Review Report of the National Open Defecation Free (ODF) and Hand Washing with Soap (HWWS) Strategies

Introduction Diarrhoeal diseases pose significant health risks for the rural population and account for 18% of deaths each year in children under the age of 5. Increasing access to basic sanitation and hand washing with soap at critical times are key interventions to the prevention of future diarrhea and cholera cases. The Government of Malawi with its development partners developed the Open Defecation Free (ODF) Malawi (2011 – 2015) and the National Hand Washing Campaign 2011-2012 Strategies, in line with the MDGs to support attainment of its goal to create a clean, safe and healthy environment. As the initial strategies came to an end (2011-2015), the global community entered the new phase of Sustainable Development Goals (SDGs 2016-2030). As such, Malawi also felt the need to up-date the ODF and the National Hand Washing Campaign strategies to be in line with the national sanitation and hygiene targets and SDG Goal 6.2: by 2030. It is against this background that the National Open Defecation Free Task Force (NOTF) commissioned this consultancy whose TORs were to provide a framework for facilitating the review and development of the new National ODF and Hand Washing with Soap (HWWS) strategies. This report is as a result of field data collection, literature review and stakeholder consultation which are informing the revision of the ODF and HWWS strategies to support Malawi in meeting the SDG targets. Objectives NOTF outlined specific objectives for this review which have been arranged in two stages as follows: Stage 1: • Review of current country strategies with emphasis on original assumptions. • Review the effectiveness of the scope, mechanisms and actions applied in the implementation of the ODF/HWWS Strategies. • Review the extent to which different programmes, approaches and other cross cutting issues (by Government, NGOs and development partners) have contributed to the implementation of the ODF/HWWS strategies. Stage 2 • Examine the extent that the changing assumptions and indicators impact achievement of ODF Malawi and Hand Washing behaviours. • Examine how the strategies link in with other WASH related strategies and approaches • Identify gaps in the ODF Malawi Strategy (2015) and National Hand Washing Campaign and incorporate lessons and practical experiences from field application. Methods The assignment used a number of data collection methods including stakeholder analysis, desk review, field research and stakeholder consultation detailed as follows: Stakeholder analysis: Stakeholder analysis was used to identify project's key people with stake, interest or influence in reducing open defecation and promoting hand washing with soap. Stakeholder analysis was a useful tool for identifying people and organizations and institutions that assisted in providing information regarding ODF and HWWS. The information from identified stakeholders was gathered using Key Informant Interviews (KII) and Focus Group Discussions (FGD) during field research and stakeholder meetings. Desk review: The desk review constituted an important step in the process of reviewing the national ODF and HWWS strategies. It provided the evidence base for the review. Reviewing all documentation (grey, published and peer reviewed information) relating to the issues covered in the existing strategies to develop as complete a picture as possible of the current state of ODF and HWWS both in and outside Malawi. This involved using the following techniques: Internal Desk Research, External Desk Research, Online Desk Research, Government published data and Customer desk research. Field Research: This involved creation and collection of primary data from the field setting. The process involved determining what precise data was necessary and from where this information needed to be obtained. Field research was performed by the consultancy team in person in 6 Districts and with key stakeholders, through KIIs (n=24) and FGDs (n=38). Purposive sampling was used to recruit participants for both the KIIs and FGDs. Stakeholder Workshop was undertaken to get provide feedback and validation of the desk review and field results, as well as receive input from further Districts and stakeholders. The workshop used presentations, world café consultation and direct feedback. Results Key Findings Findings demonstrate that there have been positive results and progress towards meeting strategic targets from 2011-2015. Nevertheless there are still significant barriers and challenges to the achievement of key goals of ODF and HWWS across Malawi. The main gaps identified include: Scope • The ODF strategy focuses only on the rural population, which has limited the focus and success of ODF achievement. • The ODF strategy referred only to households with no requirement for ODF status in public spaces and institutions. • There is no reference or integration of ODF strategy with menstrual hygiene management. • Neither strategy has specific reference or support for vulnerable and marginalized groups. Mechanism • Both the ODF and HWWS strategies do not provide specific definitions of latrines, hand washing facilities, etc. which leads to variation in implementation. • The ODF strategy does not consider the whole sanitation chain (capture to disposal). • ODF strategy implementation was to be overseen by the NOTF which represents the Ministry of Health and the Ministry of Agriculture, Irrigation and Water Development with key development partners and civil society which doesn’t include other ministries. • The current ODF strategy is limited to the use of Community Led Total Sanitation (CLTS) and sanitation marketing and does not take into consideration the use of other participatory approaches such as Participatory Hygiene and Sanitation Transformation (PHAST) and mechanisms to achieve ODF. • Although there is the inclusion of 2 levels of ODF status in the strategy (i.e. 1- appraising a community towards the attainment of the ODF status; 2- sustenance of ODF status after attaining the ODF status), there is little reference to the effective use of the sanitation ladder to achieve continued improvement and sustainability. • HWWS strategy uses health facilities and schools as key locations for good practice and development of agents of change, but in many cases these were identified as having the poorest standards. • The use of Health Surveillance Assistants (HSAs) in the drive for ODF was reported as inconsistent across partners. • CLTS was seen as a ‘project’ by HSAs, and once partners were gone the implementation also stopped. • HSAs were used to receiving allowances to undertake this work and therefore stopped their CLTS/ODF activities when they became routine activities. • Data was inconsistently reported and in some cases validity is called into question. • In the implementation of both strategies there has been a focus on infrastructure with little concentration on behavior change communication for sustained change. Key recommendations Scope • The scope of the strategies should include proper definitions of a latrine (including menstrual hygiene management) and hand washing facilities, and should consider the whole sanitation chain. • Areas must ensure ODF and HWWS in all households and public areas and institutions before they can be declared ODF. • New strategies must tackle both urban and rural populations. • Support for vulnerable and marginalized populations must be more effectively integrated. • Integration of menstrual hygiene management • Criteria and mechanisms for being declared ODF should be reviewed. Mechanism • NOTF should be more multidisciplinary in its membership with the inclusion of representatives from nutrition, disabilities and other appropriate government departments to ensure integration of services. • Effective sanitation marketing and financing models need to be more fully integrated into CLTS triggering programmes. • Movement towards a requirement for standard systems to be constructed should be considered which would improve quality of latrines and create business for masons and entrepreneurs. • Training of masons should be linked to technical training colleges and schools. • ODF must be incorporated into the routine activities of HSAs without the requirement of allowances. • Funding must be ring-fenced for ODF activities from the District budget. • Stakeholders reported the need for integration in community structures for effective implementation, and the valuable role of Natural Leaders. They suggested a continued use of traditional and natural leaders to support the implementation, achievement and sustainability of ODF status. It was also suggested that natural leaders and their roles in community sanitation and hygiene achievement should be recognized. • Vulnerable and marginalized groups should be engaged from the offset of the CLTS programme and be involved in the training, implementation and verification processes to ensure appropriate systems are in place to support them. • By laws should continue to be encouraged but must be enforced consistently for all community members and be facilitative rather than punitive, taking into consideration human rights. • Large ODF celebrations attended by the Minister and dignitaries should only take place when the District has achieved ODF status. • School WASH standards need to be completed and circulated to ensure improvement at facilities. These standards must include a range of low cost HWF suitable for school settings. • The concept of using schools and children as agents is still a welcome one but needs better integration and structure • Health facilities must be supported to ensure that they are modeling improved sanitation and HWWS to promote good behaviour. • HWWS promotion needs to be integrated into all relevant clinics, e.g. antenatal, growth monitoring, immunisations, OPD, etc. • Behaviour change messaging needs to be developed based on sound principles and with an understanding of the audience and behavioural factors which are being targeted. • The need for, and promotion of HWWS requires effective public private partnerships and these require to be engaged on a more regular and formal basis. • Strengthen CLTS and HWWS monitoring systems: There is need for more detailed monitoring and evaluation of progress and effectiveness. • Improved integration of behavior change communication to support sustained improvements in ODF and HWWS throughout Malawi. Cross cutting recommendation for future strategy development It is clear from the feedback from all stakeholders and desk review, that future strategies must address concerns regarding integration of sanitation and hygiene programmes to ensure sustained change across Malawi and achievement of the SDGs by 2030. With this in mind, it is the overall recommendation of this review that the current ODF and HWWS strategies should be integrated into a more general ‘hygiene and sanitation’ strategy. This would support not only the integration of HWWS and ODF programmes, but also the inclusion of key issues raised in stakeholder meetings such as menstrual hygiene management and solid waste management (including faecal sludge management). This would be an all encompassing strategy which targets rural and urban populations, domestic houses, commercial premises and institutions across the country. Only then can Malawi truly meet the target of Universal Sanitation and Hygiene for All

Acceptability of menstrual products interventions for menstrual hygiene management among women and girls in Malawi.

BACKGROUND: A key challenge for menstruating girls and women in low-resource countries is the inadequate and unreliable supply of menstrual products. Although development partners are implementing menstrual product interventions to address this challenge in Malawi, there is a paucity of information on the distribution of menstrual products and the acceptability of these interventions among users. METHODS: We conducted in-depth interviews with girls (n = 20) and women (n = 26) and 4 focus group discussions (FGDs) with women (n = 35) and 7 FGDs with girls (n = 60) to explore the acceptability of menstrual products interventions in 8 districts. Teachers (n = 12), community leaders (n = 6), community health workers (n = 8) and service providers (n = 9) were also interviewed to explore implementation issues and their views regarding the effect of menstrual products interventions on girls and women. Data were analyzed using content analysis. RESULTS: Common menstrual products being promoted include locally made reusable pads, commercially made disposable pads and menstrual cups. Overall, adult women preferred reusable pads and young girls preferred disposable pads. Reported benefits of using any type of material distributed included enhanced cleanliness and reduced school absenteeism for girls. While community leaders and teachers applauded the use of disposable menstrual products they expressed concern that they are not affordable for an average Malawian and bemoaned the indiscriminate disposal of used disposable pads. Women and girls highlighted their lack of facilities to effectively wash and dry reusable pads. Service providers bemoaned poor coordination and the lack of national standards to regulate the quality of menstrual products distributed at national level. Improved inclusion of males and health workers could enhance the sustainability of programmes. CONCLUSION: While the available menstrual products interventions are acceptable among participants, we note several challenges including affordability, poor disposal methods, lack of attention on sanitation facilities and the lack of standard protocols to regulate the quality of menstrual products. Recommendations to address these issues are reported

Social outcomes of a community-based water, sanitation and hygiene intervention

Social benefits of water, sanitation and hygiene (WASH) interventions are less documented compared to health benefits such as the reduction of diarrheal diseases. Although most decisions in WASH investments are based on potential health outcomes, interventions may also lead to social benefits, such as income generation, increased school enrollment, improved levels of dignity, self-esteem and civic pride, which can have a significant value both personally and to the wider community. This qualitative case study was used to assess the perceived social outcomes of purposively selected stakeholders from a WASH intervention study in Malawi. In-depth Interviews (n = 10), focus group discussions (n = 4) and key informants interviews (n = 10) were conducted with caregivers (male and female), community leaders, traditional leaders and community coordinators. Thematic analysis identified eight social outcomes: formation and strengthening of relationships (n = 32), becoming role models to community members (n = 23), women empowerment (n = 20), time-saving (n = 17), change of status (n = 12), receiving awards (n = 12), reduced medical costs (n = 11) and obtaining new skills (n = 7). Social capital among caregivers was also found to be high. No negative outcomes from the intervention were reported. WASH interventions have multiple, important, but difficult to quantify social benefits which should be measured, reported and considered in WASH investment decision-making

How do Malawian women rate the quality of maternal and newborn care? Experiences and perceptions of women in the central and southern regions

Background: While perceived quality of care is now widely recognized to influence health service utilization, limited research has been conducted to explore and measure perceived quality of care using quantitative tools. Our objective was to measure women’s perceived quality of maternal and newborn care using a composite scale and to identify individual and service delivery factors associated with such perceptions in Malawi. Methods: We conducted a cross-sectional survey in selected health facilities from March to May 2013. Exit interviews were conducted with 821 women convenience sampled at antenatal, delivery, and postnatal clinics using structured questionnaires. Experiences and the corresponding perceived quality of care were measured using a composite perception scale based on 27 items, clustered around three dimensions of care: interpersonal relations, conditions of the consultation and delivery rooms, and nursing care services. Statements reflecting the 27 items were read aloud and the women were asked to rate the quality of care received on a visual scale of 1 to 10 (10 being the highest score). For each dimension, an aggregate score was calculated using the un-weighted item means, representing three outcome variables. Descriptive statistics were used to display distribution of explanatory variables and one-way analysis of variance was used to analyse bivariate associations between the explanatory and the outcome variables. Results: A high perceived quality of care rating was observed on interpersonal relations, conditions of the examination rooms and nursing care services with an overall mean score of 9/10. Self-introduction by the health worker, explanation of examination procedures, consent seeking, encouragement to ask questions, confidentiality protection and being offered to have a guardian during delivery were associated with a high quality rating of interpersonal relations for antenatal and delivery care services. Being literate, never experienced a still birth and, first ANC visit were associated with a high quality rating of room conditions for antenatal care service. Conclusions: The study highlights some of the multiple factors associated with perceived quality of care. We conclude that proper interventions or practices and policies should consider these factors when making quality improvements

Exploiting the emergent nature of mixed methods designs: insights from a mixed methods impact evaluation in Malawi.

The application of mixed methods in Health Policy and Systems Research (HPSR) has expanded remarkably. Nevertheless, a recent review has highlighted how many mixed methods studies do not conceptualize the quantitative and the qualitative component as part of a single research effort, failing to make use of integrated approaches to data collection and analysis. More specifically, current mixed methods studies rarely rely on emergent designs as a specific feature of this methodological approach. In our work, we postulate that explicitly acknowledging the emergent nature of mixed methods research by building on a continuous exchange between quantitative and qualitative strains of data collection and analysis leads to a richer and more informative application in the field of HPSR. We illustrate our point by reflecting on our own experience conducting the mixed methods impact evaluation of a complex health system intervention in Malawi, the Results Based Financing for Maternal and Newborn Health Initiative. We describe how in the light of a contradiction between the initial set of quantitative and qualitative findings, we modified our design multiple times to include additional sources of quantitative and qualitative data and analytical approaches. To find an answer to the initial riddle, we made use of household survey data, routine health facility data, and multiple rounds of interviews with both healthcare workers and service users. We highlight what contextual factors made it possible for us to maintain the high level of methodological flexibility that ultimately allowed us to solve the riddle. This process of constant reiteration between quantitative and qualitative data allowed us to provide policymakers with a more credible and comprehensive picture of what dynamics the intervention had triggered and with what effects, in a way that we would have never been able to do had we kept faithful to our original mixed methods design

Process evaluation of "the Hygienic Family" intervention : a community-based water, sanitation and hygiene project in rural Malawi

Process evaluations of environmental health interventions are often under-reported and under-utilized in the development of future programs. The “Hygienic Family” intervention targeted improvements in hygiene behaviors of caregivers with under five-year-old children in rural Malawi. Delivered through a combination of open days, cluster meetings, household visits, and prompts, data were collected from two intervention areas for ten months. A process evaluation framework provided indicators that were measured through intervention implementation and expenditure reports, focus groups discussions, interviews, and household surveys. The collected data assessed the intervention fidelity, dose, reach, acceptability, impact, and cost. Results indicated that all planned hygiene promotion messages were delivered, and study participants were better reached primarily through household visits (78% attended over 75% of the intervention) than cluster meetings (57% attended over 75% of the intervention). However, regression found that the number of household visits or cluster meetings had no discernible effect on the presence of some household hygiene proxy indicators. Intervention implementation cost per household was USD 31.00. The intervention delivery model provided good fidelity, dose, and reach and could be used to strengthen the scope of child health and wellbeing content. The intensive face-to-face method has proven to be effective but would need to be adequately resourced through financial support for community coordinator remuneration

Implementation research to improve quality of maternal and newborn health care, Malawi.

OBJECTIVE: To evaluate the impact of a performance-based financing scheme on maternal and neonatal health service quality in Malawi. METHODS: We conducted a non-randomized controlled before and after study to evaluate the effects of district- and facility-level performance incentives for health workers and management teams. We assessed changes in the facilities' essential drug stocks, equipment maintenance and clinical obstetric care processes. Difference-in-difference regression models were used to analyse effects of the scheme on adherence to obstetric care treatment protocols and provision of essential drugs, supplies and equipment. FINDINGS: We observed 33 health facilities, 23 intervention facilities and 10 control facilities and 401 pregnant women across four districts. The scheme improved the availability of both functional equipment and essential drug stocks in the intervention facilities. We observed positive effects in respect to drug procurement and clinical care activities at non-intervention facilities, likely in response to improved district management performance. Birth assistants' adherence to clinical protocols improved across all studied facilities as district health managers supervised and coached clinical staff more actively. CONCLUSION: Despite nation-wide stock-outs and extreme health worker shortages, facilities in the study districts managed to improve maternal and neonatal health service quality by overcoming bottlenecks related to supply procurement, equipment maintenance and clinical performance. To strengthen and reform health management structures, performance-based financing may be a promising approach to sustainable improvements in quality of health care

Perceptions of quality across the maternal care continuum in the context of a health financing intervention: Evidence from a mixed methods study in rural Malawi

Background: In 2013, Malawi with its development partners introduced a Results-Based Financing for Maternal and Newborn Health (RBF4MNH) intervention to improve the quality of maternal and newborn health-care services. Financial incentives are awarded to health facilities conditional on their performance and to women for delivering in the health facility. We assessed the effect of the RBF4MNH on quality of care from women’s perspectives. Methods: We used a mixed-method prospective sequential controlled pre- and post-test design. We conducted 3060 structured client exit interviews, 36 in-depth interviews and 29 focus group discussions (FGDs) with women and 24 in-depth interviews with health service providers between 2013 and 2015. We used difference-in-differences regression models to measure the effect of the RBF4MNH on experiences and perceived quality of care. We used qualitative data to explore the matter more in depth. Results: We did not observe a statistically significant effect of the intervention on women’s perceptions of technical care, quality of amenities and interpersonal relations. However, in the qualitative interviews, most women reported improved health service provision as a result of the intervention. RBF4MNH increased the proportion of women reporting to have received medications/treatment during childbirth. Participants in interviews expressed that drugs, equipment and supplies were readily available due to the RBF4MNH. However, women also reported instances of neglect, disrespect and verbal abuse during the process of care. Providers attributed these negative instances to an increased workload resulting from an increased number of women seeking services at RBF4MNH facilities. Conclusion: Our qualitative findings suggest improvements in the availability of drugs and supplies due to RBF4MNH. Despite the intervention, challenges in the provision of quality care persisted, especially with regard to interpersonal relations. RBF interventions may need to consider including indicators that specifically target the provision of respectful maternity care as a means to foster providers’ positive attitudes towards women in labour. In parallel, governments should consider enhancing staff and infrastructural capacity before implementing RBF

'The money can be a motivator, to me a little, but mostly PBF just helps me to do better in my job.' An exploration of the motivational mechanisms of performance-based financing for health workers in Malawi.

Performance-based financing (PBF) is assumed to improve health care delivery by motivating health workers to enhance their work performance. However, the exact motivational mechanisms through which PBF is assumed to produce such changes are poorly understood to date. Although PBF is increasingly recognized as a complex health systems intervention, its motivational effect for individual health workers is still often reduced to financial 'carrots and sticks' in the literature and discourse. Aiming to contribute to the development of a more comprehensive understanding of the motivational mechanisms, we explored how PBF impacted health worker motivation in the context of the Malawian Results-based Financing for Maternal and Newborn Health (RBF4MNH) Initiative. We conducted in-depth interviews with 41 nurses, medical assistants and clinical officers from primary- and secondary-level health facilities 1 and 2 years after the introduction of RBF4MNH in 2013. Six categories of motivational mechanisms emerged: RBF4MNH motivated health workers to improve their performance (1) by acting as a periodic wake-up call to deficiencies in their day-to-day practice; (2) by providing direction and goals to work towards; (3) by strengthening perceived ability to perform successfully at work and triggering a sense of accomplishment; (4) by instilling feelings of recognition; (5) by altering social dynamics, improving team work towards a common goal, but also introducing social pressure; and (6) by offering a 'nice to have' opportunity to earn extra income. However, respondents also perceived weaknesses of the intervention design, implementation-related challenges and contextual constraints that kept RBF4MNH from developing its full motivating potential. Our results underline PBF's potential to affect health workers' motivation in ways which go far beyond the direct effects of financial rewards to individuals. We strongly recommend considering all motivational mechanisms more explicitly in future PBF design to fully exploit the approach's capacity for enhancing health worker performance