FINAL REPORT
Project 5 - Health and Poverty Demonstration Project
A Model for Participatory Hygiene and Sanitaion
Transformation in 4 Slum Areas in Sylhet, Bangladesh
Report prepared by Lis Alminde, Health International/Municipality of Horsens
November 2002

2.4.1 Visit by HI February 2002
2.4.2 Interim period (March)
2.4.3 Visit by HI April 2002
2.4.4 Implementation April to October 2002
2.4.5 Visit by HI October 2002 - Participatory evaluation of the "Health and Poverty" demonstration project

1 Preface contents

1.1 Introduction contents

This report is the final report of the pilot project "Health and Poverty Demonstration Project: A Model for Participatory Hygiene and Sanitation Transformation in 4 Slum Areas in Sylhet, Bangladesh".

This project was carried out during 6 months from April to September 2002 as part of the

Asia Urbs, Sylhet Partnership Project financed by the European Union and project partners.

Implementing Agencies of the demonstration project were the 2 NGOs SSKS and OMI, Sylhet, supported by the Sylhet Partnership Office.

Health International, Horsens, Denmark provided consultancy during Planning, Training and Evaluation.

1.2 Project Background contents

Horsens Municipality and Health International (HI) are partners in the Asia-Urbs Sylhet Partnership Project together with Sylhet Municipality and Tower Hamlets, London.

HI have taken the responsibility to contribute to the project through the implementation of a pilot-demonstration-project under the headline "Health and Poverty" with the issues of "women’s and community participation" playing a major role.

Basic key area for improving the health and hygiene situation is water and sanitation in combination with knowledge, attitudes and practices for using available facilities. Through visits to the slums it has been very obvious that there was a big scope for improvement, but also that change in practices and other inexpensive changes could contribute considerably to improved health. This could be enhanced if needed structures to operate in, appropriate methods and materials existed.

Water and sanitation are key for improving health hygiene.

These structures turned out to exist in NGO’s working in the area.

1.3 The situation in Sylhet - Health, Water and Sanitation contents

According to the baseline survey carried out by the Asia-Urbs Partnership Project, 21% of people in urban Sylhet are considered to be poor. Of these the people living in slums are among the poorest.

Slums in Sylhet are special in the sense that they are so-called private slums, which indicate that the areas are rented from private owners, who are responsible for the facilities. The slum dwellers are said to be mainly migrant workers staying in the town on a not entirely permanent basis, but some of them often for periods of several years.

Generally the health situation in the slum areas is not very good, level of hygiene is low, children suffer from malnutrition and diarrhoea, and also malaria and dengue are said to increase.

The baseline survey reports the water- and sanitary condition in Sylhet to be good. This is, however, not the case in the slums, where lack of basic facilities causes an obvious health hazard. 30 - 170 families in each slum-area are sharing one well with a hand-pump for water. Wells - often with no or broken slabs - are placed next to huge rubbish heaps and a few latrines, all in a very unhygienic condition.

In these areas children suffer regularly from diarrhoea and since late January this health problem is increasing. The Civil Surgeon of Sylhet therefore recommended this to be a focus area for a demonstration project on health and poverty. This opinion is seconded by many others.

1.4 Health situation in general in Bangladesh contents

General National Health Policy:

Health and Population Sector Programme (HPSP) was launched in the country in July 1998, integrating health and family planning at the service delivery level. The integration is to take place from bottom-up in response to partly the resource constraints but also to provide better services to clients, particularly in the services for reproductive health. The programme is, however, reported to have met several difficulties, and seem not to be very sufficient, as only approximately 10% of the population are reported to make use of the government health services. Findings of a recent major national level survey revealed, according to an article in The daily Star , that : "most of the reasons for non use of government services are due to lack of medicines, poor treatment, bad behaviour of staff and staff demanding payments" and "little over one tenth of the clients reported visiting government health services for illness in the near past, and furthermore persons using the service reported that there was no health worker to attend them."

In the newspaper article Dr. Syed Jahangeer Haider advocates that only a shift replacing HPSP with HPCP (Health and Population Community Programmes) will fit into a national goal of poverty alleviation, and "in a country with resource stringency, people may become a vital source for mobilisation of resources. The need is not to fall in the trap of finding bureaucratic solutions, but to commit to achieve and build a long term and sustainable health and population programme competent to prioritise people’s interest for health and population sector development."

Indicator
Life expectancy at birth	61 for both male and female (1998)
Infant mortality rate	< 1 year 66 per 1000 live births < 5 years 94 per 1000 live births
Maternal mortality rate	4.1 per 1000 births

 

Table 1: Key health indicators for Bangladesh

Cause of death	Percentage (%)
Diarrhoea	11.6 (Children under five 12.5 %)
Heart disease	7.87
Asthma	5.20
Tetanus	4.98
Pneumonia	4.47
Cancer	4.05
Dysentery	3.54
Accident	3.04
Tuberculosis	2.64
Typhoid	2.19

Table 2: Percentage of death from top 10 causes in Bangladesh 1999

The above figures are all mean figures for all ages. The figures differ from rural and urban areas, the situation in urban area being the better for most diseases, for example is the incidence of diarrhoea much higher in rural area. For heart diseases this situation is, however, opposite and in urban areas they overtake the diarrhoea as the top most mortal disease.

1.5 The NGO’s in the Sylhet slum areas contents

The NGO OMI (Organisation Mothers and Infants) is having activities of literacy training and mobilisation programmes in 15 groups in slum areas, and pay major attention to participation of women in specific and the community based activities in general. General problems faced in the areas are the many children sick with diarrhoea combined with difficulty in getting support from health services, slum owners and municipality.

Participatory Event.

SSKS (Sylhet Samaj Kallyan Songsta) is a NGO, with links also to common health services, providing health services for mothers and children. SSKS has clinics in Sylhet where women and children can attend for curative as well as preventive health services. Furthermore field workers are employed visiting households providing health information.

2 The Project contents

2.1 The partners of the project contents

1. Asia-Urbs Sylhet Partnership, providing co-ordination, some financial support, training and overall monitoring and evaluation. 2. OMI with in depth knowledge of slum areas, providing 2 trainers to implement the project at grass roots level. 3. SSKS with in depth knowledge of health problems of women and children in the slum areas, providing 2 trainers for the project and assistance in providing needed health services.

Participatory Hygiene and Sanitation Project Volunteers.

2.2 Objectives contents

The overall objective of the project was to demonstrate a participatory method for developing people’s own solutions of health and hygiene problems in order to improve their living conditions and thereby their health.

Specific objectives of the project were:

1. To assist people in slums of Sylhet in setting their rules for improved hygienic and health environment in their settlements
2. Reduce rate of sickness of children caused by unhygienic conditions
3. To assist women, being the persons of the household responsible for health and hygiene, in improving basic hygienic conditions.

2.3 Expected output contents

The expected output of the project was an adapted model for Participatory Hygiene and Sanitation Transformation, including a set of appropriate tools for implementation piloted in minimum 4 different groups in slum areas in Sylhet.

The 4 areas chosen were:
1. Mozlu Miah Colony
2. Shahid Miah Colony
3. Farud Miah
4. Shahan Miah


PHAST (Participatory Hygiene and Sanitation Transformation)

PHAST is a rather new innovative approach to promoting hygiene, sanitation and community management of water and sanitation facilities, developed over the last 10 - 20 years in WB and UNDP WATSAN sections, now refined in collaboration with WHO after which an easily understandable and very practical step-by-step guide has been developed.

The approach builds on people’s innate ability to address and resolve their own problems. It aims to empower communities to manage their water and to control sanitation-related diseases, and it does so by promoting health awareness and understanding which, in turn, lead to environmental and behavioural improvements.

The Consultant from Horsens/HI has very good experience in working with this method in other Asian countries.

2.4 Activities contents

2.4.1 Visit by HI February 2002 contents

1. Fact-finding

Involvement and focusing on women issues is not easy in Sylhet. Although there in all Municipal boards in Bangladesh are supposed to be elected a proportion of female commissioners, this is not the case in Sylhet. The consultant was informed that this was due to a pending case, causing women were not allowed to run for election.

The Asia Urbs Partnership board have no active female members either.

Hygiene situation in slums were non-describable and also non-ignorable. No matter which interventions or introduction of hardware that may be in mind will have less effect when basic level of hygiene is absent, which is the case in these slums.

There were many issues to address, it is, however, important to start with a smaller well defined area for pilot, after which the trained and experienced persons could disseminate to more people, organisations and areas.

The consultant found the following factors to be satisfying for the implementation of the pilot project:

- organisation;
- structure to work in;
- method.

The following were still lacking:

- materials;
- full consensus on objectives, scope of work and methodology;
- memorandum of understanding between the partners of the project;
- training of facilitators to ease the process in the areas in question;
- identified groups.

The consultant recommended the following:

- To create a new health related partnership involving NGO well known in the slum areas, HGO working for promoting Women’s health and the Municipality through the Healthy Cities Programme (This role was later taken by the SPO);
- A group of people representing these to work for the pilot project for a 6 month period, before evaluation.

2. Meeting with municipality representatives, board members and other stakeholders

As part of the fact-finding the consultant met with the following:

Sylhet:
Chairman of Sylhet Municipality, Mr. Bathar Uddin Ahmad Kamran;
Mr. Abul Hashim, Sylhet Municipality Chief Executive Officer;
Mr. Sudhamay Majumdar, Health Officer, Co-ordinator Sylhet Healthy City Programme;
Mr. Amin Alam, Field Officer, Sylhet Healthy City Programme;
Mr. Ayub Korum Ali, Project Director, Asia-Urbs Sylhet Partnership;
Mr. Parvez Alam, Project Director SSKS;
Ms. Shohita Begum Meera, Managing Director, Reliant People’s & Nextron Computer (RPNC).;
Mr. Muhammad M.A. Laskar, Executive Director World Turism Ltd., Sylhet and Adviser to RPNC;
Mr. Mahmud Rushid, Trainer, Association of Development Agencies Bangladesh (ADAB);
Mr. Syed Abul Farah, Project Manager, Organisation for Mothers and Infants (OMI);
Mr., Civil Surgeon, Sylhet District.


Dhaka:
Mrs. Rina Sen Gupta, IOM (International Organisation for Migration);
Mrs. Begum Shamsun Nahar, Gender Specialist, LGED, Small Scale Water Resources Development Sector Project;
Mr. Saiyid Musharraf Husain, Environment Monitoring Adviser, LGED, Secondary Towns Infrastructure Development project II, Financed by ADB;
Ms. Samia Afrain, Naripakkho;
Ms. Kazi Sufia Akhter, Consultant, previously DPHE water and sanitation projects.

3. Draft Project Plan

A draft project plan was worked out in co-operation with the local partners.

2.4.2 Interim period (March) contents

The responsibility of the partners in this period was the following:
- Identify groups
- Identify candidates for trainers (SSKS, OMI)
- Identify strengths and weaknesses, success criteria, practical issues


2.4.3 Visit by HI April 2002 contents

1. Detailed Planning

Baseline data has been collected from first 2 slums (one in OMI area, one in SSKS area).

The present situation can only be described as very, very bad. The majority of the inhabitants in the slums are illiterate. It is found, however, that many of them have some knowledge about safe hygienic lifestyle but feel that there is no scope to practise this.

The main health problems in the areas are diarrhoea, fever and skin diseases.

Most people go directly to a pharmacy to buy medicine when they or their children are sick. Children below 5 do not use latrines but defecate everywhere. Small children’s faeces are not thought to be harmful. Many old people do the same.

Slum owners have shown positive interest for the project and groups of people in the slums are ready to participate.

It was planned to start implementation first in 2 groups in 2 different slum areas or colonies, as they are also called. The 4 facilitators will work together in these first groups and thereby also together develop the tools, as they are needed for the different steps. After app. 2 months implementation they will start in 2 groups more. It is important to note that a whole course of implementing the PHAST method includes 16 to 18 different activities in 7 steps. If therefore one activity is carried out in one meeting and the groups meet once a week, it will take app. 4 month before the group has prepared its final plan.

Until the planning meeting could take place preliminary preparation was carried out. An Asia-Urbs Sylhet Partnership Board meeting was held on April 7, and the consultant had the opportunity to participate and present the pilot project to the board.

2. Preparation and agreement of Memorandum of Understanding for partners of pilot demonstration project.

A Memorandum of Understanding was agreed on by the partners of the project. The MoU specifies:

• The partners of the project
• Objectives and expected outputs of the project
• The project organisation/ structure with specification of the responsibility areas of the various partners.
• Methodology
• Materials needed for the project
• Budget for the pilot demonstration project.

3. Training of facilitators and other support staff

From April 9 training of facilitators from OMI, SSKS and an artist was carried out. During the training also some planning of tools/pictures took place and the training was followed by more detailed planning of the implementation.

It was the intention to train facilitators from the 2 implementing NGOs (SSKS and OMI) as well as support staff in the PHAST method, including representatives from FIVDB and Healthy Cities Office. However, only SSKS and OMI managed to send staff (the coming facilitators) to participate in the training.

The training was therefore carried out with only 4 core members and an artist. This was a small group to work with and it limited to some extend the exchange of views and experience, but was an advantage in the sense that the training was more intensive. It was, however, a problem when one of the core members was called to his home urgently. For 2 days 2 different members from the organisation participated in stead, this made the process difficult as those 2 members had had no previous chance to get to know the method, we were working with, and this was therefore entirely new to them. Fortunately all 4 members were again together for the planning of the activities in the groups.

The main aim of the project is to demonstrate a participatory method for developing people’s own solutions of health and hygiene problems in order to improve their living conditions and thereby their health and in this process, the expected output being an adapted model for Participatory Hygiene and Sanitation Transformation (PHAST), including a set of appropriate tools for implementation, piloted in minimum 4 different groups in slum areas of Sylhet.

During the training the main focus has been on:

• Maximum local adaptation and innovation of method and materials
• Developing "our" model while implementing
• The project/process should be experimental and creative

The materials used during the training were Vietnamese tools, which were adapted/ re-drawn to match the local situation.

4. Launching of pilot project

On April 17 the work in the first groups in the first 2 slum areas was officially launched/introduced in a community meeting, and persons from the 2 slums plus different agencies and organisations important for co-operation and smooth implementation of the project were invited to participate in this. The meeting was carried out in a very good atmosphere and more than 100 people participated.

2.4.4 Implementation April to October 2002 contents

The actual activities undertaken have been described in monthly reports from the NGO’s. Overall the activities have consisted of:

• Base line survey
• Trainings
• Community meetings
• Community stories (story telling on experiences with water, sanitation and hygiene)
• "Health problems in our community" (group discussions)
• "Mapping water and sanitation in our community" (group actions in the local community)
• Participatory identification of good and bad hygiene behaviours (group discussions)
• Community members:
  • Investigating community practices on sanitation and hygiene
  • How diseases spread
  • Blocking the spread of disease
  • Selecting the barriers for spread of disease
  • Identifying the task division between the genders in the community
  (The above mentioned activities constitute the first 4 (out of 7) steps of the PHAST process)
• Activities on barrel composting (training, survey, implementation)

2.4.5 Visit by HI October 2002 - Participatory evaluation of the "Health and Poverty" demonstration project contents

The process working with SSKS and OMI was very co-operative, pleasant and covering all levels. Discussions were held with people living in the slums, a participatory evaluation process was carried out with facilitators, the Project Directors of SSKS and OMI were participating part of the time and the Executive Directors of the organisations were briefed.

The contact to the Sylhet Partnership office was during this visit influenced by different complicating circumstances (sick leave, marriages, puja, planning of important delegations’ visits etc.) and unfortunately we did not succeed in meeting for a final mutual discussion or evaluation of the process. PD was briefed shortly in his home on October 12 evening.

The evaluation was carried out following the steps mentioned below:

1. Visit to 4 slums:
   - Discussion with dwellers
   - Observation and comparing "before and after"
   - Photos to compare
2. Evaluation of the method and tools.
3. Evaluation related to assumptions.
4. Evaluation related to baseline information.
5. Evaluation of co-operation among partners.
6. Evaluation according to expected output and objectives
7. De-briefing meetings with stakeholders in Sylhet
8. Follow up meetings in Dhaka.

3. Results of the evaluation of the project contents

The evaluation was carried out jointly by the consultant and facilitators from the NGO’s: SSKS and OMI.

3.1 Visit to 4 slums: contents

a. Impression on observation.

In all slums we are welcomed by the inhabitants, who expresses satisfaction with the process, that has been started, and for which there seem to be a common interest.

All colonies have been supplied with barrels for composting and waste collection by the Sylhet Partnership Office (SPO).

Especially one slum/colony, the Mozlu Miah Colony appear to have changed considerably. Tube wells have good slabs and are clean, latrines are in good condition and very clean, alleys are clean with no litter to be seen. Waste is collected by individual families in buckets standing outside their doors. These buckets, which have no lids, are emptied into the barrels supplied by and emptied on request by the SPO.

The other 3 colonies are at different steps of the process, we are, however, in them all met by positive people, who actively take part in the discussion about hygiene.

All the colonies appear cleaner than in April, and some improvements are seen in them all. One colony has got a new tube well. However the sanitary conditions are still to be improved. The new tube well is installed next to the old one, neither have a slab to prevent wastewater from entering into the wells and both are placed just next to simple, still unhygienic latrines.

Participatory Hygiene and Sanitation Project target area.

One colony, which appears tidy this time, has only one simple, unhygienic latrine for all inhabitants. The dwellers have collected some funds to supplement the owners cost for new constructions. We meet the owner of the slum, who confirmed that he will support and start the construction, now when the rainy season is over.

In the last colony the alleys are cleaner, one slab at a well has been repaired, latrines have got doors for privacy and are cleaner, and a bathroom has been repaired.

b. Comparing with baseline information

Each of the NGOs, SSKS and OMI have analysed the result with their baseline surveys with results now, the analysis are attached in annexes

Mentioned here is therefore only the conclusions of this analysis.

Comparing photos.

Sets of photos were taken in the colonies before start of the project and after completion of the project. A clear tendency of improvement can be seen.

d. Trainer’s opinion on process and sustainability

Mozlu Miah Colony: *****

The activities will continue, due to mutual agreement and arrangement with owner, who also acknowledges his benefits of better hygiene in the settlement. An arrangement has been made so that each family pay extra Taka 10/month for which a person is employed to sweep the alleys and clean latrines daily.

Inhabitants are continuously working on finding solutions to put their knowledge into practice, presently they are working on solutions to eradicate flies. Children are very engaged and involved in the activities. SSKS is planning to start child education in the slum, as requested by the dwellers.

Shahid Miah Colony: **

The owner try to ignore the activities, fearing possible demands of inhabitants. However, the dwellers are very interested in improving their situation, and continuation and improved facilities is expected to result in a very quickly improved situation.

Farud Miah: ***(*)

The start was difficult, however now the owner is supporting the activities and agreement has been made on some improvements of facilities (to build new latrines). It is assumed that much positive change is on the way.

Shahan Miah: **

Owners ignore and fear the activities.

(It is remarkable that the 2 owners who are not supporting the activities both are participating in the election as counsellors in the new City Corporation.)

3.2 Evaluation according to expected output and objectives contents

Expected output:
An adapted model for Participatory Hygiene and Sanitation Transformation, including a set of appropriate tools for implementation piloted in minimum 4 different groups in slum areas in Sylhet.

A full model with a set of adapted tools was not developed.

The first 4 steps were implemented according to plan, but the need for participatory selection of options and solutions was not met. Main emphasis was given to demonstrate and implement only one solution: the barrel composting and waste collection, as introduced by the SPO.

An artist was not employed to assist in preparing new drawings.

However, the result after the implemented steps is very promising for the success of the model, if carried out fully and "bottom-up".

Overall objective:

To demonstrate a participatory method for developing people’s own solutions of health and hygiene problems in order to improve their living conditions and thereby their health

It was demonstrated that the PHAST method is appropriate for developing people’s solutions of health and hygiene problems. People participated actively in finding solutions for solving basic problems, and improved hygiene behaviour. However, due to the reasons mentioned above, the whole model was not carried through.

Objectives were:

To assist people in slums of Sylhet in setting their rules for improved hygienic and health environment in their settlements.

The method and tools proved to be valuable in assisting people in setting their rules for improved hygienic and health environment.

Reduce rate of sickness of children caused by unhygienic conditions

According to the survey made by the implementing NGOs the diarrhoea and skin-diseases in the colonies are declining The period of implementation is, however, too short to verify this.

To assist women, being the persons of the household responsible for health and hygiene, in improving basic hygienic conditions

Basic hygienic conditions in the households have improved, alleys and common areas appear cleaner, and certainly the rooms looked into during visits to the slums demonstrated this.

3.3 Evaluation according to assumptions contents

The high number of migrating people in the slums makes work there almost impossible, due to lack of continuity

The quickly changing population was a problem, but one that could be overcome, especially when the slum owner supported the proposed solutions of improvements, ex. Payment for sweeping and cleaning toilet cleaning.

The new culture that was created, with cleaner surroundings and no litter in the alleys proved to have a positive effect also on the behaviour of the newcomers.

We are confident with the method but worried whether it will work

The method proved to be both appropriate and possible to implement – realising that good participation takes time, and patience in this sense is very important.

All the trainers and their organisations are very interested in continued work with this method, and have planned for continuation.

3.4 Discussion of findings. contents

The barrel composting and waste collection was proposed by the SPO as a means to solve the waste problem, and was subsequently implemented in all pilot colonies. As a result of this, all available resources was spent for this purpose, leaving no funds for improving water and sanitary facilities. Furthermore the implementation of this was following the supply driven approach, whereas the key idea of the PHAST method is to work according to the demand of the inhabitants. The 2 different approaches cannot be combined successfully and therefore the original approach was diverted at this stage.

Horsens/HI was not consulted in relation to this change of approach.

It was originally planned and agreed in the MOU that also Sylhet Healthy Cities Project and the NGO FIVDB should participate in project implementation. This did, however not take place.

4. Recommendations contents

Community participation and the PHAST method seems also to be appropriate as a means to developing people’s own solutions of health and hygiene problems in order to improve their living conditions and thereby their health in slums in Sylhet.

A short time and limited resources were available for the demonstration project. The facilitators have, however, together with their institutions and people in the slums, managed to start a promising process and demonstrated remarkable results. They have shown dedication to the work, the method and – what is equally important – respect and care for the people living in the slums, with whom they have worked with humour and in a good spirit, which calls for high respect for their skills and capability.

The result of the work is obvious, so is the recognition of the facilitators and their work demonstrated by the population in the 4 slum areas.

It has been demonstrated that the PHAST method and tools are appropriate and carry a good potential for this kind of work. However, for different reasons it was not possible to implement all steps fully. Therefore possibilities and finance to carry out a more comprehensive – exclusively "bottom-up" - pilot should be searched. This should also include further development of appropriate pictures/drawings. Continued training and support to the facilitators during such an implementation is also recommended.

People not directly involved at grass root level may have different opinions on how to implement participatory activities, opinions that may be very relevant in other projects. It is, however, very important that the facilitators trained, who have the detailed knowledge and confidence in the PHAST method, are left with the responsibility to implement this in the groups, according to the plan prepared by them, and that they are given the freedom and support to demonstrate this bottom-up approach.

5. List of literature contents

Bangladesh Bureau of Statistics: Statistical Pocketbook of Bangladesh 99

Final report, Baseline Study of Sylhet Municipality, Asia-Urbs Sylhet Partnership , Shah Jalal University of Science & Technology, Sylhet February 2002

The Daily Star, Dhaka Thursday 14 February:

Dr.Syed Jahangeer Haider, Chairman, Research Evaluation Associates for Development (READ): For an effective health and population service programme

The Dancing Horizon, Human development prospects for Bangladesh, ADB, FAO, ILO,UNDP, UNESCO, WB and others, Dhaka, Bangladesh 1997

WHO: Water for Health, Taking Charge, Geneva 2001

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