Championing hygiene behaviour change in South Africa

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WaterAid/Sam James

The simple act of washing hands with soap can prevent diarrhoeal diseases and respiratory infections, yet many people still do not do it. How can we help governments to change this? Sakhile Khaweka, WaterAid’s Regional Support Officer for Southern Africa, describes South Africa’s progress on prioritising hygiene and suggests how partners can help.

Handwashing with soap is the single most effective way to prevent diarrhoea – it can reduce the rate by almost 40% and acute respiratory diseases by up to a quarter. Yet few people do it.

The dangers of not washing hands are enormous. Diarrhoeal diseases are the third leading cause of death of children under five, and a major contributor to malnutrition and stunting. This is a huge public health problem. The simple action of washing hands offers the opportunity to impact hugely on public health, and save our governments money spent on treating diseases. So how can we make handwashing a normal part of life?

To form a habit, people need the basics

According to the JMP, South Africa has achieved 85% access to basic water, which is above the Millennium Development Goal target. But that leaves a lot of people behind. Many live in settlements where the risk of contracting water, sanitation and hygiene (WASH)-related diseases is still high because there is no access to safe water or adequate toilets, and hygiene habits are poor.

As a result, the country has high infant and child mortality ratios. In 2014 the South African National Department of Health (NDH) therefore initiated a programme to intensify efforts to improve hygiene, as one of the interventions identified to reduce this mortality and morbidity. First, they needed to find out where the blockages were.

Finding the bottlenecks

To find the roots of the problems in access to safe WASH, the NDH, supported by UNICEF, conducted a WASH Bottleneck Analysis using the WASH-BAT analysis tool. They identified the following bottlenecks:

  • Weak leadership and coordination, resulting in work in silos and lack of inter-sectoral collaboration. 
  • Theories that assume health education is the key driver of hygiene behaviour change, rather than constant messaging and other innovative, more holistic approaches to influencing behaviour change. 
  • Untracked and insufficient budget allocation across sectors for hygiene – it was not prioritised in resource allocation.
  • No functioning monitoring system to capture hygiene and handwashing delivery and to track progress to improve service quality and behaviour change.
  • No agreed national targets for hygiene, which limits planning and accountability for delivery.
  • Lack of capacity of frontline (community) workers in behaviour change.
  • Lack of a national hygiene evidence base to support programmes and initiatives.

Governments must prioritise hygiene

Based on the identified bottlenecks and actions required, a key action by the NDOH was the development of a National Hand Hygiene Behavioural Change Strategy, 2016–2020. The strategy aims to provide a framework for advancement of handwashing hygiene in the country through multi-sectoral action, for prevention and reduction of diarrhoeal deaths in the country, especially in children under five years.

Another recommendation from the analysis is to establish a national hygiene coordinating committee (NHCC) including different WASH stakeholders. The aim of the NHCC is to ensure improved coordination of hygiene and handwashing promotion initiatives in the country, and to ensure the facilitation of the implementation hygiene components of the Sustainable Development Goal (SDG) to improve health outcomes. The South African Government invited WaterAid to be part of this committee, and Regional Programme Manager Elijah Adera and I are members.

The NHCC held the first National Hygiene Symposium in Pretoria in August, on behalf of the Departments of Health, Basic Education and Water and Sanitation in partnership with WaterAid Southern Africa, UNICEF and South African Local Government Association (SALGA). This high-profile, cross-sectoral event brought together participants including stakeholders, government officials, NGOs, the private sector and academics.

The aim was to gather concrete examples of successful behaviour change in South Africa and globally, and to share the analysis of bottlenecks and its recommendations for delivering effective, sustainable hygiene services and behaviour in South Africa. It was also an opportunity to kick off the handwashing campaign leading up to Global Handwashing Day, when the Government will launch the National Hand Hygiene Behaviour Change Strategy 2016–2020. The Symposium was a great platform for us to collaborate with the South African Government to help effect real change.

How can we support responsive and willing governments to meet their hygiene aims?

We aim to persuade governments to prioritise WASH by recognising it as a human right, allocating a bigger budget and owning up to regional and global commitments. How? I have a few ideas:

  • The private sector has taken keen interest in handwashing and hygiene because it helps promote their sanitary products. Development agencies and governments can take advantage of this by working in partnership with the private sector to promote hygiene behaviour change.
  • We can provide evidence needed for planning interventions for programmes.
  • We can provide innovative approaches to hygiene behaviour change.

The South African initiative could not have come at a better time. It is significant to WaterAid in Southern Africa because our key strategic shift in the region is the prioritisation of hygiene, and we envisage great opportunities for influencing hygiene in other countries and regionally.

Hygiene and sanitation still lag behind in Southern Africa despite access to safe water having improved in some countries; the resulting burden our nations carry is unacceptable. Improving hygiene habits and ensuring people have the means to maintain them would save countless lives – we need to act now to make the difference.

Sakhile tweets as @Sakhilek