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After a decade of emphasis on accelerating water and sanitation infrastructure development, South Africa circles back to behaviour change.

"Ensuring that the public knows about the role of hand washing in preventing infections and viruses are only part of the battle. The real challenge comes in ensuring that the behaviour is practiced at critical times, and for this to happen, people must not just get into the habit of washing their hands; they must have universal, convenient access to functional handwashing stations with soap and running water, whether in hospitals, in schools or in the home."
 - Aaron Motsoaledi, Minister of Health South Africa 

Why WASH behaviour change?

Diarrhoea is one of the leading causes of morbidity and mortality amongst South African children, accounting for approximately 20% of under-five deaths.

Diarrhoeal death rates for all ages in South Africa

WASH interventions are shown to avert more than 50% of the diarrhoeal deaths. Since 1994 there has been a significant improvement but despite that 15% of the population still require improvements to their water supply and 26.6% to sanitation services to meet local standards, and municipalities are struggling to meet service targets and maintenance requirements.

Hand hygiene promotion policies are fully integrated into extensive Primary Health Care and Environmental Health Care programmes. However, the National Health and Hygiene Education Strategy related to Water Supply and Sanitation Services, developed in coordination with the National Sanitation Task Team (NSTT, 2006), has not been adequately implemented.

Low cost high impact: Although it's the lowest-cost highest-impact preventative health intervention, hygiene behaviour change has not been a priority in water and sanitation services delivery in South Africa. Diarrhoeal morbidity and mortality cannot be solved by either health interventions alone. Regardless how good water and sanitation infrastructure is, if it isn't hygienically used and operated, the intended health and socioeconomic benefits won't be realised.

Revitalizing hygiene and handwashing: There was a clear need to revitalize hygiene and handwashing (HHW) in WASH services. The National Department of Water and Sanitation (DWS) has drafted a new National Sanitation Policy (2016) which includes Hygiene and End-user Education. This provides an opportune moment for handwashing to be prioritised in WASH services delivery. A review of the integration of HHW within WASH and the evidence base on hygiene and handwashing found surprisingly little local literature, monitoring or lessons, and recommended that an analysis of the main drivers and barriers be undertaken.

Identifying barriers and actions: Supported by UNICEF South Africa, the Water, Sanitation and Hygiene (WASH) Bottleneck Analysis Tool (WASHBAT) was adapted, and a diverse group of Health and WASH professionals, researchers, product developers and government officials identified key actions to address the priority bottlenecks. These are set out below:

  • Set specific and integrated national targets for HHW, integrate into national monitoring systems, and undertake a baseline survey against which to measure progress.
  • Renew and broaden commitment to joint initiatives between the Departments of Health, Water and Sanitation, and Education.
  • Make earmarked, trackable prioritized budget allocations for HHW.
  • Establish an inter-Ministerial coordinating platform, with a clear leadership role for the National Department of Health (Environmental Health), and a multi-departmental Task Team encouraging the regular participation of leading multilateral, donor, civil society and private sector agencies.
  • Identify evidence gaps and a clear research agenda, including the efficacy and cost-benefits of different hygiene behaviour change approaches.
  • Develop a specific human resources strategy and action plan to reach the HHW targets.

Linking with WASH: The WISA Conference 2016

In the spirit of fostering intersectoral collaboration, the National Department of Health held a session to launch the Hand Hygiene Behaviour Change Strategy 2016-2020 in the WASH sector at the 2016 WISA (Water Institute of Southern Africa) Conference in May this year.

Facilitated by Piers Cross, the session started with a key note address from Aneliswa Cele (Chief Director of Environmental Health) and a lead presentation of the HHW Strategy by Belinda Makhofola (NDoH). Pumla Ntlabati from UNICEF South Africa presented on the importance of handwashing and hygiene for health outcomes, which led into a panel discussion with Dr. Nonhlanhla Kalebiala (Water Research Commission (WRC)), Vimla Moodley (Director of Heath Promotion), Alana Potter (IRC), Prof. Karen Hofman and Lutendo Mudau (experts from the Tshwane and Witwatersrand Universities). Cases from uMgungundlovu district municipality and from Kwa-Zulu Natal Health departments explored practical implementation examples. The session was summarised by Aneliswa Cele.

The Department of Health is forging ahead with scaling up handwashing and hygiene promotion through a multi-sectoral approach and in formulating partnerships with interested private sector and non-profit institutions. IRC hopes to be able to provide technical assistance to an integrated monitoring system.

For more information, contact Belinda Makhafola, (Deputy Director: National Department of Health) or Aneliswa Cele (Chief Director: Environmental Health).