Follow Up MANDONA: community action approach to improved sanitation

Published on: 12/08/2016

Agelilyec is a lush village in Aromo Sub County, Lira district. The landscape is dotted with sprawling gardens and neatly manicured grass-thatched huts touched up with red soil. The compounds are kempt, with heaps of farm produce put out to dry. The children may be barefooted but they look healthy and clean – their hair is black and their tummies are not distended. As we snake through the winding village roads, sights of boreholes and women carrying water are common. And when we finally reach our destination – a meeting place under a huge mango tree in one of the compounds – the whole village bursts into glorious song and dance. Not only is it a typical Langi welcome, it is also a celebration of the achievement of high levels of sanitation in the village in a space of just one year.

Further afield in Agweng Sub County, a similar scene awaits in Note-En-Teko and Aton villages. At both places, we are welcomed with singing and dancing. The celebrations are so ecstatic and contagious that even the guests join in. The USF field officials from Ministry of Health led by the Assistant Commissioner Julian Kyomuhangi; the District officials led by Nelson Opio; the NGO workers.....all join in the dance to celebrate sanitation.

Such is the scene that defines a typical Follow Up MANDONA exercise. Follow Up MANDONA is an action-oriented approach to accelerate the end of open defecation, after initial triggering with Community Led Total Sanitation (CLTS). Based on CLTS principles, Follow Up MANDONA involves a series of facilitated sessions with the entire community to reinforce behavior change and collectively undertake Small, Immediate, Doable Actions (SIDAs) for a community to become Open Defecation Free (ODF) in the shortest time possible. Mandona is a Malagasy word that means "to push".

Agelilyec, Note-en-Teko and Aton are among the nine villages that attained ODF status in Lira district, between July 2014 and June 2016. The Uganda Sanitation Fund (USF) under the Ministry of Health Environmental Health Division (MOH-EHD) has been implementing the CLTS approach in Lira district, targeting 225 villages in five sub counties. The district has a total of 13 sub counties, and a population of 410,160. The USF Focal person, Nelson Opio reports that when the programme started in July 2014, the district latrine coverage was at 82%, while hand washing with soap was at 44%. There wasn't a single village that would boast of ODF status.

In spite of the relatively high latrine coverage, many people in Lira do not use their latrines. The Assistant District Water Officer, Jimmy Otim notes that in Lira, latrines are commonly known as "by-law" because people are forced to construct them by law. Many people locate the latrines in the front yard of their homesteads, so that the law enforcers can see them easily when they pass by. However, many people are shy and do not want to be seen going to the latrine. So the toilets are located prominently in the courtyard, but no one uses them – and open defecation continues.

Using the CLTS approach, USF set out to attain ODF status in Lira district. Typically, the USF technical staff work in teams of eight to undertake sanitation improvement at village level. The teams act independently and take necessary actions when faced with challenges. They work with village-based Community Resource Persons (CORPs) and volunteers. They also work within existing community groups and structures such as Village Savings and Loan Associations (VSLAs). To enable information flow, the eight-member teams meet daily and regularly compile and submit field reports to the USF. On a monthly basis, the technical team meets with the CORPS and community level-volunteers.

By June 2016, nine villages had been declared ODF, 13 villages were set to be declared, having met all the necessary conditions. Another 58 villages had improved and were making all efforts to reach ODF status. Many other villages had been triggered by other actors like Plan International, SNV, and Welt Hunger Filfe. Over 600 villages in the district were yet to be triggered.

Thus, the Follow Up MANDONA visit to the three villages in Lira district, was the essence of a learning journey in June 2016, organised by IRC Uganda, under the auspices of the National Sanitation Working Group. The main purpose of the learning journey was to have a first had interaction with the communities that had benefited from the USF interventions, with a view to learn and make recommendations for scaling up and sustaining the good practices that had been achieved.The exercise was undertaken following the key steps in the Follow Up MANDONA approach including: Pre-visit for mobilization; community visit in form of a meeting; triggering at the facility; SIDAs at the facility; feedback and commitment.

Prior to the visit, the field technical officers mobilized communities and informed them of the impending visit. The welcome celebration that involved both the hosts and the guests was all the motivation that both parties needed to get going. The sight of an Assistant Commissioner and her team, jumping up and down to the rhythm of Langi folk songs; the sight of presence of leaders like the Local Council Chairman, Sub County chairman and councilors.... immediately struck a chord with the community members and helped the guests establish rapport.

After the motivation session, community meetings were conducted during which the guests were introduced to the community. Selected community members, mainly the area chairman, the VHT or the natural leaders, gave brief about the sanitation situation and also reflected on the journey to ODF status. Some of the community members then volunteered to take guests to their households to see the actual improvement in sanitation.

At the household, the visiting team as well as other community members took turns to look at the latrines and the compounds. And right at the facility, there was a critical analysis of the state of the latrine. Where a latrine was found lacking, recommendations were made and some immediate actions (SIDAs) were also taken.

Take for example, in Agelilyec village, the latrine of Anna and Constantine Olum was found wanting. While it was well constructed with a slab, there were huge blue houseflies hovering, which heightened chances of transmission of diseases. Additionally, it was found that the couple's tippy-tap had been poorly constructed. They also didn't have a soap-dish and an ash-scoop. Immediately, the Health Assistant (HA) showed them how to make the soap-dish and ash-scoop using an empty plastic water bottle. The HA also advised the couple to use ash to prevent houseflies hovering over their squat hole. By the end of the visit, Anna and Constantine had been supported to address all the missing items and had their facility now met the basic required standards.

After visiting the selected households, the guests and the community members reconvened under the mango trees to provide feedback and to share lessons. The members whose households had been visited took turns to explain what had happened at their respective homes and the immediate actions that had been taken to raise the standard of their latrines.

One of the volunteers, Grace reported, "My toilet had a cover and anal cleansing materials but there was a hole near the pit and it was covered immediately." Another volunteer, Solomon reported that his latrine had been found without a cover hence flies were hovering and maggots were creeping up from the squat hole. His toilet also lacked anal cleansing materials and a handwashing facility. "I was instantly taught how to make a toilet cover using an old jerrycan and how to wash hands properly after using the latrine," Solomon said. However, he reported that it was risky to put the soap near the latrine as some passersby sometimes steal the soap.

During the feedback session, other community members were also given a chance to make observations from the household visits. The Health Assistant who was moderating the session then asked community members: "How many of you have all the required items for your latrines? How many of you want to continue eating faeces?"

At that point, the HA emphasized that it was possible to commit and advance to ODF status. Community members agreed and started raising their hands pledging to go back and construct their own facilities at home. At this particular meeting, 15 people committed to construct latrines in their homes. Another lady said she would make a toilet cover before going to the garden the next day. Some people even volunteered to monitor their fellow residents to ensure they all acquired standard facilities. Even people from neighboring villages promised to go home and implement the lessons learnt.

Outstanding achievements
Facilities constructed: In all the villages and homesteads visited, the required household sanitation facilities were in place and they were in use. Otim Dickens the H/A of Waleta H/C II in Aromo sub county, says that before the USF intervention, latrines in Agelilyec village were not up to required standard. They lacked the requisites like hand washing facilities, squat-hole cover and ash-scoops. But after the USF interventions, 33 out of the 52 household acquired the recommended sanitation facilities. In Agweng Sub County, ODF status was declared in Aton village with 50 households (174 People) and Note-en-Teko village with 67 households.

Improved health: Aromo HA Dickens Otim says that Out Patient Department records at the Health Centre have improved because of reduced cases of diarrhea, dysentery and such diseases. In Agweng S/C Health Assistant Bonny Alaya, 32 years old says that cholera outbreaks had reduced significantly.

Attitude/mindset change: There is a remarkable change in the mindset of community members. Their attitude towards sanitation has changed for the better. People are showing concern about sanitation. People are now treating the health inspection team as part of their community which was not the case in the past. Whenever people saw the health inspectors, they would run away. But now they come, sit with them and even entertain them.

Gender equity and non-discrimination: In Agweng and Aromo sub counties, engagement in the USF sanitation activities has resulted into the blurring of the lines of gender and age. The community meetings were attended by children, the elderly, and the women – without discrimination. It was also reported in both sub counties that the vulnerable people who cannot construct their own sanitation facilities are assisted by the community members.

Factors for success
During the Follow Up MANDONA, community members, extension workers and leaders were keen to identify the factors that have led to the tremendous improvement in sanitation situation in these communities.
• The use of drama has made CLTS interesting. For example, the people of NOTE-En-Teko have formed a drama group and they present skits and plays about sanitation.
• Frequent monitoring visits from USF which creates a friendly atmosphere. People are now treating the health inspection team as part of their community which was not the case in the past. Whenever people saw the health inspectors, they would run away. But now they come, sit with them, dance and sing with them.
• Involvement of religious leaders in the training and implementation. Particularly in Aton and Note-en-Teko it was reported that the religious leaders are given sanitation messages to take to their flocks. ATON has been ODF for 2 years now.
• People in communities are generally disciplined and they listen to their leaders.
• The cluster approach at village level facilitates work e.g where a member of the sanitation committee is assigned a number of households to supervise and follow up.
• Participation of both technical and political leaders: The process involves leaders right from district level through the sub county, parish and village level. For the learning journey, the Lira Chief Administrative Officer (CAO), Mr Byamungu blessed the learning journey and demonstrated that he was well aware of the key sanitation developments in his district. The Odoro Parish Chief, Toby Olwe as well as Councillor Ayo Vincent, participated in the follow up exercise in Agelilyec village. Similarly in Aton and Note-En-Teko villages, the area Local Council Leaders and the Agweng sub county chief all participated.

Challenges: The most outstanding challenges are related to resources – both human and financial.
• The Lira District USF Focal person observed that that some people in the communities expect to receive "motivation" for improving sanitation in their households, they are not self-driven. They expect that the technical and extension staff will give them some rewards – monetary or otherwise – for improving sanitation in their communities.
• Community members also lamented the high cost of constructing latrines. It was reported that for excavation, hired labourers charge between UGX2000 and UGX 5000 per foot. A good and long lasting latrine would be at least ten feet deep. Add to that the cost of a plastic slab, small jerry can and soap. Many households cannot afford that. As a result, some of them have resorted to doing the latrine construction themselves, which compromises on the standards. Others pay with their cocks or goats – which also affects their livelihoods.
• On the side of technical staff, it was reported that the villages are far flung, yet the members of staff are not well facilitated with transport. They also reported that sometimes the late release of funds delays the declaration of ODF. If an officer triggers a village, he/she has to follow up but with limited funds this follow up becomes impossible.
• Working with shifting goals: There are concerns about the quality of latrines being constructed at community level, which apparently do not meet the JMP standards. But the Lira District USF Focal Person Nelson Opio recommends that there is need to be consistent with targets. "We need to appreciate how far we have come. Even communities should be allowed to grow gradually not to run before they crawl, or they will be demotivated. The important thing is to move in the right direction. We need not shift goals before we even meet what we have set," Opio says.

Reflecting upon the exercise, participants from the National Sanitation Working Group discussed the key lessons they had learnt from the Follow Up MANDONA experience. They mainly pointed to the fact that the process had been highly interactive and motivational for community members. They also observed that once communities understand the purpose of an intervention, they will act on the message. The involvement of local leaders and the integration of VSLA in sanitation promotion were also highlighted as key lessons.

Going forward, it was recommended that USF considers building the capacity of community resource persons and train the sanitation committees, teaching them the required standards of sanitation facilities. USF should also consider reducing the staff-to-population ratio and facilitating them to reach all the households in need of technical support. It would also be worthwhile to explore ways of using technology to reach those households.