwo daysafterthe sixth month.

BaselinesurveyA baselinesurvey was carriedout as part of the VSM pre-servicetraining to assessthe existingsanitationandhygieneconditionsin the area.It was foundthat 78% of thehouse-holdsusetube-wellwaterfor drinking. However,only 1.5%usethis sourcefor all their domesticneeds.Only 3% of thehouseholdshadaccessto a sanitarylatrine; 81% usedanopenlatrine and 16% did not haveanylatrine at all. Nearly4% of the householdsindicated that family memberswashedtheir handswith soapor ashafter defecationandbeforehandlingfood.

In-depthreview:TheRamgotiexperience 73

In view of the limited time available,the baselinestudycbnsistedof abrief householdquestionnaire.As it wasreal-ized thatmorein-depthinformationwasrequiredfor anef-fective hygienepromotionprogramme,the VSM5 usedtheirfirst householdvisit to also discusscurrent ideas,beliefsandconstraintswith regardto water, sanitationandhealth.

Activities

Householdvisits

Becausethe programmewas designedto reachevery familythroughhouse-to-housevisits at least four times during theprojectperiod,VSMs neededto visit at least six householdsaday. Somefamilies indicatedthattheyhadbeenvisitedbetween8 and 12 timesduring the project. The large numberof visitsprobablyresultedfrom thefact thattheVSM lived closeby.

During the first visit, the VSMs explainedthe programmeand, using flip charts,discussedthe benefitsof safewater,sanitationand hygiene.This first visit was felt to be themostdifficult. The VSM5 foundpeoplereluctantto interrupttheirhouseholdchores.Also, the VSMs hadnot fully growninto their roles as communicatorsandmotivators.FemaleVSMs, in particular, experiencedshynessduring the firstvisits, feeling that their youth—mostwere youngerthan25—madeit difficult to establishcredibility andgain arap-port with householdmembers.But, as the VSMs gainedexperienceand as their work becamemore widely knownand more acceptedby the community,they becamemoreconfidentandthe situationimproved.

74 HygieneEducation in Bangladesh

The VSMs’ secondvisit, threeweeksafter the first, wasintendedto reinforceearliermessagesandto motivatefami-lies to constructa sanitarylatrine. (It hadbeenthoughtimportantto have this secondvisit soonafter the first inorder to maintain andstrengthenrelationships,but experi-encerevealedthat this was not necessary.)The third visitfollowed after two to four monthsand the last visit two tothreemonthsafter that.

A register,in which eachvisit was recorded,was main-tainedfor eachfamily by theVSM, who carriedit whenvis-iting the householdin order to note any changesin thehousehold.For its part, eachhouseholdmaintainedamoni-toringcard,which wasupdatedon eachvisit.

The FSS5 organizedtwice-weekly (once-weekly,during thefirst month) meetingswith the 19 or so VSM5 they super-vised.The meetingsenabledthe VSMs to shareexperiencesandto discussways of tacklingproblemsfacedin the field.In addition, the FSSsaccompaniedtheirVSMson householdvisits at leastonceaweek in order to provide guidanceandsupport.The VSM5 tendedto use the visits of the FSS tomotivate families to build latrines,suggestingthat the FSSwould be unfavourablyimpressedunlessaction weretakenbeforethe FSS’snextvisit.

SocialmobilizationMale ‘seminars’

Sincemenusually work outsidethe homeduring the dayandwere thusunableto meetwith the VSM, meetingswereheldonceweekly for malemembersof the householdsvisit-ed that week. Theseso-calledmale seminarstook up the

In-depthreview:TheRamgotiexperience 75

sameissuesthat the VSMs haddealtwith during householdvisits, but femaleVSM5 often found leading theseseminarsadifficult taskandappreciatedsupportfrom their FSS5.

Involving men in sanitationand hygieneimprovementsturns out to be very important. Severalwomen reportedconstructingahygienichomemadelatrineon their own ini-tiative only to find that the menwould not use it, claimingthat they were only interestedin ring/slab latrines,whichwere far too expensivefor the householdto purchase.Inaddition to resistingthe useof homemadelatrines, malehouseholdmembers,womenreported,also tendedto leavethe hygienetraining of childrento mothersandolderdaugh-ters.Thus, many fatherswere criticized both for failing toprovidegoodmodelsfor hygienepracticesandfor failing totake anactive role in the hygienetraining of their children.

Hygieneandsanitationclassesin schoolsandmadrashas

FSSs, togetherwith the family’s VSM and local teachers,conductedbimonthly classeson hygieneandsanitationforchildren in primary andsecondaryschools andmadrashas.The main aim of the classeswas to ensuremaximumsupportfor the programmeactivities. (Becauseschoolswere closedfor a numberof days on accountof a national festival, nodirect information could be obtainedon theseclassesforthis study.)

Involvementof religious leaders

At first, it was difficult to obtain the active supportof theimams in the area, who were reluctantto acceptwomenVSM5 becauseit would require women to travel in public.However, through fruitful communicationswith the pro-grammestaff andbecausethe VSMs showedthat they did a


good job, the imams changedtheir mindsandbecameverycooperative.Imamsof the mosquesincluded adiscussionon hygieneandsanitationin their sermonsbefore the Fridayprayer. Also, on severaloccasions,the imams permittedmale FSS5and VSMs to addressprayer gatheringson thesubjectof sanitationandcleanliness.

MasspropagandaRallies andmeetingswereheldfor the generalmobilizationof the populationin supportof the programmeduring threeconsecutivedayshalfway throughthe programmeperiod.Postersweredisplayed,leafletsdistributedandprocessionsheld, followed by meetingswith local authoritiesandGovernmentofficials.

Health CommitteesBecausethe aim was to createa grass-rootsorganizationthat would survive afterPRISM hadphasedout, theworkingareaof eachVSM was divided into four blocks, andeachblock set up its own Health Committee,consistingof 7 to11 respectedpersonsfrom the block area.It remainsto beseenwhetherthesecommitteeswill continuetheir activitiesnow thatthe projectis finished.

Progressand achievementsWhen the programmeconcludedat the endof September1993,all householdshadbeenvisited at least four times. Inaddition,an impressivenumberof meetingshad beenheldwith various audiences.A detailedoverview of the totalnumberof householdvisits and meetingsis presentedinChapter2.

in-depthreview:TheRamgoti experience 77

Latrine constructionanduseThe main emphasisof the programmewas on latrine promo-tion. The result wasan increasein sanitarylatrine coveragefrom 3% to 59%. To whatextentthis also implies an exclu-siveuseof the latrines installedis not yet clear.A brief visitto two villages resultedin a mixed view. Somevery nicelyconstructedandapparentlyusedring/slabandhomemadelatrines were observed,especiallyin the better-off Hinduvillage. None of the homemadelatrines in the poorerMuslim village hadasuperstructure,but the womendid notindicate that this was aproblem,becausethe latrineswerelocatedbehindthe houseswhere nobody is supposedto go.Some of the homemadelatrines hadalreadycollapseddueto heavy rains, adversesoil conditionsandconstructionproblems.Someotherswere not used or only partly used.As indicatedabove,menusedthe latrines less thanwomen.All homemadelatrinesthatwerein usehadacover.

According to the menand women interviewed,the mainreasonsfor latrine constructionwere preventionof flies,diarrhoeaandbadsmells.This contrastswith the usualrea-sons given for latrine construction,such as convenience,privacy andstatus,but the contrastis understandablein thecircumstances.Most peoplealready used some type oflatrine, and thusthe majorchangewas from an unhygienicto ahygieniclatrine.

Otherhygienepractices

Other hygienepracticesthatwere promoted includedhand-washingwith soapor ashafter defecationand before han-dling food, the use of tube-well water’for all domesticpur-posesand a clean householdenvironment.To facilitate the


useof tube-wellwater, supportwas given to the construc-tion of tube-wellsin areaswith low tube-wellcoverageandto tube-well repair.Supportwas alsoextendedto the privatesectorto induceit to stocksparepartsfor tube-wells.

The figures in the overviewin Chapter2 showthe achieve-mentsin hygienepractices.Thesefigureshaveto be consid-eredwith the usualprecautions,sincejudgementsaboutthecleanlinessof the householdenvironmentwerebasedon thesubjectiveassessmentof theVSM, andassessmentsof wateruse andhand-washingpracticeswere basedon what thewomenthemselvesreported.One woman indicated,“Weknew that we shouldwashhandswith soapor ash,but nowwe alsodo it.” Still, researcherscanneverbe surethatpeo-ple do what theysay theyare doing. An attemptwas madeto estimatehand-washingafterdefecationby looking at theavailability of ashor soapin or nearthe latrine,but this wasan unreliableindicator, especiallywhere therewas nosuperstructure.Also, the availability of ashor soapis notalwaysa sign of use:its presencemayindicate adesiretopleasethe VSM.

CoordinationandcollaborationThe programmewascoordinatedwith the thanaadministra-tion, DPHE (EE andSAE) andthe Ministry of Healththrough meetingsand reports. However, this did not resultin collaborationand integrationof activities.For example,PRISM would hold ameetinganti invite the SAE to partici-pate,and vice versa,ratherthanorganizinga combinedmeeting.Therewasno cooperationbetweenthe TWM5 andthe VSMs, andtheDPHE division healtheducatorwasneverseen.Clearly, DPHE acknowledgedthe work by PRISM but

in-depthreview:TheRamgotiexperience 79

at the sametime felt that motivation shouldbe under itsown aegis,with motivationalstaffdirectly responsibleto it.

Also, therewas no cooperationbetweenthe VSMs and theHAs and FWAs, althoughthe union chairmeninstructedtheHAs andFWAs to work togetherwith PRISM.A compound-ing problemwas that eventhoughhygieneeducationisclearly part of PHC, and the HAs aresupervisedby healthinstructorswho haveprime responsibilityfor hygieneedu-cation, HAs andFWA5 do not seehygieneeducationas partof their duties.

Coordinationandcollaborationwith otherNGOs in theareawere more profitable. They helpedeachother in tube-wellconstructionandrehabilitationandin the provision andset-ting of uniformpricesfor ring/slablatrines.

Financial costsand lessonslearned

CastsThe total costs of this one-yearprogrammeamountedtoUS$100,540.Personnelcosts were by far the largestitem,asshownbelow:

Personnel 70%Transportandtravelling 11%

Organizationandmanagement 7%Programmepublicity anddisseminationof materials 5%

TrainingFSSsandVSM5 4%Baseline,reporting,fuel, etc. 2%

Seminarsandmeetings 1%

so HygieneEducationinBangladesh

ThefutureThe questionis now how to go forward. The projectis fin-ished,much is achieved,but much remainsto be done.Homemadelatrineshaveto be replacedregularly, andsus-tainedhygienepracticestake time to develop.PRISM itselfindicatesthat without further Governmentor NGO supportthe programmeis not yet sustainable.As donor funds aredepleted,PRISM will continueon its own with 24 VSMs, 1FSS and2 agricultural supervisors,who will mainly workthrough group discussionsand in cooperationwith theimams, schoolteachers,SAEs, HAs, FWA5, union chairmen,thanaeducationofficers and thanaadministration.Thedeputycommissionerof Laxmipur District hastargetedthewhole district for intensive sanitationpromotion, andRamgotihasbeenbroughtunderthis scheme.

Becausethe implementationmodel of the IntensiveSanitationandHealth PromotionProgrammeproved to bequite effective, it will be replicatedin a secondthanaofLaxmipur District, againwith UNICEF funds, andagainforoneyear.Someminorchangeswill be made:

• The programmewill startwith briefing seminarsatthana,union andvillage levels to solicit the interestand cooperationof local authorities,Governmentandnon-governmentstaff and the population at large. Inline with the IntegratedApproach,Water, SanitationandHygiene EducationCommitteeswill be estab-lished ateachlevel. The purposeis to get more com-munity participation andto createmore interestamongGovernmentstafffor sanitationandhygiene.

• The total numberof visits will be increasedfromfour to six to allow more time for motivation and

in-depthreview:TheRamgotiexperience 81

demonstrationof hygieneimprovements.Only thefirst roundwill be individual householdvisits, whilesubsequentroundswill consistof groupdiscussions.The people are in favour of group discussionsbecausetheyaremoreinterestingandenjoyableandallow for abetterexchangeof views. Group discus-sionswill alsosavea lot of time, thus increasingthecost-effectivenessof the programme.However, theVSMs prefer individual householdvisits becausethey find it difficult to manageagroup discussion.Thus, the VSMs will needadditional skills in inter-personalcommunication.

• The availability of a sufficient numberof ring/slablatrinesto meetthe rising demandduring the motiva-tional campaignwill receivemore, andmoretimely,attention.

7.Learning points

Whatdid we learnfrom this review of currenthygieneedu-cation in Bangladesh?Without trying to give acompleteoverview—thevariouschaptersare full of learning experi-ences—thischapterwill look into threemainpointsthatareespeciallyimportantfor the developmentand improvementof hygieneeducationas part of water supply andsanitationprogrammes.Although the learningpointsare basedon theBangladeshexperience,they havebeenbroadenedandliftedto amore generallevel.

1. EffectivenessMuch more is neededfor effective hygieneeducation.Hygieneeducationeffectivenessdoesnot follow automatical-ly from an increasedacknowledgementof its importance.


Although thereis ageneralconsensusthathygieneeducationis essentialfor achievinghealthandsocio-economicbenefitsfrom watersupplyandsanitationprogrammes,the conceptualframework, factualknowledgeandmaterialinputsneededtomakehygieneeducationwork aregenerallylacking.

Maybe we first should specify what is meantby ‘generalconsensus’.In fact, the level of consensusrangesfrom adeepconviction thathygieneeducationis essential,to merelip-service to a current trend. Donor organizationsareinstrumentalin creatingmoresupportfor the importanceofintegratinghygieneeducationinto watersupply andsanita-Lion programmes.Countryorganizationsrespondto thegen-tle pressureof donororganizations,andwhethertheydo sowholeheartedlyor for the sakeof good donorrelationshipsis subordinateto the overriding constraintthat the country’s

pnontiesareelsewhere.

A compoundingproblem is the generallylimited under-standingof what hygieneeducationreally is. A commonanswerto my questionconcerningthe nature of the majorconstraintson effective hygieneeducationis the povertyand the low literacy rate of the people.Surprisingly, thisanswerwascommonbothamongengineering/technicalstaffand amonghealth staff. The answernot only showsthatthere is little understandingof hygieneeducation;it alsoimplies that major constraintsare beyondtheir sphereofinfluence.Thus, therewere also few ideasfor hygieneedu-cation improvements:only requestsfor more humanpowerand more audiovisualtools andequipmentto increasethecapacityfor impartingknowledgeto anignorantpeople.

With low commitmentto and little ideaaboutwhatconsti-tuteseffectivehygieneeducation,it is quite understandable

Learningpoints 85

thatessentialingredientsfor effectivehygieneeducationarenot always present,and if they are present,they are notalwaysusedin the right order or mix. The review showedthat thereis not much hygieneeducationplanning: clearobjectivesor a realistic work plan are generally lacking;educationactivities are usually limited to imparting infor-mation;field staff training andsupervisionareminimal, andmonitoringandevaluationarevirtually non-existent.

Of course,thereare exceptions,andtherearesomepositiveexamplesto build on and learn from. In addition, thereseemsto be agood dealof room for learningfrom andmak-ing useof developmentsin non-formaleducation,especiallywith regardto educationmethodsandtools.

2. StaffHygiene educationwill standachanceof being effectiveonly whenthereis staff thatcan do agoodjob. This maybeobvious,but it is alsoaseriousconstraint,intimately relatedto the constraintsmentionedabove.The reality is thatat alllevelsthereis a lack of staff that cando a goodjob.

At the level of development,coordinationandmanagementof hygieneeducation,we needstaff thathaveclear insightsinto the preconditionsandrequirementsfor effectivehygieneeducation.Theyneedto be ableto setprioritiesandmakerealistic plans. In addition, they needto havetheauthorityandmeansto translateplansinto action.Problemsat this level arethatsufficientstaff thatmeettheserequire-ments are not availableand that the institutional setting isnot conduciveto giving this staff theauthority it needs(seealsothe nextpoint).


At the field level, we needcommitted staff with sufficientbaggageandbackupto createhygieneeducationandmoti-vation learning opportunitiesfor specific target groups.Staff commitmentshowsamixedpicture. On the onehand,we find staff whoseown motivation leadsto their commit-ment, andwe haveseenthat the successof the IntegratedApproach andthe IntensiveSanitationMobilization is verymuch dependenton thesestaff. On the otherhand—andthisseemsto be the moregeneralpicture—wefind staffwho donot considerhealth andhygieneeducationone of theirduties. Pre-serviceandin-servicetraining—if anyis provid-ed—arenot sufficient to equip staff with the necessaryskills, attitude and knowledge.Working conditionsandcareerstructuredo not stimulatestaff to be moreactiveedu-cators andmotivators.Lack of supervisionandmonitoringpavesthe way to disregardinghygieneeducationtasks andactivities.

One way of overcomingthe field-level staff problemis toturn to NGO staff. This may be the way out, at leastin theshort run, but only when the right NGO5 are selectedandrealistic demandsaremadeon them.This requiresappropri-ate staff atcentral level to be in place.In the long run, thiswill not provide asustainablesolution, unlessthe involve-ment of NGOs is institutionalized.But suchinstitutionaliza-tion may jeopardizethe strengthsof NGOs and, ultimately,the reasonfor their involvement.

3. OrganizationalstructureInstitutional weaknessis a characteristicof most hygieneeducation,andthis haseverythingto do with the constraintsdiscussedabove. From an outsider’s point of view, it may

Learningpoints 87

be self-evidentthat only the Ministry of Health can be theright homefor healthandhygieneeducation,with themin-istries responsiblefor water, sanitationandeducationhav-ing supporting,enablingandcontributing roles. However,reality is neversimple, andcertainly not in this case.Theorganizationalstructureof hygieneeducation—orthe lackof it—is acomplicatedproblemthatdoesnot standachanceof beingsolvedin the foreseeablefuture. It maybe that thisproblemcanonly be overcomewhenthereis apolitical andsocial changein the direction of greateremphasison pre-ventive healthandprimaryhealthcare.Until then,onemustmakedo, but whatis bestdone mayrequire moreconsidera-tion basedon an openmind, imaginationandwill.

Social mobilizationThe abovepoints are specifically concernedwith hygieneeducation.To acertainextentthey are also learningpointsfor social mobilization and require due attentionto ensurethatthe ambitiousandimportantprogrammeof socialmobi-lization for sanitationis more thana balloon thatwill growandgrow but in the endwill burst,leavingbehindmuchlessthan hopedfor. The programmehasmuch potential; thechallengeis to makeit work, andto do sobeyondthe levelof merelatrine construction,with the goal of safeexcretadisposalby all as anenduringpracticefor the future.

Abbreviations

ACE AssociatedConsultingEngineersAE assistantengineerAll! assistanthealthinspectorBHE Bureauof HealthEducationBRAC BangladeshRuralAdvancementCommitteeCDD control of diarrhoea!diseasesCHW communityhealthworkerCTO communicationtrainingofficerDC deputycommissionerDGHS DirectorateGeneralHealth ServicesDPC DevelopmentPlannersandConsultantsDPHE Departmentof Public HealthEngineeringEE executiveengineer18DTP 18 District Towns ProjectEPI expandedprogrammeon immunizationFSS field sanitationsupervisorFWA family welfareassistantGSS GonoshahajyaSangsthaHA healthassistantHQ headquartersICDDR,B InternationalCentrefor DiarrhoealDisease

Research,BangladeshINFEP integratednon-formaleducationprogrammeISHPP IntensiveSanitationandHygienePromotion

ProgrammeLGED Local GovernmentEngineeringDepartment(under

MLGRDC)


MLGRDC Ministry of Local Government,RuralDevelopmentandCooperatives

MOHFW Ministry of Health andFamily WelfareNCTB National CurriculumandTextbookBoardNFPE non-formalprimary educationNGO non-governmentalorganizationORT oral rehydrationtherapyPCIS ProgrammeCommunicationandInformationSection

(UNICEF)PHC primaryhealthcarePEP PrimaryEducationProgrammePRISM Projectin Agriculture,Rural Industry,Scienceand

MedicineSAFE SanitationandFamily Education(project)SAE sub-assistantengineerSCTO seniorcommunicationtrainingofficerSDC SwissDevelopmentCorporationSDE sub-divisionalengineerSE superintendingengineerTNO thananirbahiofficerTWM tube-wellmechanicUNDP United NationsDevelopmentProgrammeVSM village sanitationmotivatorWES WaterandEnvironmentalSanitation(section,

UNICEF)WHO World HealthOrganization

hanginglatrine: elementarylatrine structure(sometimesjust apieceof wood, with or without an upright stick tohold with one’shandto keepone’sbalancewhile squatting)with an openareabelow, allowingfecesto fall into apond,ditch or on the ground.

homemadelatrine: ordinarypit latrine, constructedby thehousehold,using readily availablematerialsthatcostnoth-ing. Thepit is usuallyrathershaliow.

madrasha:religious(Islamic)school.

thana:administrativeunit underthe district andabove theunion. Eachthanahasonesub-assistantengineer(SAE) andfour tube-wellmechanics(TWMs).

tube-well: a small-diameterprotected(sealed)well with ahandpump.

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Kamal, GhulamMustafaand Chowdhury,Jamil Hussain.(1993).‘NeedsAssessmentfor the SanitationProgramme’.Dhaka,Bangladesh.

Kanchwale,Rashida.(1993). ‘Report on National WorkshoponRole of PartnerNGOs in Implementingthe SOCMOBProject’. NGO Forum for Drinking Water Supply andSanitation.Dhaka,Bangladesh.

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(1993a). ‘Intensive SanitationandHygienePromotionProgramme.FourthQuarterly Report.May toJuly 1993’. Dhaka,Bangladesh.

(1993b). ‘IntensiveSanitationandHygienePromotionProgrammein RamgotiThanaof LaxmipurDis-trict. A UNICEF—supportedProgrammeFunded by Aus-tralian Government and Implemented by PRISMBangladesh.Mid-term Report (August 1992—January1993)’. Dhaka,Bangladesh.

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tOO HygieneEducationin Bangladesh

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Annex:List of persons met and field visits

UNICEF Headquarters:Ms. VanessaTobin, SeniorProgrammeOfficer

UNICEF Bangladesh:Mr. RolfC. Carriere,RepresentativeMr. Philip Wan, Chief, WES Section

Mr. A.S.Azad,ProjectOfficer, WES Section

Mr. T. Danagarajan,ProjectOfficer, WES SectionMs. AyeshaHossain,ProjectOfficer, WESSection

Mr. M.J.Kabir, AssistantProgrammeOfficer, WES Section

Ms. ShailaKhan,ProjectAssistant,WES SectionMs. FarhanaHuq,ProjectAssistant,WES SectionMr. Neill H. McKee,Chief, PCIS Section

Ms. PamelaClifton Reitemeier,PCIS Section

Mr. Selim Ahmed,ProgrammeOfficer, EducationSection


Dr. Kamal Islam, ProjectOfficer, Health andNutrition SectionMs. ShabitaSaha,IntegratedBasicServicesMs. MaheraKhatun, Chief, DhakaDivisional OfficeMr. A.T. Siddiquee,Chief,DhakaDivisionalOffice

Mr. MizanurRahmanKhandker,FieldAssistant,KhulnaOffice

Mr. ManjurUl Alam, ChiefRajshahiDivisional Office

Departmentof PublicHealthEngineering:

Mr. Amin Uddin Ahmad,Chief Engineer

Mr. FaridUddin AhmedMia, SE Planning

Dr. A.M.S. Hoque, SE, Project Director Water Supply andSanitationfor Urban Slums and Fringe Projects,andActingProjectDirector,Village Sanitation

Mr. AhmedMofazzalHuq,EE, Village Sanitation

Mr. Al Haj SyedA.N., Md. Kabirushan,Chief, Health EducationProgramme

Mr. Asadul Hoque,EE, LaxmipurDistrictMr. Rafiqul Islam, SAE, RamgotiThana

Mr. Kazi NasiruddinAhmad,SE, BarisalMr. BazlurRahman,EE, Barisal

Mr. Nuruzzaman,SAE, Banaripara

Mr. Md. AbdurRahimKhan, SAE, Gournadi

Mr. SultanAhamed,TWM, Gournadi

Ministry of Healthand Family Planning,DirectorateGeneralof HealthServices:

Dr. SukumarSarker,AssistantProject Director, Control ofDiarrhoealDiseasesProgramme

Dr. Mutiur RahmanChaudhuri,Director,PrimaryHealthCareandDiseaseControl

Dr. A. MannanBangali,AssistantDirector,Malaria and ParasiticDiseaseControl

Mr. Abdur RashidSikder, Md., Malaria and ParasiticDiseaseControl

List ofpersonsmetandfield visits 105

Mr. Fakrul Islam, ThanaHealth and Family Planning Officer,Banaripara,BarisalDistrict

Mr. Ali Akbar, Divisional Health Education Officer, RajshahDivision

Bureauof Health Education:

Mr. A.M. Zaurul Alam, Chief

Mr. XhondoxerMahfuzul Haque,AssistantChiefMr. SazzadurRahman,Training andFieldOfficer

NationalCurriculum andTextbookBoard:

ProfessorMd. Ali Azam, Chairman,NCTBDr M.A. WahabMian, Specialist,BHE

International Centre for Diarrhoeal DiseaseResearch,Bangladesh:

Dr. Bilqis Amin Hoque,Coordinator,CommunityHealthDivision

Dr. K.M.A. Aziz, Social Anthropologist,Community HealthDivision

Dr. SushilaZeitlyn, Social Anthropologist, Community HealthDivision

Mr. 0. MasseeBateman,Epidemiologist,CommunityHealthDivision

Non-GovernmentalOrganizations:

Dr. SadiaA. Chowdhuri, Coordinator,EssentialNational HealthResearch,and Director, Women’s Health and DevelopmentProgramme,BRAC

Ms. SumanaBrahman, Health Sector Coordinator,CAREBangladesh

Ms. RaquibaA. Jahan,Coordinator,SAFE Pilot Project,CAREBangladesh

RekhaKibria, EducationSection,GSS


Mr. S.M.A. Rashid,NGO Forum for Drinking Water Supply andSanitation

Mr. Rafiqul Haider,SanitationProgrammeCoordinator,PRISM

Mr. FerozKabir Khan, ProgrammeOfficer, Ramgoti Thana,PRISM

World HealthOrganization:

Mr. Alex Redekopp,SanitaryEngineer,TeamLeader

SwissDevelopmentCorporation:

Mr. PeterTschumi,First Secretary(Development)

Consultants/advisors:

Ms. TahrunnesaAbdullah,DevelopmentConsultantMr. Nizam Uddin Ahmed,Social Anthropologist,ConsultantWES

Section,UNICEFMs. NurzhatShahzadi,Consultant,PCIS Section,UNICEF

Mr. Abdul Aziz, Consultant,EducationSection,UNICEFMs. FaridaAkhtar, Consultant,EducationSection,UNICEF

Mr. AshokeChatterjee,National Instituteof Design,Ahmedabad,India

Ms. RachelCarnegie,Child-to-Child, HealthEducationMr. David Watson,UNICEF/DPHE OrganizationalStudy, Matrix

ConsultantsMr. Keesvan derPoort,UNICEF/DPHE OrganizationalStudy,

Matrix Consultants

Mr. Taccode Vries, ProjectManager,18 District TownsProjectMs. Corinne H. Hinlopen, CommunityParticipation,Hygiene

Educationand WED, 18 District TownsProject

Field visit RamgotlThana:

Visit to oneMuslim village andoneHindu village. Informal indi-vidual and group discussionswith menand women (sep-

List ofpersonsmetandfield visits 107

arately).A numberof latrineswereobserved.

Individual andgroupdiscussionswith maleand femaleVSM5 andFSS5.

Visit to the thanahealth complex in Koritola, LawrenceUnion,anddiscussionwith thethanahealthand family planningoffi-cer in charge,a healthassistantanda healthinspector.

Visit to DPHE office in Laxmipur anddiscussionwith the EE andthe SAEof RamgotiThana(seeabove).

Fieldvisit BanariparaandGournadiThanas:Visit to threevillages.Informal individual andgroupdiscussions

with men andwomen(separately).A numberof latrineswereobserved.

Discussionwith Ms. FatemaBegum,Headmistress,GournadiGirls’ High School,Barisal District.

Visit to DPHE offices and village sanitationcentresin Banariparaand Gournadiand discussionswith the SAE5. In Gournadialsodiscussionwith TWM (seeabove).

Visit to DPHE office in Barisal anddiscussionwith SE and EE (seeabove).

Visit to thanahealth complex in Banariparaand discussionwiththanahealthandfamily planningofficer.

-a ~ , ~

-~ -~*— - “~frr ;c- *l1~!

This case-studypresentsan overviewof hygieneeducationin Bangladesh.The overview in-cludes both hygieneeducationactivities re-lated to water and sanitationinterventionsand hygiene educationactivities in schoolsand non-formal educationsettings. In addi-tion, the case-studycovers the challengingprogrammeon social mobilization that start-ed a few years ago with the aim of creatingmass supportfor sanitation.

IThe case-studyidentifies threemain learningpoints for the developmentand improvementof hygiene educationas partof water supplyand sanitationprogrammes.Theselearningpoints areclosely related to one another;theyconcernthe effectivenessof the hygiene edu-cation,the competenceand availability of staffat all levels and the organizationalstructurefor sustainablehygieneeducation.

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