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ENVIRONMENTAL HEALTH PROJECT

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ENVIRONMENTAL HEALTH DIVISION.OFFICE OF HEALTH AND NUTRITION

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ENVIRONMENTAL HEALTH PROJECT

WASH Reprint: Field Report No. 434

Creating Institutional Capability forCommunity-Based Environmental Health Programs

May YacoobBob Hollister

Al RollinsGail Kostinko

— — -

~ r~f’~(~i~ ~L~—’~- Irr~~ (~ ~JL~ ~March19~4

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Prepared for the Global BureauOffice of Health, Population, and Nutrition

U.S. Agency for International Developmentunder WASH Task No. 483

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Environmental Health ProjectContract No HRN-5994-C-0O-3036-00, Project No 936-5994

is sponsored by the Bureau for Global Programs, Field Support and ResearchOffice of Health and Nutntion

U S. Agency for International DevelopmentWashington, DC 20523

I — — —

WASH and EHP

With the launching of the United Nations International Drinking WaterSupply and Sanitation Decade in 1979, the United States Agency forInternational Development (USAID) decided to augment and streamline itstechnical assistance capability in water and sanitation and, in 1980, fundedthe Water and Sanitation for Health Project (WASH). The fundingmechanism was a multiyear, multimillion-dollar contract, secured throughcompetitive bidding. The first WASH contract was awarded to a consortiumof organizations headed by Camp Dresser & McKee International Inc.(CDM), an international consulting firm specializing in environmentalengineering services. Through two other bid proceedings, CDM continuedas the prime contractor through 1994.

Working under the direction of USAID’s Bureau for Global Programs, FieldSupport and Research, Office of Health and Nutrition, the WASH Projectprovided technical assistance to USAID missions and bureaus, other U.S.agencies (such as the Peace Corps), host governments, and nongovernmentalorganizations. WASH technical assistance was multidisciplinary, drawingon experts in environmental health, training, finance, epidemiology,anthropology, institutional development, engineering, communityorganization, environmental management, pollution control, and otherspecialties.

At the end of December 1994, the WASH Project closed its doors. Workformerly carried out by WASH is now subsumed within the broaderEnvironmental Health Project (EHP), inaugurated in April 1994. The newproject provides technical assistance to address a wide range of healthproblems broughtabout by environmental pollution and the negative effectsof development. These are not restricted to the water-and-sanitation-relateddiseases of concern to WASH but include tropical diseases, respiratorydiseases caused and aggravated by ambient and indoor air pollution, and arange of worsening health problems attributable to industrial and chemicalwastes and pesticide residues.

WASH reports and publications continue to be available through theEnvironmental Health Project. Direct all requests to the EnvironmentalHealth Project, 1611 North Kent Street, Suite 300, Arlington, Virginia22209-2111, U.S.A. Telephone (703) 247-8730. Facsimile (703) 243-9004.Internet EHP@ACCESS.DIGEX.COM.

WASH Field ReportNo. 434

Creating Institutional Capability forCommunity-Based Environmental Health Programs:

Lessonsfrom Belize

Preparedfor the Global Bureau,Office of Health, Population,and Nutrition,U.S.Agency for InternationalDevelopment,

underWASH TaskNo. 483

by

May YacoobBob Hollister

Al Rollinsand

Gail Kostinko

March 1994

WaterandSanitationfor HealthProjectContractNo. 5973-Z-00-8081-00,ProjectNo. 936-5973

is sponsoredby theOffice of Health, Global BureauU.S. Agencyfor International Development

Washington, DC 20523

RELATED WASH REPORTS

Improved Productivity Through Better Health (IPTBH) Project: Phase One of theAmendment,TechnicalAssistanceandAssessment.WASH Field Report No. 356. (VectorBiology and Control ReportNo. 82248.)January1992.

Program Planning Workshopfor theImprovedProductivity Through BetterHealth Project:Belize, AprIl 29-30, 1992. WASH Field ReportNo. 365. August 1992.

RethinkingSanitation:AddingBehavioralChangeto theProjectMix. WASHTechnicalReportNo. 72. July 1992.

CONTENTS

ABOUT THE AUTHORS vACKNOWLEDGMENTS viiACRONYMS lxEXECUTIVE SUMMARY xi

1. THE INCREASED PRODUCTIVITY THROUGH BETTER HEALTH PROJECT . 11.1 Background 11.2 ConsultativeProcessto Addressthe Problem 2

1.2.1 Phase1: Assessment 21.2.2 Phase2: Addressingthe Constraints 41.2.3 Phase3: ProgramPlanningWorkshop 4

1.3 Training Methodologiesand Approachesto TechnicalAssistance 5

2. IMPLEMENTING COMMUNITY-BASED ENVIRONMENTAL HEALTHPROGRAMS: LESSONSLEARNED 7

3. GUIDING ELEMENTSFOR IMPLEMENTING AN ENVIRONMENTALHEALTH PROGRAM 133.1 Community Participationasa Basisfor CapacityBuilding 13

4. BUILDING A BEHAVIOR-BASED ENVIRONMENTAL HEALTHINFORMATION SYSTEM 23

5. CONCLUSIONS 27

APPENDIX

A. Materials Developedin the CBEHP 29B. Building Training Skills to Develop

Institutional Capability 31

lii

ABOUT THE AUTHORS

MayYacoobis anappliedmedicalanthropologistwith apost-doctoraldegreein healthservicesmanagementandover20 yearsofexperiencein communitypublic healthprogramsin Africa,Asia, andCentralAmerica. She hasbeenwith the WASH Projectsince1986, and prior toWASH workedon UNDPandWorld Bank watersupply andsanitationprojects.Herareasofspecialtyareissuesof sustainability,communitymanagement,women,andhygieneeducation.

Bob Hollister worksfor theResearchTriangleInstitute’sCenterfor InternationalDevelopmentin Raleigh-Durham,North Carolina.He is thecoordinatorof RTI’s programsand servicesininternationalhealth. He hasover 20 yearsof experiencein healthprogrammanagement,training, decentralization,institutional strengthening,andconsulting. Mr. Hollister hasa B.A.in Political Sciencefrom Guilford College and an M.S. in Public Health from the Universityof North Carolina, ChapelHifi.

Al Rollins is an independentconsultant/trainer,with 30 yearsof experiencein personal,group,organization,and communitydevelopment.Prior to enteringprivatepractice,he wasPresidentandExecutiveDirectorof theMid-Atlantic Associationfor TrainingandConsulting,Inc. HeservedastheTrainingDirectorandInternalOrganizationDevelopmentConsultantforan internationalreligioussystem.He now specializesin thetrainingof trainers,managementand organizationdevelopment,internationaldevelopment,anddevelopmenteducation.Hehas extensiveconsultingand training experiencein Africa and the Caribbean,with specialinterestin rural village developmentwith governmentand private voluntary organizationclients.

Gail Kostinko is an informationmanagementconsultantwith over 15 yearsof experienceinthedesignanddevelopmentof informationservices,systems,andproducts.Shehasprovidedconsulting servicesto a wide variety of international agenciesand developing countryinstitutions.

V

ACKNOWLEDGMENTS

ThIs three-yeareffort would not have materialized without the active participation ofGovernmentof Belizestaff fromthe Ministry ofHealthandtheMinistry of NaturalResources;membersof theCentralManagementTeam,Anthony Nicaslo, Kathy Buttaro, Dr. Figuroa,Dr. Polanco,andMr. Westby;andtheDistrict Teamswho enthusiasticallyparticipatedin thisyear-longintensivetraining.

TheUSAID missionwasinstrumentalin makingtheeffortsuccessful,particularlystaff membersPatrickMacDuffie, GDO, andAmelia Cadle,HPN Officer. Thanksalsoto BarbaraSandoval,USAID Mission Director,for askingall thosequestionsthat we oftenhadno answersfor, andto Zakir Merchantfor all the assistanceIn computertechnologiesandfor alwaysrising to theoccasionto provide neededhelp.

Within A.I.D. Washingtonan importantpersonin this entireeffort is DennisCarroll, ProjectManagerfor WASH in A.I.D.’s Office of Health,who waspart of thetwo-personteamthatinitiated this process. He provided continued hands-onsupport, encouragement,andconstructivefeedback.

Dr. Andy Arata, currently with TulaneUniversity, wasthe teamleaderand malariacontrolspecialistfor this effort.

Within WASH, manyhavehelped.Specialthanksgo to David Femandesfor all his help infielding consultantsandtrackingbudgets.Also thanksto CourtneyRoberts,who workedwiththe whole Belize teamin supervisingthe productionof theJobGuides.

For the future, we wish UNICEF/Belize the bestof luck in continuing this exploration ofmethodologiesandapproachesfor promotion of environmentalhealth in Belize.

vu

ACRONYMS

A.I.D. Agency for InternationalDevelopment(Washington)

CBE1-IP Community-BasedEnvironmentalHealth Program

DLEHSC District-Level EnvironmentalHealthSubcommittee

GOB Governmentof Belize

HIS health information system

IPTBH IncreasedProductivity Through BetterHealth Project

MNR Ministry of NaturalResources

MOH Ministry of Health

TA technicalassistance

TOT training-of-trainers(workshop)

VHC village healthcommittee

WASH Waterand Sanitationfor Health Project

USAID U.S. Agencyfor InternationalDevelopment(overseasmissions)

ix

EXECUTIVE SUMMARY

In July 1990,USAID/Belize requestedthattheWaterandSanitationfor Health (WASH) andVector Biological Controlprojectsdesignan amendmentto the recentlycompletedsix-yearproject, ImprovedProductivityThroughBetterHealth (IPTBH). While the project’snumericaltargetshadbeenmet (numberof watersystemsandlatrinesconstructed,housessprayedtocontrol mosquitos,and, to the extentpossible,blood slides examinedto confirm malariacases),the diseaseburdencontinuedto increase.Public health issuesrelatedto malaria,dengue,andwateruse andsanitationstill neededto be addressed.

The designof the amendmentdrew on the WASH Project’s accumulatedexperiencefromwork throughoutthe decade.As the IPTBH project wasreformulatedandrefocusedin theamendment,it wasrenamedthe Community-BasedEnvironmental Health Programandbrought togetherprogram elementsfrom primary healthcare, malariacontrol, and watersupply andsanitation.Severalfundamentalissuesemergedwhich were viewed asdirectlyrelevantto building an effectivepublic healthprogram:

• Governmentofficials—from policymakersto district-levelstaff—needto recognizewhy additional numericaltargetswill not necessarilyreducethe diseaseburden.

• National- andcommunity-level Institutions needto jointly developsolutionstopublic healthproblemssothat they havejoint ownershipof the processandvestedinterestin its implementation.

• Multiple agenciesand programsare involved. Public health problemsarisingfrom poorenvironmentalhealthconditionsrequiretheattentionof stafffrom anumberof public healthprogramswho do not normally work together.In Belize,Ministry ofHealth(MOH) staffwork in theprimaryhealthcareprogram,the healtheducationandcommunityparticipationprogram,andthemalariacontrolprogram.Ministry of NaturalResources(MNR) staff areresponsiblefor rural watersupply andsanitation. All ofthesepeople areinvolved in areasconcernedwith environmentalhealthandpublichealthIssues.

• New institutional arrangements are needed to integrate curative andpreventivehealth programs. In Belize,thesearrangementsgaveriseto nationwideDistrict-Level Environmental Health Subcommitteeswith the skills and technicalexpertiseto addressissuesrelatedto environmentalhealthin communities.(UNICEFIs currentlybroadeningdistrict-level staffcapabilitiesin this area.)

In order to addressthesefundamentalIssues,technical assistanceand programmingweredivided into threeareas:

1. Technicalareasto strengthenthevectorcontrol program’scapabilities.Thisincludedconductingastudy tour in El Salvadorto show Belizeanpolicymakershow asuccessful malaria control program can work; developing norms for volunteercollaborators;resolvingsomeIssuesrelatedto identification of the vector; andproviding

xi

technical input into developing alternative chemical and nonchemical methods ofcontrolling mosquitos. -

2. Technical areas to strengthen the effectiveness of water supply andsanitation systems.This included generatingpolicies and proceduresto improveoperationsandmaintenance(andtherebycontinueduseof the systems)anddevelopingpoliciesandproceduresto achievewaterquality standards;trainingstaff in otherspecific,targetedskills in disinfectionandsurfacewatertechnologies;andresolvingIssuesrelatedto moreefficient drilling procedures.

3. ~Common areas” to build community-level capacity to manage theenvironmentalhealth program.This Induded developing institutional, policy, andprocessskills of MOH andMNR staffandcultivating apublic healthapproachfocusedoncommunity capability,control, andmanagement.Activities in the following areasformedthe basisfor the developmentof such capabilities:

• Transferringtraining-of-trainersandorganizationaldevelopmentskills,communitymanagementandempowermentskills, andfield methodsfor determininghealthstatusbasedon the prevalenceof high-riskbehaviors;

• Developingan informationsystemthat indudesabehavioraldatacomponenttomonitor hygieneandotherbehaviorsrelating to environmentalhealth;

• Producingapositionpaper,written andendorsedby nationalstaff,sothatpolicysupport is ensuredandresourcesareallocatedfor the continuedoperationof acommunity-basedprogram.

Approach to Community Participation as a Basisfor Capacity Building

The approach taken in Belize was based on the following principles of communityparticipation:

• Start with the community: its history, structure, leadership,beliefs, strengths,knowledge,andperceptionsof what it needs.

• Analyze health-related beliefs and behaviors. Build messagesand designprogramsto alter behavior basedon individuals’ understandingof the causality ofdiseaseandstarting with their current behaviorfor avoiding or curing illness.

• Focus on skill developmentand transfer. Sustainablehealth-relatedbehaviorchange and sustainableInfrastructure improvementsare built upon social andorganizationalskills that aredevelopedIn the peoplein the communities.

• Develop health teamsat the district level to integrate service delivery at thecommunity level.

• Establish clear lines of communicationbetweenprogram implementorsandcommunity membersandbetweenprogramstaff andpolicymakers.

xli

• Identify the roles various community members play in health andresourceallocation.This local analysiswill determinewhatadditionaltrainingandresourcesareneeded.

• Develop a supportive context for capacity building. This implies a changeinorientationamonghealthworkers.Ratherthan“giving” something(e.g. healthtalks,handpumps,latrines),the health workersmust becomepartnersin adevelopmenteffort whose goal is to transfer skills, knowledge, managerial capacity, andcommitmentsothatcommunitieswill sustainthe programsandbehaviorsthatimprovetheir health.

N Makethetransferof responsibility openand purposeful.In Belize, aclearandcarefully monitoredgoalwasto transferprogramresponsibilitiesto district teamsandcommunity groups.This explicit goalwasopenly discussedandnegotiatedasdistrictandcommunity groupstook increasingresponsibility. -

Purposeof This Report

The approachusedIn Belize soughtto combinelessonslearnedandmethodologiesusedbythe WASH Projectduring its 13 yearsof operationin manycountriesandprograms.Theselessonshaveimportantimplicationsfor the future. First, this effort broughttogetherdifferentprogramandministry staff responsiblefor environmentalhealth, water andsanitation,andvectorcontrol.Theeffort alsoprovidessomelessonsaboutintegratingcurativeandpreventivepublic healthservicesandabout creatingmechanismsto ensurethe sustainabiityof theseprograms.

Second,the processesfor training, the methodologiesused,andthe sequencingof activitiesto achieveinstitutionalcapabilityprovide importantlessonsfor similar initiatives in thefuture.

This report describesthe processesandproceduresthat weredevelopedover a three-yearperiod to meet the objective of improving community-levelpublic health conditions. Theprocessesbeganwith consultationsandinvestigationsto Identifythe constraintsregardingtypesof activities and the linkagesbetween local-level issuesand policy. The most importantassumptionsmade in Belize were that new relationshipsmust be createdamongvariousinstitutions (national,district, andlocal) to addresslocal-levelenvironmentalhealthconditionsandthatanynew institutionsin this networkmustbe formed andshapedby the actorsandstakeholdersthemselves,i.e., thosewhowifi implementthe programsandthosewho will beaffectedby them.

Chapter1 of this reportprovidesthe backgroundanddescribesthe activitiesleadingup to theone-yeareffort thatwas initially calledthe IPTBH Amendmentandbecamethe Community-BasedEnvironmentalHealth Program(CBEHP).

Chapter2 takesa more generic approachto the implementation of a community-basedenvironmentalhealthprogram.It describeskey lessonslearnedandis intendedas aset ofpreliminary guidelinesfor the design of similar projectselsewhere.

xin

Chapter3 reviewsthe elementsfor implementinganeffective,sustainablecommunity-basedenvironmentalhealth program,basedon the experiencein Belize andWASH’s experienceover 13 years.

Chapter4 details the behavior-basedmanagementinformation systems,which were anintegrativeforcedesignedto give all programstaffaccessto the samedataandanalysis.

Finally, Chapter5 summarizesthe conclusionsdrawn from WASH community managementactivitiesin Belize. A seriesof job guideswerepreparedfor long-termuseby thoseinvolvedin the CBEHP; their titles aregiven in AppendixA. Appendix B givesdetailson the trainingskills emphasizedIn the project.

xiv

Chapter 1

THE INCREASED PRODUCTIVITY THROUGH

BETTER HEALTH PROJECT

1.1 Background

This chapterdescribesthe institutional andprogramsetting of the work carriedout in Belize.It provides an overview of the assessmentof the problems, the institutional setting, theconsultativeprocess,andtraining elements.

In 1985, the Governmentof Belize and the U.S. Agency for International Development(USAID) agreedto implementahealthprojectcalledIncreasedProductivity ThroughBetterHealth (IPTBH). Theprojectfocusedon vectorcontrol (dengueandmalaria)andwaterandsanitationactivities. In January1989, an evaluationof the project wascarriedout. A majorconduslonwas that afterfive yearsof inputs from USAID andother Internationalagencies,including village piped-watersystems,latrines, spray operations,and processesfor casemanagementof vectorcontrol,the expectedhealthbenefitshadfailed to occur. In fact, atthetime of theevaluation,the incidenceof malariain Belize was the highestper capita in all ofCentralandSouthAmerica;diarrhearateshadnot gonedown; andcholerapresentedanewthreat.

The evaluationcited weakcommunity participationandmanagementasthe majordeficiencyin implementing the project. It wasdeterminedthat village healthcommittees(VHCs) hadreceived inadequatetraining, support, and supervisiondue to the project’s emphasisonattainingphysicaltargets,such asnumberof wells drilled, numberof housessprayed,healtheducationsessionsconducted,and latrines constructed.In terms of number of systemsestablishedandnumberof latrinesbuilt, this projectmight havebeenconsideredasuccess,but USAID/Belize wasnot satisfied.Wherewerethe healtheffectsthatwerepredictedto havecomeabout from theseinterventions?

In responseto the problemsidentified by the evaluation,the U.S. Agency for InternationalDevelopmentbegan, in 1990, an Institutional strengtheningprogram, designedto addresstheseandrelatedproblemsplaguingBelize’s healthprogram.USAID/BelizerequestedthattheWaterandSanitationfor Health (WASH) and Vector Biological Control projectsdesignaprojectamendmentto strengthenperformancein communityparticipationandmanagement.A one-weekconsultativemeetingwas heldwith MOH andMNR staff in summer1990. Theparticipantsconcludedthatadysfunctionalbureaucraticstructureandlackof communicationat all levels were hindering Belize’s healthprogram.

In thecourseof assessmentanddesignof afollow-on program,district-levelstaffactuallyspenttimein villagesfinding out whatthe issuesandproblemswere.They foundthat villagerswerenot usingthe latrinesbecausetheywereliterally swarmingwith mosquitoes;thatvillagerswerewashingclotheswith piped waterwhile theydrankrainwaterbecausetheypreferredits taste;

1

that therewasaseverepossibility of excessiveleadlevelsin drinking waterbecausevillagerspaint their catchmenttanks on a regularbasiswith oil-basedpaint containing lead (barely 2percentof importedpaintsareleadfree);andthatvillagersgenerallyattributedchillsandfeversto changesin the seasons,not to malaria.Clearly, an effective hygieneeducationprogramwould have to begin with an accurateunderstandingof people’sperceptions,beliefs, andpracticesaboutwhen, why, andhow peoplegetsick andwhat they needto do to get well.

As a result of a seriesof follow-up workshops,meetings,visits to other countries, and athoroughinstitutionalassessment,theministryofficials identified whatwasmakingtheirsystemdysfunctional.Theydevisedprogramsto addressthe shortcomingsbasedon their vision ofwhatan effectivewaterandsanitation,vectorcontrol, primary health,andhealtheducationprogramshouldbe. Theycondudedthattheyneededto developthe capabilitiesof the districthealthteams,whichwould becomethe backboneof thesystem.It wastheseteamsthat wouldinteractdirectly with communities.They alsosawthat they neededto changebureaucraticbehaviorandto expandcommunication-with communities.

TheUSAID missionrecommendedthatposition papers,designedto establishclearobjectives,procedures,responsibilities,andpolicies,bedeveloped.Thesepositionpaperswould ensurea consensuson program policy, with a sustainablestrategy of training, communitymanagement,planning, monitoring, andevaluation.

1.2 Consultative Processto Address the Problem

The evaluation focused attention on the need for greater emphasis on communityparticipation/management,training, and institution building to ensure that projectactIvities—installingwatersystems,consth.ictinglatrines,conductingvectorcontrol activities,anddeliveringhealtheducationtalks—wouldresultin intended,long-termhealthbenefitsforcommunities.

As mentionedabove,operational(program-level)staff from the two ministriesandhigh-levelGovernmentof Belize (GOB) officials, in collaborationwith consultants,metand identifiedconstraintsto achievingcommunity-basedinstitutional capability in planning, implementing,andmanagingbroad environmentalhealthaétivities.A three-phasedapproachwasusedtoaddressthe problem.

1.2.1 Phase1: Assessment

With the team of consultants,MOH and MNR program and policy staff developed andconductedbaselineassessmentsineachof thetechnicalandinstitutional areas.TheassessmentlookedattheGOB’s organizationalcapacityto implementwatersupplyandsanitationactivitieseffectively andto developincreasedcapability in communitiesto carry out more technicalresponsibilities,suchasoperationsandmaintenanceof the waterandsanitationinfrastructureandvectorcontrol activitiesconductedby community volunteers.The assessmentpointedtothe following majorconstraints.

2

Vertical program. The greatestconstraintto delivery of effectiveservicesat the communitylevel wasthe verticalnatureof communityhealthprograms.Operationalstaff from eachof theprogramsat the national, district, and community levels felt they hadno way of reachingdecision-makersandpolicymakers.The overall approachin vectorcontrol wassimilar to theverticalapproachtakenin malariaeradicationprogramssetup in the 1950s. Evolution of thevector, community residencepatterns,andvariedlocalknowledgeor healthparadigmsthatinformed how community membersdealtwith diseasewerenot takeninto consideration.

Lack of data.Databasedon the needs,practices,anddemandsof population groupsdidnot exist.Therefore,technicaldataon positivecasesof malariawererarelyusedto tracecasesto theirsources.Instead,malariacontrol stafftendedtoundertakemassivesprayingoperationsor simply to sprayon demandin communitieswith political pull.

Lack of community support. The water supply andsanitationprogram, which requiredextensivecapital support for constructionof handpumps,latrines, andrudimentary watersystems,lackedthe level of communitysupportnecessaryto ensurelong-termmaintenance,effectiveuse,andanticipatedhealthimpacts.This wasespeciallytrue in the casesof latrinesandhandpumps.

Poormanagement.Therewasno policy statementor legislationto supporttheestablishmentof villagehealthcommitteesandboardsof management(which managethe rudimentarywatersystems)andfee collection. As aresult, somecommunitiessufferedfrom poor maintenanceandneglectof watersupplysystemsanddormantor dysfunctionalcommunityorganizations.In othercommunities,the malariaprogramsprayedInsecticideon demandfrom politicians,regardlessof needor concurrentcommunity or householdprogramsfor vectorcontrol.

Inappropriatepolicy. Becausethe MNR hadno policiesforconstructionor for infrastructureoperationsand maintenance,ad hoc, often politically-based decisions gave priority toconstructionoverplannedactivitiesfor creatingeffective,community-basedentitiescapableofcompetentmanagementandoperationsandmaintenanceor for trainingstaffof theseentitiesin hygieneeducation.Themalariaprogramhadno policies regardinginsecticidesusedor howsprayingoperationswereto be conducted.

Lack of trainedstaff. Engineeringandtechnicalstaff training focusedprimarily on locatinganddevelopinggroundwatersources.Engineerslackedthe appropriatetechnologiesto reviseproceduresfor sourceselection,designconsumption,watersupplysystemstanksizing, andnetworkdesign.Malariasprayteams,evaluators,andlocal-levelvolunteersreceivedvery littletraining aschangesin the vector, hosts,andenvironmentsoccurred.

1.2.2 Phase2: Addressing the Constraints

Data gathering. Major programmaticchangescanhappenonly whenthoseinvolved in theprocessseewhy things do not work anddiscoverfor themselveswhatcanbe doneto makethosechanges.This phasewas initially designedasastudy tour for programstaffand high-leveldecision-makersto specificcountriesin theregionwherecommunity-basedenvironmental

3

healthactivitiesare beingcarriedout with relativesuccess.The vectorcontrol programstaffvisited El Salvador,whereavectorcontrol programhassucceededin controlling malaria;the -

national water and sanitationprogramstaff spent time assessingcommunity capabilities,resources,knowledgeof risk factors,andactualhealthbehaviorswith variousdatagatheringinstruments.

Study tour results/DatacollectIon.Thevectorcontrolstaffrecognizedthatin El Salvador,which is similar ecologicallyto Bellze andwhere avertical programis in place,motivatedcollaboratorsandevaluatorscould createeffective community-levelsupport for the malariacontrol. ParticipantsgainedIdeasand recognizedthat new approacheswould haveto beimplementedto achieveanticipatedprogramresults.

The data collection phase alsoshowed central- and district-level staff that communities’knowledgeof vector- andwater-bornediseaserisks, hygiene,andsanitationdid not matchinformationdeliveredin “healthtalks.” Staffrealizedthathealthmessagesdisseminatedduringhealtheducationtalks werenot relevantto actualhealthpracticesandcommunity behaviors.Despitethe presenceof awaterandsanitationinfrastructure,consistingof latrinesandwatersystems,andvectorcontrol activities,I.e., spraying,communitybehaviorwasunchangedandhealthstatuswasunaffected.

1.2.3 Phase3: ProgramPlanningWorkshop

A two-day workshop,heldIn March 1992, was the culminationof the previoustwo phases.It included high-level policymakers—specifically,permanentsecretaries,chief executiveofficers, the director of health services,and operational staff from districts and centralministries—andhadthe following objectives:

• To inform policymakersof the phase1 and2 activities;

• To developaclearobjectivefor eachof the respectiveministries;

• To agreeon strategiesandmechanismsfor achievingthis objective;and

• To ~iscussthe policy supportrequiredto implementcommunitymanagementin vectorcontrol andwaterandsanitationprograms.

Participantsworkedtogetherto developobjectivesandstrategies,drawup an actionplan,anddiscusstraining needs.Some“common areas”emergedfrom thesediscussions,includingtraining areasthat would develop district- and national-levelcapacity-buildingcapabilities.Thesecommontraining areaswereusedto groupandsortthosestafffrom the two ministrieswho hadcommunity-levelsupervisoryandcapacity-buildingresponsibilities.Thefour areasofcommonInterestIncluded:

• Training-of-trainersskills andapplicationof theseskills to carrying out effectivecommunitymanagement.

4

• Community analysisand developmentof effectivehygieneeducationskills. Thisconsistedof field techniquesin qualitativedatacollection, analyzingthedatacollected,and making summarystatementsfrom the analysis for the purpose of behaviorchange.

• Designandimplementationof aninformationsystemto monitor the effectivenessandproperfunctioning of variousenvironmentalhealthactivities.

• Developmentof a “position paper” to outline the processof creatingcommunity-basedinstitutions andto delineateareasthat require policy changesto ensurethattheseInstitutions continue to function. The document was designedto reflect theiterativeprocessbetweenoperationalstaff andpolicymakersover the courseof theprogram.

In addition,sometechnicalareaswerenotedasdirectly relevantto improving the operationsof a community-basedenvironmental health approach. These included water qualitymonitoring, norms for voluntary collaborators, and operationsand maintenanceof theimprovedwatersystems.

1.3 Training Methodologies and Approaches to Technical Assistance

The training methodologiesusedto createthe institutional capability for acommunity-basedenvironmentalhealthprogramare relatedto three fundamentalconclusions(from WASHexperience)abouttechnicalassistance.

• One-time training workshops without follow-up interventions rarely succeedindevelopingintendedskills.

• Technical assistancereports on the developmentof solutions, if producedwithoutcollaborationfrom nationalstaff, serveno purpose.

• Technicalassistanceis more effectively carriedout through short-terminterventionsthanby In-countryteamsthatstaylongenoughfordependencyto develop.Long-termassistancecan build resentmentamongnationalsif advisors are unableto provideanswersto problemsin all technical areas,andcosts much more than short-termassistance.

TraIning workshopswere designedto be no longer than one work-week. This was veryimportantin Belize becausethe strategyof developingcoretraining capability in eachof thedistrictsrequiredthatamajorityof district programstaffattend,keepingthemfrom completingtheir regularly scheduledwork.

5

Chapter 2

IMPLEMENTING COMMUNITY-BASED ENVIRONMENTAL HEALTH

PROGRAMS: LESSONSLEARNED

A numberof lessonshaveemergedfrom theexperiencein Belize which haveimplicationsforthe developmentof community-basedenvironmentalhealth programsin other countries.These lessonsremind us that the essenceof “development” placesmore emphasisonindividuals’ skillsand ability to exertinfluenceandcontrol in their personalandprofessionallivesandlesson numericaltargets,suchaswatersystemsInstalled,housessprayed,or latrinesbuilt. Regardlessof whetherthe individualsaregovernmentemployeesworking in thehealthsector,membersof village healthcommitteesworking in communities,or parentscaringfortheir children, they all needthe knowledge, skills, andresourcesto make decisions,takeaction, andexertcontrol over their life or work situations.

The lessonslearnedin Belize provideaframeworkfor replicatingtheprocessin othercontexts.Successfullyapplied, these lessonsempower workers, communities, and individuals tounderstandandexercisecontrol overproblemsthatrelateto theirhealthandwell-being.Theyremindusof whatoneobserverhascalled,”.. .the fundamentalassociationof healthstatuswith social,economic,andpolitical circumstance,on theonehand,and links betweenhealthcarereformand broaderpolitical action and struggleon the other.”’

1. False participationtemporarilyenlists input from community members butfails to build capacity or ensuresustalnability. Plannersand participants incommunity participationeffortsneedto understandthat thereis suchathing as falseorsuperficialcommunity participation. This typeof participationis oftenmanipulativeandis usuallydetrimentalto the long-termgoalsof true capacitybuilding. Falseparticipationis exploitativein natureandorientedtowardtheachievementof short-termornumericaltargets.It temporarilyenlistsparticipationfor thepurposeofcompletingsomeconstructiontaskor specialproject.

For example, once latrines are built, water systemsInstalled, or the “campaign”completed,the“outsiders”disappear,neverto beseenagain.Communitiesareoftenleftwithout theorganization,skills, orcommitmentto managethenewsystems.Communitieshavenot, In suchcases,broadenedtheircapacityto addressproblemsandmanagetheirown affairs. There is little likelihood that the new systemswill be maintained,and theimpact mayevenbe negative,in termsof motivation for future efforts.

1 H. JackGeiger.“Community-OrientedPrimaryCare:TheLegacyof SidneyKark,” American Journal ofPublic

Health, July 1993, Vol. 83, No. 7, p 946.

7

2. Genuinecommunity participation is a long-term processaimed at developingleadership, technical skill, and social cohesionas well as achieving specifichealthbenefits.Communityparticipationrequiresaperiodoffairly intensivework in thecommunity and along-termcommitmentto support,train, andnurtureorganizationsorgroupsin the community who areinterestedin healthissues.An intersectoralapproachis valuedwherebyvariousgovernmentprogramsandpersonnelintegrateservicedeliveryatthecommunitylevel. An importantlessonfrom Belize isthatcommunitiesrespondwithcollaboration and motivation when they seethesesamequalities in the governmentworkers.

3. It is necessaryto take a dual approach which not only teachesthe skillsnecessaryto operate successfullyat the village level, but also focuseson thedevelopmentof the district team itself. A government,or ministry of health, thatwantsto involve communitiesin managementor implementationof environmentalhealthprogramsmustusuallyrely on existingdistrict-level healthworkersto carryout the work.Theseworkers include nurses,health educators,inspectors,vector control personnel,outreachworkers,supervisors,and other technical officers who often work in verticalprograms.Suchprogramsor servicesfrequently operateindependentlyof eachother,receivingtheir technicalandday-to-daysupervisionfrom the central level.

Unless the district team is strengthenedand supported, it cannot be expectedtoadequatelysupportandtrain village leadersandvillage healthcommittees.Manyof thesedistrict-level workershavenever worked as a teamwith their counterpartsfrom otherprograms.Thisusuallymeansthattime andeffort mustbe investedto developsomethingthat hasbeennon-existentor weak: district-levelteamswith somediscretion over theirownwork planningandpriority setting.District-level staffneedtraining andsupportfromtheir owncentral-levelsupervisorsto adoptacollaborativeandintegratedapproachin theworktheycarryout in communities.In order fortheseworkersto functionasateamthereare issues of policy, leadership,management,coordination, planning, and resourcesharingthat haveto be addressed.

4. Establishing village health committees should be considered an effort todecentralizethehealthcaresystem.Individual behaviorandcommunity actionplaya crucial role in improving and promoting health, particularly environmentalhealth.Governmentprogramsto supportcommunitiesin effortsto improveenvironmentalhealthconditionsare,in reality, attemptsto createnew socialinstitutionsatthevillagelevel. Thegoal in any health-relatedprogramis for people(individually andcollectively) to be ableto respondto theirown healthproblemsthroughknowledge,organization,andcollectiveaction.

Empowermentis aprocessin which a personor group beginsto exertmorecontrol orInfluenceoverthe forcesthataffect their lives. At the individual level, this meansgaininginsight and developingskills to interact creatively and assertivelywith others. At thecommunity level, it meansthe acquisition of knowledge,leadershipability, andskills tomakedecisions,takecollective action,andacquireandmanageresourcesfor the benefit

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of the community. In the sphereof environmentalhealth, it meansthatthe community,families,andindividualsunderstandhowhealthanddiseaseareaffectedby environmentalfactorsandby their own behaviors(wateruse practices,sanitarypractices,and vectorcontrol measures,for example).Empowermentin the context of community healthprograms is the processwhereby the community develops the social structures,knowledge,andwill to take individual andcollectiveactionto improveor protecthealthstatus.

5. Increasedattention should be focusedon the quality of work at the districtlevel,which leadsto the developmentof viable community institutions. In thepast,theorganizationalstructureof ministriesandthegoal-settingprocessesusedin healthprogramsin Belizehaveledhealthworkersandprogrammanagersto focuson short-termgoalsandnumericaltargets.Ordershavetendedto comedownfrom abovethroughthevariousverticalprograms,andquantifiabletargets(suchasthenumberof wells drilled orthenumberof presentationsmade)havebeenemphasized.Relatively little attentionwasgiven to the types of work neededto form village health committeesand supportindividual behaviorchange.

Most districts aremanagedby a District Medical Officer, a Chief Nursing Officer, andperhapsa District Administrator and others whose orientation is toward clinical careprograms delivered in fixed facilities. These individuals may have relatively littleunderstandingor appreciationfor the types of community interventions andoutreachprogramsthatarerequiredfor a community-basedprogram.Yet thesedistrict leadersareresponsiblefor the supervisionof staffwho mustcarry out thoseprograms,aswell as forthe budgetsand transportationresourcesthat areneededfor thoseefforts.

To counteracttheseproblems,district-levelhealthteamshavebeenformed, trained,andgivenresponsibilityfor establishingor re-establishingvillagehealthcommittees.Thedistrictteamsincludepersonnelfrom acrossprogramandministry lines,andtheyareencouragedto involve nongovernmentalandotherorganizationsin theIr work. The district teamsareincreasinglygiven discretionto setgoals,coordinatework schedules,andshareresourcesin order to takean integratedapproachto the work they do with communities.

From the perspectiveof the centralprogrammanagers,thedistrict teamsnow constitutea resourcetheycanrely uponto carry out multifaceted,intersectoralprogramactivities.Theteamshavebegunto developtheir own leadership,planning, communication,andproblem-solving skills to the point that the central offices can delegateincreasedresponsibilityto the teamswith confidencethat the work will be plannedandcarriedouteffectively. Lines of communicationhavebeenopenedup betweendistrict teamsandprogram managersand with senior managementwithin the Ministries of Health andNaturalResources.

6. Mid-level program managersalsohave a central role in assuring the quality ofservice provided at the community level. Mid-level programmanagersmust beinvolved in selling, supporting,and sustainingthe useof intersectoraland interministryteamsat the disthct level for the purposeof Implementingcommunity environmental

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healthprograms.In addition,supervisionalsoImplies monitoring the quality of servicesdelivered, identifying training needs,and understandinginstitutional constraints.Theproject in Belize witnessedthe emergenceof programmanagersfrom the centralMOHandMNR officesasactiveleadersandcoordinatorsof the country’senvironmentalhealthprogram. Just asdistrict personnelformed teams,programmanagersbeganholdingregular meetings,making joint decisions,andfunctioning as a teamto manageandsuperviseactivitiesin the districts.Individual programmanagersweredesignatedasliaisonpersonsto specific districts to maintainconsistentandregular communicationbetweendistrictsandthecentraloffice.

7. Policy development can and should be included as a component of anycommunityparticipation project. “Community participation”is anephemeralprojectgoalor component.And yet, experienceddevelopmentprofessionalsrecognizethat it isan essentialelement,albeit costly, labor-intensive,andtime-consuming.Many programmanagersandpolicymakersdo not fully comprehendthe time andresourcesneededtodevelopand train village healthcommitteesand to supporttheir activities.2

To provide a forum for reflection and critique, the Belize project usedthe techniqueofinduding in the projectdesignthe taskof writing “Position Papers.”This gaveall partiesthe responsibility, at mid-point and end of project, of writing analytical paperstodocumentproject successesandto examineneedsfor structuralandpolicy changesinoperating the environmental health program. By making these papers a projectrequirement,avehicle wasprovided for periodic meetingsto review, think about, andwrite abouttheenvironmentalhealthprogram.Theseeffortsledto suggestionsforchangesin policies, budgets,andprogrampriorities.

8. “Ownership” of the project should be transferred to local institutions. In thisUSAID-sponsoredproject,there was an explicit goalof transferring“ownership” of theproject to Belizeaninstitutions. The inclusionof thisgoalcreateda discussionagendathatwasvisited andrevisitedmany timesasparticipantsstruggledwith the questionof takingover activemanagementof andresponsibilityfor the project. An importantaspectof thisprocesswastheselectionof consultantswhodo not haveahigh needfor controland whoarewilling to work hardto facilitate andtransfercontrol to local leadersandgroups.

9. Genuine community participation is not easy,fast, or inexpensive.This hasimportant implications for budgets,timeframes,andpersonnel.Too many projectsaredesignedaroundconstructionschedulesandsimply “addon” acommunity participationor healtheducationcomponentasan afterthought.More attentionis neededto the socialprocessesthat givethe communityareal voice in the design,construction,maintenance,anduse of an infrastructureproject.

2 P. Roark, J. Aubel, K 0. Hodin, aridA. Maria. Final Evaluation of the USAID/Togo Rural Water Supply and

Sanitation Project WASH Field Report, No 228.WaterandSanitationfor HealthProject,Arlington, VA 1988.

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In Belize,to setup aconsultativeprocesswith centralministry personnelandto establishthe environmentalhealthinfrastructureatthedistrict level took closeto threeyears.Over30 technicalassistanceconsultations,workshops,andpolicy dialoguemeetingsoccurredfrom 1990 to 1993.At theendof thisperiod,theprogramwasfully incorporatedinto thepolicies andprogrammaticactionsof Belize Institutions.

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Chapter 3

GUIDING ELEMENTS FOR IMPLEMENTING

AN ENVIRONMENTAL HEALTH PROGRAM

Thefollowing guidelinesfor implementinganintegrated,effective,andsustainablecommunity-basedprogramin environmentalhealtharebasedon lessonslearnedfromtechnicalassistanceInterventionsin Belize. Morespecifically,theyarecenteredon theexperiencesin the training-of-trainers (TOT) workshopsand surrounding interventions.The elementsare listed in asuggestedchronologicalorder.Thoughtheseguidelinesaredrawnfromsituationsencounteredin Bellze,theycan serveassuggestionsfor othersto considerin attemptingasimilar projector program.

As describedearlier in this paper,the consultativeprocessin 1990 setup a3-yearprogramof activities;however,actualtraining activitiestook placeoverthe last yearonly (1993). FourseparateTOTinterventionswereheld,duringwhichtwotraining/organizationaldevelopmentspecialistsspentapproximately40 dayseachwith district teamsandcentralmanagementteammembers.Fromthatexperience,the specificprocessesbelowaresuggestedfor establishingan institutional capability for acommunity-basedenvironmentalhealthprogram.

3.1 Community Participationas a Basis for Capacity Building

In Belize,the conceptof communityparticipationwascentralto developingthe Community-BasedEnvironmentalHealthProgram.Linkagesweredevelopedto bring togetheranumberof the Ministry of Health’s vertical programsandprogramswithin the Ministry of NaturalResources.

Over the pasttwo decadesof public health programs, it has becomeevident that in thedevelopinganddevelopednationsof the world, local participationis anecessarycomponentfor sustainingany public healthimprovement.For donor-assistedprograms,however, theconceptof local participationhassometimesmeantlocal compliancewith ordersandmessagesfrom the top. In water andsanitation,for example,the conceptof participationhasbeenmeasuredin two basicways: how much moneycommunitiescontributedand/or how muchlabor they provided. For many communities, participation was almost synonymouswithdigging, paying,taking full dosageof malariaprophylaxis,allowing sprayingto occur, usingoral rehydration salts, and forming committees. Such actions are easily counted as“interventions,”giving the ifiusion of benefitingacommunity’slong-termhealth;whatevertheimmediateeffect, however,thereis little hope of sustainingthe project benefitsafter donor-assistanceis concludedif theseactionsarein theform of complianceratherthanself-directedbehaviorchangesor voluntary community actions.

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In contrast,whenactivitiesfocuson individual andcollectiveresponsibilityandempowerment,thereis abetterchanceof sustainabiity.This happensonly whenthe implicationsof usage,care,and, ultimately, health benefitsare well understoodand integratedinto daily life. Toreachsuch an understanding,theremust be agood exchangeof information betweenthecommunity andthe project designersandImplementors.

The approachusedin developingthe Community-BasedEnvironmentalHealth PrograminBelize usedthe following principlesof communityparticipation:

• The community as the starting point. Great emphasis was placed onunderstanding,openingdialoguewith, andinvolving the community in the diagnosisof problemsandthe decision-makingaboutwhat to do aboutthem.

• Analysis of beliefsandbehaviors.Any attemptat health-relatedbehaviorchangemust begin with an understandingof people’s ideasabout what causesillness ordiseaseandananalysisof specificbehaviors(e.g., wateruse,personalhygiene,insectcontrol, andchild protectivepractices)usedby community membersto protecttheirhealth. Change efforts and messagesare then grounded in people’s existingperceptionsandunderstandingof diseasecausalityandon existingbehaviorsto protecthealth.

• Focuson skill developmentandtransfer. For community membersanddistrict-levelworkers,emphasiswasplacedon developingandtransferringspecific leadershipskills such as how to lead adiscussion,how to helpagroup establishpriorities, howto evokebroad participation, andhow to support emergingleaders.Theseareskillsthat help build social organizations and ensure commitment, participation, andsustainabiityof health-promotinginterventions.

• Organizational focuson district teamdevelopment.If servicedelivery is to beintegratedatthe communitylevel, district healthteamsmustbe formedto providethecollaboration,communication,and coordinationthat is required.District teamswereempoweredto determinetheir own priorities, schedules,andagendasunder generalguidelinesapprovedat the central level.

• Clear lines of communication. There must be clear avenuesof informationexchangebetweenthe programimplementorsandcommunitymembersandbetweenprogramstaffandpolicymakers.This impliesthatstaffworkingwith communitiesneedto treat community people as knowledgeable about their own conditions. Forsignificant communicationto take place,programstaff mustrecognize,accept,andoperationalizecommunitymembers’approachesto healthproblems.It alsomeansthattheir dealingswith community peoplemustmodelabehaviorof respect.Communitymembersshould feel confidentenoughto presenttheir viewsto implementorsandpolicymakers,andpolicymakers,whohavearesponsibilityto listen,shouldincorporatetheseviewsin policies thatarerelevantto the electoratethey serve.

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• Understanding the community members’ roles in health and resourceallocation and conservation. This is a prerequisite to determining whatadditional training and resourcesare needed.While this conceptmay seemsimple, in the pastpolicymakers,operationalstaff, and community membershavefailed to recognizeits importancein ensuringactionsthatmaintaingood hygieneandhealthbehaviors.While community membersaremore knowledgeablethanprojectstaffaboutthe conditionsof theirowncommunity,theymayneedtrainingin causalityandotherscientificparadigms.Forexample,their understandingof why diseaseoccursmaybe very differentfrom whatprogramstaff attribute as thecauseof disease.

• A supportivecontextfor capacitybuilding. Forsometime, participationhasbeenviewed as a way for the governmentto delegatesome of its responsibilitiestocommunitiesanddefray associatedcosts.Such participation,with little collaborationandalmostno guidance,is aformulaforfailure. Instead,policymakersshouldallocateresources with which extra-community organizations—eithergovernmental ornongovernmental—canprovide continued and supportive supervision to buildcommunity capacity.

Step1: initiating a Community-BasedEnvironmentalHealth Program (CBEHP)

Ideally, the requestfor assistancein developinga community-basedenvironmentalhealthprogram (CBEHP) would be initiated by the host-countrygovernment.However initiated,commitmentfrom the hostcountry’spolicymakersandkeyprogrammanagersin theMinistryof Health(particularly thoseresponsiblefor primaryhealthcareprograms)andotherministrypolicy andprogrampersonnelresponsibleforwaterandsanitationandvectorcontrolprogramsis essentialif the CBEHP is to be integrated,effective, and sustainable.Ideally, all of theministries, donors, and private voluntary organizationswith community-basedpersonnel,salariedor volunteer,wouldalsobeinvolved in theseopeningconsultations,agreements,andcommitments.

In this initial CBEI-IP consultation,thereshould be apresentationof the program’svalues,goals,and objectives;organizationaland managementstructuresthat are appropriate orrequired; resourcesthat are availableto implement the program; andthe implementationguidelines.After adiscussion,amendmentsmaybe proposed,andformal agreementsshouldbe made. Careful planning, sufficient time, and skilled facilitation are important in thisintroductoryconsultation.

Step2: institutional Assessment

After commitmentshavebeenmadeandagreementshavebeenreachedin Step1, ameetingof the key program managerswould be scheduled.At this meeting, the key institutionalconstraintsarereviewed.Someissueswhich are likely to arisearethe following:

• The currentverticalstructureof programs

• Lack of dataon which to baseactivities

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• Lackof community support (or variationsin support)

• Poor managementat the local level

• Inappropriatepolicy framework

• Lack of trainedstaff

In addition, the meetingshould coverthe following items:

• A reviewof agreementsandthe program’skey elements

• Identification of the organizationalstructureand staffing of the governmentlevelresponsiblefor interactingwith communities(often the district level)

• Discussion and agreementson the central-levelstaff roles and responsibilitiesasmanagersof the CBEHP.

Step3: GovernmentPolicy and Program Managers’Meeting

At thismeeting,basedon the findings from Step2 assessments,thedonorstaff, thetechnicalassistanceteam,andCBEHPmanagersmeetwith governmentpolicymakersandkeyministrypersonnel.At thismeetingthe proposedlist of activitiesandscheduleto addressthe findingsof theassessmentarepresented.Therationalefor thetechnicalinterventionsandareportthatdescribestheproject’simplementationandmethodologicalapproacharediscussedandagreedon. Based on agreementsreachedwith the governmentpolicymakers and key ministrypersonneland further discussionat this meeting,the TOT workshop participantsand theprojectimplementationactivitiescanbe identified.The scopeof work canbe developed,andagreementssigned.

Step4: Project Start-Up Workshop

This interventionis aimedatall partiesin the project/programandis designedto helpthemreachacommonunderstandingof the background,scopeof work, andpurposeof theproject.Other objectivesareto define roles andresponsibilitiesandto place emphasison improvedworking relationshipsand clearcommitmentsamongall participants.Additional outcomeswould be written agreementson major Issues,including the project/programandwork plansfor the first 6 to 12 monthsof implementation.

Start-up workshop participantswould include key staff of the government implementingagenciesconcernedwith any aspectsof public health,the technicalassistanceteam,andthedonor agency (or agencies)project officer(s). Attendanceby high-levelministry officials, theUSAIDmissiondirector,andotherpolitical representativesis likely to increasethecoordinationandsupportfor future implementation.

This workshop should bemanagedby at leastone impartial, skilled facilitator. Prior to theworkshop, he or shewill gatherrelevantInformation andanalyzeit with aworkshop steering

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committeecomprisedof the partiesmostIntimately involved in orderto achieveconsensusinthe following key areas:

• Developmentof the workshop’sbasicdesign

• Methodsfor managingandmonitoring the workshopprocess

• Design and implementationof workshopfollow-up activities.

Followingtheworkshop,a comprehensivereport shouldbeprepareddescribingtheworkshop process, issuesdiscussed,and agreementsreached.This report should bedistributedto all the participantsandotherinterestedparties.

The project start-up workshop generally requires a minimum of four days to meet theimportantgoalsof this stepandshould be held in aresidentialsetting,awayfrom officesandinterruptions.Adequatemeetingspacefor the plenary sessionsand break-outrooms forgroups of up to ten persons,dependingon the numberof participants, should also beavailable.A moredetailedoverviewof thestart-upworkshop is containedin Facilitator Guidefor Conductinga Project Start-Up Workshop.3

Step’5: Training NeedsAssessment

Identifyingthe ministrystaffwhointeractwith communitiesandthereforewill havethe primaryresponsibilityfor implementinganycommunity-basedenvironmentalhealthprogramisthefirst

stepthatguidesthe training assessment(seeStep3). The nextkey elementIn this seriesofsteps would be acareful training needsassessmentof all implementing staff identified andselectedfor the TOT workshops. Teachingbasic adult learning principles and buildingfacilitationskills requiredfor immediatefield useby theseimplementorsautomaticallybecomesan essentialelementof the initial training design. Other elementsare addedbasedon theneedsidentified in the assessment.

Additional purposesfor this needsassessmentinclude: gathering information about thecountry’snewcommunity-basedenvironmentalhealthprogramdirections;formingagreementsby top policymakersandprogramstaff;devisingplansfor TOT Interventionsandparticipationin its contentandprocess;andproviding anopportunity forthe facilitators andparticipantstomeetoneanotherpersonallybeforethe plannedworkshop interventions.

Step6: InItial TOTintervention

This training for 20 to 30 personsfrom district staffswould be for no morethanfive days.Inmanywaysthisinitial TOT repeatselementsof the projectstart-upworkshop,especiallyif theparticipantsare from more than one governmentministry or from two or more differentdepartmentsin thesameministry.With suchinterministerialandintraministerialrepresentation,it is likely that participants will have receivedno official notice of the project/program’s

WASH TechnicalReportNo 41, 1988. This documentis availablefrom the WASH Project.

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purposeandof the agreementsof key policy and programstaff. (Thus, it is important toreview with participantsthe designfor the workshop, information gatheredin the needsassessmentphase,andcommonagreementson goalsor outcomesof the workshop.)Also itis likely that many of the participants will not havemet before and that the mandateforfunctioning asan integrateddistrict teamwifi be anew direction for staff usedto workingunderdirectivesfrom nationallevels.Implementingacommunity-basedenvironmentalhealthprogram will change the expectationsof how staff function, individually and as a team.Therefore,it is essentialthat the participantsall understandthe new informationaboutandapproachto their work and begin the processof making a personalcommitment to acommunity-basedperspective.

As much aspossible,this Initial TOT should be experientialeducationbasedon practical,work-relatedtasksin community developmentandempowerment.Facilitatorsshould modelthe behaviortheparticipantswill usein meetingsandtraining conductedin the communities.(In Belize, the two TOT facilitators modeledthe steps in community developmentandcapacity-buildingateverystagein thetraining-of-trainersprocess.Thisexampleof participatoryleadershipandskill-building madeapowerful impacton the workshopparticipants.)

Basicknowledge,attitudes,andskills should be taught in the following contentareas:

• Experientialeducation,needsassessment,andverbalandnonverbalcommunicationskills

• Using open-endedandprobing questionsto get variouskinds of information

• Techniquesfor planning,facilitating, andleadinggroup discussions

• Problem-solvingandactionplanningmodelsfor community use

• ConflIct resolution

As with thestart-upworkshop,the training site should be residential,awayfrom daily work-relatedactivities.It should haveacomfortablemeetingspacefor 20 to 30 persons.Severalbreak-outareasfor smallgroups(six or sevenpersons)areessentialin theseTOTssincemuchof the activity wifi take place in small groups organized by district teamsor appropriategovernmentalunits in the hostcountry. Thesegroupingsbegintheprocessof team-building,which will be new to the participantsbut essentialto their effectivenessin the CBEHPactivities.

Key elementsin eachTOT activity arework planningand“homework” assignmentsfor bothparticipantsand facilitators following the workshop. There should be dearagreementsforfollow-up monitoring and evaluation and needsassessmentat subsequentworkshopsormeetingswith the consultants.Onevery positivelearningfrom the Belize TOT interventionswasthenecessityof includingdevelopmentalactivitiesatboththedistrictandcommunity levelsin thesehomeworkassignments.

Another key elementis an agreementbetweenparticipantsandfacilitators concerningtheirrespectiveroles and responsibilities in developinga collaborativeand functional training

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manual. In Belize this documentwas titled CommunityDevelopmentand EmpowermentManual andwas designedfor use in the CBEHP. Progressivedrafts of this manual werediscussedin each successiveworkshop, and changeswere agreed upon and tested inhomeworkassignments.

If the appropriatemanagementstructureexists,key CBEHPdistrict teamsupervisorswouldbe informed of the follow-up monitoring and work planning agreementsand invited toparticipatein them.Suchinclusionpromotetheirsupportrole andreinforcescommunicationchannelsbetweendistrict andnationalprogramstaff.

If an integratedCBEHPmanagementgrouphasnot yetbeenappointedanddeveloped,thiswould beanecessarynextdevelopmentalinterventionon the partof donor andgovernmentalprojectpersonnel.Themanagementgroupplaysan essentialcoordinatingrole amongdistrictteamsandsenior-levelstaff andgovernmentpolicymakers.

Step7: MonitorIng Visit, IdentificationofSkillAreas,andDevelopmentofTrainingNeedsAssessment

The secondTOT activity involvesvisiting all district staff teams,with key CBEHPsupervisorspresentif possible,to monitorthe activitiesandidentify the constraintsto implementation.Acarefully planned“shadow-consultancy”is carriedout, in which the facilitatorsandmanagersserveas observersandprocessconsultantsto assistthe teamswith their work plans at thedistrict or communitylevels. This interventionstrategyprovidesavery valuableopportunityfor collaborative,developmentalevaluation,training needsassessment,andactivesupportofthe CBEHPteams’effortsat building district- andcommunity-levelcapacities.Findingsfromthis activity, in turn, providethe goalsandobjectivesforthe nextTOT workshop.Its markedadvantageis thatactualskills needed,ratherthanthosethoughtto be needed,aredevelopedin the courseof the workshop.

Step8: Mid-Project Review, Analysis, and Action Planning (In-Country and in theDonor’s Project/ProgramOffice)

The first part of the mid-programreview would include all of the CBEHPdistrict teamstaff,the key programmanagementstaff, project officers of the donor agency,andthe technicalassistanceconsultants.This review andassessmentwould be participatory,with the districtteams having the key role in describing activities, accomplishments,and constraintsinimplementation.Thecentralprogrammanagementteam(atthe ministry level) would providethe sameInformation from anationalperspective.All would thenengagein acollaborativeproblem-solvingandaction-planningexercise.This activity would identify both programmaticchangesandpolicy needsto be presentedto seniorministrypersonnelfor action. Thedonoragencystaff andTOT facilitatorswould serveprimarily asprocessmanagersandconsultantsforthisactivity, with the additionalresponsibilityof communicatinganyessentialchangein theproject agreementsto the donor agency.

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Thefindingsof thismid-projectreviewwill becomethecontentsof areportto the host-countrygovernmentpolicymakersandaposition paper,developedtowardthe endof the project bythe CBEI-IPcentralmanagementteamwith the assistanceof donoragencyprojectofficers. Attheendof the projectperiod, it is importantthatthe projectbecomesthe hostcountry’s ownprogramandthatthis be reflectedin the position paperandIn operationsof the responsibleCBEHP govemmentagenciesandstaff.

A secondprogram planning and review meeting—in the donor’s offices with the centralmanagementteam,donoragencyprojectofficers, andTA consultants—wouldbe avaluableintervention.Away from theconstantinterruptions of day-to-daydutiesandresponsibilities,the central managementteam would be able to focus on Its own integrationand teamdevelopment.

Up until this point, the centralmanagementteammembershaveparticipatedasco-trainersand have been active participants in providing supervision and monitoring for theinstitutionalizationof CBEHPin districtoffices andcommunities.Now the time hascomeforthe central managementteamto recognize that continued support of this effort is theirresponsibility(without TA consultantsanddonorsprojectstaff). At this meeting,the centralmanagementteammembersshouldexaminetheirown performanceasateam,analyzinghowthey work as a teamand what their strengthsand weaknessesare. By this point, they willhaveacquiredexperiencein analyzingthe variousroles andresponsibilitiesof implementingCBEHP. It is helpful at this point to develop an organizationchart outlining roles andresponsibilitiesof actorsinvolved:

• Centralmanagementteam

• Policymakers

• District-level staff

• Communities

In addition,thischartwill outlinethe linesof authority,that is, whatreportingmechanismsareprovidedfor districtsto shareinformation with the centralmanagementteam,how meetingsarecalledwith policymakersto reportprogressandconstraints,what reportingandmonitoringsystemsdistrictenvironmentalhealthcommitteeswill needto respondto, andhow communitycommitteeswill be supportedandtrained.

Step9: SecondTOTIntervention

Thissecondfive-dayTOT workshopwould beheldfor 20 to 30 district-teamparticipants.Theworkshop content is basedon the need to review and practiceskills learnedin the firstworkshop (Step 6), to review the datagatheredfrom the monitoringand assessmentvisits(Step7),andto determinethe practicalstepsin selecting,organizing,andtrainingcommunity-basedgroupsandprogramstaff. Participantswould spendsometime at the workshop ondevelopingthe trainingmanualfor CBEHPimplementors.Homeworkassignmentsfrom thisworkshopwould alsoinclude district- andcommunity-levelcapacity-buildingexercises.

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Step10: MonItoring Visit; On BecomingTrainers andDoing NeedsAssessment

Thepatternof this interventionfollows thatof thepreviousmonitoringvisitby facilitators (Step7). This time, however,the district team’s community-levelinterventionsarethe emphasis.Hands-ontrainingfocuseson providing feedbackto thedistrict-levelstaff on the skills requiredto facilitate communitydevelopmentandempowerment.If thereisto be no additional TOTworkshop, aswas the casein the Belize program,it is importantto incorporateinformationgatheredin this visit into the training manual,programmaticandpolicy planningdocuments,andthe final position paper.

Step11: PresentatIonof Position Paper; Policy andProgram Planningfor Sustainability

Thissteprepresentsthe critical interphasebetweenthe Initiation of the CBEHPand its long-term sustainabiity:whatneedsto happenhereis to lay the groundworkfor thefuture. Thisinterventionconsistsof ameetingwith host-countrygovernmentpolicymakersto presentanassessmentof the program to date and recommendationsfor programmaticand policyrequirementsto transferresponsibilityfor implementationfrom the donor agencyandTAconsultantsto the host-country government. The position paper sets the guidelines forsustainingandimproving the programbasedon the experienceandrecommendationsof thedistrict teamsandcentral-levelprogrammanagers,with assistancefrom the donor agency’sproject officers.

Participantsin thismeetingwould includehost-countrypolicymakersandseniorstafffrom theministry or ministries involved, the central-levelmanagementteam,selectedstaff from thedistrict teams,project officers andseniorstaff from the donor agency,otherdonor agenciesandPVOsfocusedon healthin the hostcountry, andany otherinterestedparties.

This meetingandpresentationwould be designedandmanagedby selectedstaff from thedistrictteamsandcentral-levelmanagementteam,with anyassistancerequestedby thatgroupfrom the donor agencyproject staff.

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Chapter 4

BUILDING A BEHAVIOR-BASED ENVIRONMENTAL HEALTH

INFORMATION SYSTEM

The normfor Informationsystemsin public healthis to trackmorbidity andmortality data. InBelize,bothUNICEFandthePanAmericanHealth Organizationhaveprovidedassistanceinplanninganationalhealthinformationsystemthat wifi monitorhealthandmedicalconditionsas well as the operationanduseof healthservices.The type of information this systemwifisupply is clearly essentialfor assessingchangesin the healthstatusof the population andaccessto health services.However, the CBEHP calls for an information systemthat wifisupportthe program’sbroad-based,community-managedintegratedapproachto the controlandpreventionof vector- andwater-bornediseases.This approachrecognizesthe complexinteractionof factorsthatimpactdiseasepreventionandcontrol, specifically:the watersupplyinfrastructure, water quality, humanbehaviors,and measurestaken at the local level tomanageandcontrol malariaanddengue.

The necessityof monitoringinfrastructureandwaterquality datais generallyaccepted;whatis less frequently recognizedis the needto track behavioraldata relatedto environmentalhealth.Specific high-riskbehaviorsmustbe identified, understood,andmonitoredin order toformulateeffectivehealthandhygieneeducationinterventions.Yet,no matterhow well theseinterventionsaredesignedandcarriedout, their impactwill be limited If the Infrastructureisnot functioning or if the watersupply is contaminated.Conversely,evenif the watersupplysystemis functioning perfectly, improvementin healthstatuswill not occurif the waterIs notbeing usedor is beingusedimproperly.

The informationsystemdesignedfor the CBEHP reflectsthe interdependentnatureof thesefactors. Becauseone of the indicators is behavior-based,(1) it can be monitored bycommunity-levelenvironmentalhealthvolunteers-and (2) remedialactioncanbe focusedonspecific households.Community-basedmonitoring allows for identification of householdswheresanitationfacilities arenot beingutilized or householdswheresprayfor preventionofmosquito-breedingis washedoff. With thisInformation,district-levelenvironmentalhealthstaffcanfocusspecificallyon the whereandthe why in orderto designremedialapproaches.Thebehavior-baseddata is then linked to Ministry of Health mortality and morbidity dataondiarrhea,vector-bornediseasesandintestinalparasites,andMinistry of NaturalResourcesdataon infrastructuremaintenance.In Belize, datacollectedby the MOH provide informationonthefirst threepointsbelow.Informationis gatheredthroughsurveysforthefourth point. Thesefour areascombinedform the databasefor the health informationsystem.

• Watersupplyoperationsandmaintenance:operationsandmaintenancedataareused to assemblea picture of how watersystemsandinstallationsare functioning,providinginformation on communities’ accessto andsupply of water.

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• Water quality: data on the frequencyof watersamplecollection andthe resultsoftesting providethe informationnecessaryto assessthe safetyof the water supply.

• Epldemiologicaldatagatheredin Ministry of Healthmonitoringsystemsformalaria,dengue,anddiarrhealandotherintestinaldiseases

• Behaviors related to hygieneandvector control: thesedataareusedto planhealth and hygiene educationInterventions and to measurethe impact of thoseinterventionson behaviors.

The datacollection andanalysisproceduresdevelopedfor eachof thesecomponentsaredifferent.While subsetsof thedatamaybe storedandprocessedat onephysicallocation, forexample,on acomputeratadistrict-leveloffice, the data for eachcomponentdo not needto be integratedinto the samefile or processedby the samesoftwareprogram. In designingthe CBEHP system,the conceptof integrationwasapplied to useof the data.

The informationprovidedby eachof thesystem’sdistinctcomponentswifi be examinedasanensemblein order to assessvector-andwater-bornediseasecontrol andpreventionactivities.Measuringtheeffectof thoseactivitieson healthconditionswill requiredatafrom the nationalhealthinformationsystem.It is in the areaof healthimpactindicatorsthatthe nationalhealthInformationsystemandtheCBEHP informationsystemintersect.Theseindicators arebeingdevelopedthroughacollaborativeeffort betweenthetwo systems’usersandmanagers—MOHandMNR.

In additionto reflectingthe interdependentfactorsthataffectvector-andwater-bornediseases,anotherdistinguishingfeatureof the CBEHPinformationsystemis thatits designis basedonthe following premise:anyonewhohasastakein changingthe basicsituationthatthe systemis monitoring canand should be involved in collecting data,analyzingit to determinewhatinformation it reveals,andusing that information to makedecisionsandtake actions.Thelong-termgoalof the CBEHPsystemis to befunctionalatthe central,district,andcommunitylevels. Implementingthe behavioralcomponentof the systemat the community level is apriority. The plan for this componentanticipatesthat village health committees,with theassIstanceof districthealthworkers,will be ableto collect, process,anduseat leasta minimalamountof behavioraldata relevantto their specific needs.

Clearly, the full developmentof all of the componentsof the CBEHPinformationsystem,atthe central, district, and community levels, is a long-term process.However, with theconceptual design of the system completed and the initial steps taken toward itsimplementation,the following lessonscanbe put forth:

• The processof designingthe informationsystemhasbeenan integrativefunction forthe CBEHP. TheCBEHP managementteam’s understandingof the interdependentfactorsthat impact diseasecontrol and preventionwas enhancedby the processofidentifyingthe intersectinginformationneedsof the Ministry of Healthandthe Ministryof NaturalResourcesanddefiningthe indicatorsfor eachcomponentof the system.

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• Theinformationsystemhasadistinctrole in helping tosustainthe CBEHP.All aspectsof systemdesignandplanningweredirectedtowardsupportingtheCBEHPapproachof decentralizedproblem-solving.This approachinfluenced the choiceof computerequipment:aportable,ratherthanastandardoffice-type, computerwaspurchased,and a plan was developedto assurea wide range of systemusersaccessto thecomputer.

• During the designprocess,the focus waskepton the overall purposeof the systemby consistentlyemphasizingdataflows, bothverticalandhorizontal,andthe reportinganddisseminationof information derivedfrom the system.

• Both the current andfuture developmentof the information systemdraws on thetraining andinstitutional capacitybuilding activities carriedout through otheraspectsof the CBEHP.

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Chapter 5

CONCLUSIONS

Evenastermssuchas“ownership,” “participation,” and“empowerment”arebrought into thelexicon of internationaldevelopment,thereseemsto be a greatdeal of unclarity or evennaivetéaboutwhatis involved in establishingandinstitutionalizingtheseconcepts.Ownership,participation, andempowermentaremorethanstrategiesto cut costsby delegatingpublic-sectorresponsibilitiesto communities.In fact, superficial “community participation”is almostsureto be disappointingIn the long run andmayevencastashadowon realeffortsto makeacommunity-basedapproachwork in asustainablemanner.

In communitiesthat suffer from a diseaseburden brought on by poverty and poorenvironmentalhealthconditions,meetingbasicneedsconsumesamajority of availabletimeandenergy.Giving thesecommunitiesmoreresponsibilitieswith very little supportwill neitherfacilitate norsustaindiseaseprevention.Communitiesneedexternalsupportandnurturinginorder to learngood public healthpracticesand to incorporatethosepracticesinto everydaylife .‘~

Institutions thatwifi supportandnurturecommunitiesneedto be created.Theseinstitutionswill be differentfrom thosealreadyin place andarelikely to consistof programandministrystaff who haveneverworkedtogetheranddo not know eachother. Managersandstafffromthe country in which the programis implementedwill have to make decisionsabout thecompositionof theseinstitutions.

Within thesenew institutions, staffmembersassignedto work directly with communitieswifineedtraining. Manywill haveneverworkedin teams;manymorewill haveneverexperiencedempowerment.Thesestaff memberswill be usedto taking orders, being lecturedto, andreceivingnegativereinforcement,andit will be importantto preventthemfrom usingsimilartechniquesin their work with communities.

Identifyingthe skills requiredto changesuchbehaviorandtraining staffwill requiremorethanone workshop. In Belize, training was conductedIn a series of short workshops,reviewmeetings,andoperationalassignmentsdesignedto reinforceskills. This multistageapproachfacilitated institutionalizationof thesenewly acquiredskills.

Communityparticipationandmanagementcannotexistwithoutthe supportof policymakers.Recognitionand support of community-basedinstitutions translatesinto policy support,expressedthrough allocation of funds andstaff resourcesfor technicalandprocesstraining.Thesuccessof thebroad,community-basedapproachtakenin Belize demonstratesthatdonor

~ See Rethinking Sanitntion: Adding Behavioral Change to the Project Mix. WASH Technical Report No. 72.1992.

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agenciescannot afford to focus all resourceson a single diseaseor a single governmentprogram.As internationaldevelopmentresourcesdiminish andthe numberandcomplexityof public healthproblemsmount, the merit of addressingonediseaseata time needsto bere-evaluated.

The most difficult aspectof the effort in Belize was integratingcurative interventionsinto abroad-basedpublic health approach.Accommodatingthe malariacontrol program’s case-managementapproachwas the most challengingof the team’s tasks.Incorporatingotherprogramor ministry staff who viewed the programfrom acurativeratherthan apreventiveperspectivewas alsodifficult for the district-levelenvironmentalhealthsubcommittees.

Historically (andin Belize), the MOH approachto curative,verticalhealthprogramsis amajorstumbling block to community-basedenvironmentalhealth approaches.Efforts such asinstallation of watersystemsand watertesting emphasizethe preventiveside, but withoutaccompanyingchangesIn hygienebehaviorscanbe very disappointing.A multidisciplinaryapproachattemptsto bridgethe gapsbetweencurativeandpreventiveefforts, andbetweenbiomedicalandethnomedicalapproaches.

Theultimate responsibilityof programslike theCBEHP in Belize is to emphasizevaluesandestablishsystemsthatpromotecooperationacrossvertical, disease-specifichealthprogramsandto empowerpeopletotakeactionsto improvetheir surroundings.In developing-countrycontexts,wheredataarescarceand unreliableandwhere theagent,host, andenvironmentareconstantlyshifting, community participationis the mosteffectivepublic healthstrategytocombatdisease.

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AppendixA

MATERIALS DEVELOPED IN THE CBEHP

BelizeNationalDrinking WaterQuality Monitoring Program. Preparedby Ministry of HealthandMinistry of NaturalResourcesand Becky Myton. September1993.

Community-BasedEnvironmentalHealth:HygieneBehaviorandCommunicationsJobGuide.Preparedby David PattersonandEdward Douglass.August 1993.

Community Developmentand EmpowermentManual. Preparedby Ministries of NaturalResourcesand Health with Bob Hollister andAl Rollins. September1993.

Disinfection/ChlorinationWorkshopJobGuideIncreasedProductivitythroughBetterHealth(IPTBH) Project. Preparedby BarnesR. Bierck. January1994.

Guidelinesfor Building an EnvironmentalHealth Information Systemin Belize.PreparedbyGail Kostlnko. September1993.

OperationsandMaintenanceManual.Preparedby Ministries of NaturalResourcesandHealthwith Alan Wyatt andJonathanHodgkin. September1993.

Position Paper. Preparedby Ministry of Health andMinistry of NaturalResources.August1993.

SurfaceWaterSourcesand Wells Job Guide. Preparedby JamesF. Ruff. August 1993.

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Appendix B

BUILDING TRAINING SKILLS TO DEVELOPINSTITUTIONAL CAPABILITY

Learning from the Training of Trainers Component of the CBEHP

It is necessaryto take an incremental,skill-building, and applied approachto developingsp~cificskills that healthworkersneedin order to work successfullyin villages.Someof the

specific skills taughtin the Belize TOT included:

• Making introductions

• Using open-ended,closed-ended,checking,and otherquestions

• Techniquesto achieveearly, balancedparticipation

• Using aflip chart/preparingvisual aids

• Formulatingsimple, doabletasksfor group assignments

• How to startand leadagroup discussion

• Participatorywaysto plan an agenda

• Interviewing skills/focus group skills

• How to do ahomevisit

• Conductingan initial meetingwith avillage council

• Conductingan initial meetingwith a village healthcommittee

• Conductingan initial meetingwith acommunity group

• Giving a short, informative “lecturette.”

• Designingand implementinga skill-building session

• Giving andreceivingfeedbackandothercommunicationskills

Greatemphasiswasplacedon 1) defining the skill, 2) demonstratingthe skill, 3) learningthecomponentpartsof the skill, 4) practicingor applyingthe skill in asafe,workshopsetting, 5)providing supportive feedbackto improve performance,6) providing more practice andfeedback,7) applying andusingthe skill in acommunity settingvia homeworkassignments,and8) carefully analyzingsuccessesandfailuresforthepurposeof improvingperformancethenexttime. Theconsultants’frequentfeedbackforcedall trainingparticipantsto rethink,replan,

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andredothe sessions,which led to avisible andsatisfyingsenseof progress,improvement,andconfidence.

The conceptof the experientiallearningmodelbecameacentralthemeof the learningin theTOT. This evolved into a norm wherebyparticipantslearnedto practice, give correctivefeedback,andpracticeagainIn preparationforfield work assignments.Theideaof deliberatelyexaminingandlearning from experiencebecamealmost habitual,asparticipantslearnedtotake an experimentalapproachto their work and to help each other with suggestions,critiques,andIdeasin asupportiveandhelpful way. Participantscameto look forwardtotheirfield assignmentsbecausetheyhadplannedandpracticedwhattheywould do,andtheyknewthey would get help from their teammatesif any problemsdeveloped.They becamemuchmoreawareof the importanceof devotingtimeto examiningtheprocessof working together.

As notedabove,animportantlearningwasthe needto work on two levels: thedevelopmentand functioning of the district teamandthe work to be done in villages. By creatingasupportiveandskilled team,the enthusiasmand“role modeling” spilled over into the workthatwasdone in the villages.It should alsobe notedthat the district workerswerehungry towork asateamandincreasinglyfrustratedby institutional constraints(lack of time, transport,and per diem) that limited their ability to do morefieldwork as a team. They seemedtounderstandintuitively thathealthwork atthe vifiage level needsto be integrated,thatateamapproachwifi be moresuccessful,andthatthe involvementof villagersin respondingto healthconcernsis practicalandneeded.

This was the first time that personnelfrom the samedistricts were encouragedto work asteamsandthat teamsfrom all six districts were ableto spendextendedtime together.Animportantcontributingfactor to programsuccesswasthe ability of teamsto learnfrom andaboutwhat washappeningIn otherdistricts. This sharingof knowledgeandinformation ledto a senseof empowermentin that the teamswere able to give common voice to theirfrustrationsandneeds.Theycameto understandthat theypossessatypeof experienceandinsightinto problemsandopportunitiesthat theirbossesdo not haveandthatareimportantto communicate.

The workshopsand meetingsprovided opportunitiesto open up communicationsand forsystem-wide problem solving. Because the workshop was skills- and value-oriented,participantswereableto expressgrievances,formulateplans,andcommunicatewith programmanagersin waysthatopenedup linesof communicationandledto moreeffectiveproblemsolving. Theability tofight, disagree,andbeopenwith eachotherdemonstratedadevelopinglevel of trust andcommitmentthat hadbeenlacking previously. In addition,participantswereinvolved in planningandpreparingfor meetings,with the PermanentSecretariesandothersenior-levelmanagers,forthepurposeof makingrecommendationsforprogramchange.Theygainedskills in reachingpolicymakersandmakingpresentationsto them.Again, thisprovidedopportunitiesfor contact,communication,and influenceon importantissues.

Theparticipantsreportedthattheproject’sability to usethesametwo consultantsto makefourtrips, which coveredall six districts over aone-yearperiod, madeadifferenceto their ownmotivationandcommitment.Overtimetheparticipantsbeganto takethework andhomework

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more andmore seriously,anda level of trust, experiencetogether,andunderstandingwasdevelopedthat wasuseful for all concerned. -

In Belize, numerousfield guidesandmanualswere discoveredthathadbeendevelopedbyvarious projectsover the years,but virtually none of them were in use, anddistrict-levelpersonnelwerenot awareof theirexistence.In thisproject,participantswereactivelyinvolvedin the review, critique,andactualwriting of a“Community DevelopmentandEmpowermentManual.”

At everyworkshop,draftchaptersof the manualwerehandedout forreview,andparticipantswere given responsibilityfor using the draft materialsin their homeworkassignments.As aresult, the participantsareintimately familiarwith the content,haveactivelyusedthe manual,andreportedthat it is ausefultool to supporttheir work. The lessonlearnedhereis an oldone: if peopleareinvolved in the developmentof atool andhavelearnedhow to useit in apracticalsetting, they aremorelikely to useit in daily life.

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I

7

The Environmental Health Project (EHP) provides technical assistance to

USAID missions and bureaus and other development organizations innine areas: tropical diseases, water and sanitation, wastewatei; solidwaste, air pollution, hazardous waste, food hygiene, occLipauon~1lhealth,and injury. It is part of the Office of- Health and Nutrition~response torequests from USAID missions and bureaus for an integrated approachto addressing environment-related health problems. In addition to EHPthis effort includes an Environmental Health Requirements Contract anda PASA (Participating Agency Support Agreement) with the U.S. Centersfor Disease Control and Prevention. A wide range of expertise is madeavailable by EHP through a consortium of specialized organizations (seelist below). In addition to reports on its techrical assistance, EHP pub-lishes guidelines, concept pafers, lessons learned dlocuirjenls, and cap-sule reports on topics of vital interest to the environmental health sector.For information on the reports available, contact El-IP headquarters.

ENVIRONMENTAL HEALTH PROJECT