WHO/EOS/96.

11
ORIGINAL: ENGLISH

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Participatory
Hygiene and
Sanitation
Transformation
A new approach to
working with communities

World Health Organization

Geneva

UNDP-World Bank Water

and Sanitation Program
 Prepared by Mayling Simpson-Hebert, Ron Sawyer and Lucy Clarke
as an information document to the water supply and sanitation sector.
Front cover illustration by Victoria Francis
Photography by Mayling Simpson-Hebert
The PHAST initiative is a joint project of WHO and the
UNDP/World Bank Water and Sanitation Program.

Collaborating institutions
Botswana: Ministry of Health, Ministry of Local Government, Lands and Housing
Kenya: Ministry of Health, CARE-Kenya, Kenya Water and Health Organization (KWAHO)
Uganda: Ministry of Health, Ministry of Natural Resources, Energy and Minerals, Rural Water and
Sanitation Programme (RUWASA), Katwe Urban Pilot Project (KUPP),WaterAid
Zimbabwe: Ministry of Health, Department of Environmental Health, Rural District Council (RDC),
Agricultural Technical and Extension Services (Agritex), Ministry of National Affairs,
Employment Creation and Cooperatives (MNAECC), Africare, PLAN International,
Mvuramanzi Trust Zimbabwe, Lutheran World Federation
UNICEF country offices in Botswana, Kenya, Uganda and Zimbabwe
Network for Water and Sanitation (NETWAS)
Institute of Water and Sanitation Development (IWSD)
Swedish International Development Agency (Sida)
Danish International Development Agency (DANIDA)

Reprinted 2000

0 World Health Organization, 1997

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Contents
List of acronyms iv

Introduction V

Acknowledgements vi

1. What is PHAST?
Health awareness and understanding - a basic premise
Health-related community development principles of PHAST
New principles on hygiene and sanitation promotion
SARAR - the underlying methodology
Key factors needed for effective participation

2. How PHAST began 7

Working principles of the partnership 1
The selection of countries 8
Two creative workshops 9
Field testing 12
Monitoring and evaluation 13

3. The impact on communities 15

Examples of impact 15
Common achievements of the pilot phase 16
The impact on extension workers 17

4. The lessons learned 18

On behaviour change 18
On the requirements for success 18
On how to start 19
On how to sustain 19
On how to expand 20

5. The future and the potential of PHAST 21

Annexes
A. Synopses of experiences in pilot countries 23
B. List of collaborating institutions 30
C. List of persons involved in PHAST 31
D. Participatory approaches to water and sanitation change:
the roles of PROWWESS and SARAR. 36

...
III
List of acronyms
Agritex Agricultural Technical and Extension Services
CARE Cooperative for Assistance and Relief Everywhere, Inc.
DANIDA Danish International Development Agency
ITN International Training Network for Water and Waste Man-
agement (Zimbabwe)
IWSD Institute of Water and Sanitation Development (Zimbabwe)
KUPP Katwe Urban Pilot Project (Uganda)
KWAHO Kenya Water and Health Organization
MNAECC Ministry of National Affairs, Employment Creation and
Cooperatives (Zimbabwe)
NETWAS Network for Water and Sanitation (Kenya)
NGO Nongovernmental Organization
PALNET Participatory Learning Network (Africa)
PHAST Participatory Hygiene and Sanitation Transformation
PROWWESS Promotion of the Role of Women in Water and Environ-
mental Sanitation Services
RDC Rural District Council
REH Rural Environmental Health Unit/WHO
RWSG-EA United Nations Development Programme/World Bank
Regional Water and Sanitation Group - East Africa
RUWASA Rural Water and Sanitation Project of the Government of
Uganda
SARAR Self-esteem, Associative strengths, Resourcefulness,
Action-planning and Responsibility
Sida Swedish International Development Cooperation Agency
UNDP/DGIP United Nations Development Programme/Division for
Global and Interregional Programmes
UNICEF United Nations Childrens Fund
WHO World Health Organization
Introduction
PHAST stands for Participatory Hygiene and Sanitation Transformation. It
is an innovative approach designed to promote hygiene behaviours, sani-
tation improvements and community management of water and sanita-
tion facilities using specifically developed participatory techniques.
This document describes the underlying principles of the approach, the
development of the specific participatory tools, and the results of the field
tests done in four African countries.
PHAST is unique because the underlying basis for the approach is that no
lasting change in peoples behaviour will occur without understanding
and believing. To summarize the approach, specific participatory activi-
ties were developed for community groups to discover for themselves the
faecal-oral contamination routes of disease. They then analyze their own
hygiene behaviours in the light of this information and plan how to block
the contamination routes.
The approach was field tested in four African countries: Botswana, Kenya,
Uganda and Zimbabwe in both rural and urban areas. The results were
very encouraging. The approach involved community groups in a way
never before possible. Groups planned ways to improve hygiene behav-
iours in the community, to build or improve facilities and they made plans
for operation and maintenance of facilities. The PHAST initiative laid the
ground work for communities to take their own development forward.
Even though the approach was tried in different countries and different
types of communities, the results were equally inspiring. The approach
can be replicated successfully provided a number of supporting condi-
tions exist.
This report documents:
n the principles which underlie the approach;
n how the methodology was developed at workshops in the African re-
gion;
n the impact that PHAST made on communities and extension workers
that were part of the field test;
n the lessons learned during the field test;
n how the approach can be adopted more widely and what the enabling
factors for this are.
PI-MST generated a ground swell of motivation and enthusiasm which
we would like to share with others. This document is a start in that direc-
tion. It will be followed by a guide for extension workers on how to im-
plement the approach at community level, a sample tool kit of graphic
materials which accompany the approach and a managers guide.

V
Acknowledgements
The PHAST initiative owes its success to all the people who have faith in
the capacity of all human beings to be creative and to be leaders of change,
if approached in the correct manner. This includes not only the master
trainers and extension staff who promoted the methodology, but also the
institutions that supported the effort without necessarily knowing very
precisely the methodology.
Thus, thanks go to the UNDP/World Bank Water and Sanitation Program
who was a joint partner with WHO in this initiative.
The initiative, however, would not have been possible without the sup-
port and participation of the Ministries of Health in the four pilot coun-
tries: Botswana, Kenya, Uganda and Zimbabwe, to whom we- are most ~
grateful. In order not to overlook another important contribution, men-
tion needs-to be made of the Environmental Health Department of the
Ministry of Health in Ethiopia which was represented in all the regional
workshops.
Particular thanks also go to the Regional Water and Sanitation Group -
East Africa (RWSG-EA) part of the UNDP/World Bank Water and Sanita-
tion Program for facilitating the adaptation of the PROWWESS/SARAR
methodology for pilot testing PHAST.
Special acknowledgement for their contribution goes to all those involved
in the training workshops and in field testing of the PHAST approach in-
cluding; Ugandas Rural Water and Sanitation (RUWASA) project, UNICEF
in Kenya, Botswana and Zimbabwe, the Regional and Water Sanitation
Group-East Africa, the Institute of Water and Sanitation Development (IWSD)
in Zimbabwe, the Network for Water and Sanitation (NETWAS) in Kenya,
CARE International in Kenya, the Kenya Water and Health Organization
(KWAHO), the Katwe Urban Pilot Project (KUPP) and WaterAid/Uganda.
Special thanks to Gunnar Schultzberg who provided encouragement to-
wards the collaboration between the World Health Organization/Rural
Environmental Health and the UNDP/World Bank Water and Sanitation
Program Group in Nairobi (Regional Water and Sanitation Group-East
Africa). Thanks also go to Rose Lidonde, Noma Musabayane, T. Motsemme,
and Therese Dooley for gathering specific, sometimes obscure informa-
tion for the country synopses; to Eric Dudley, Jose Mar-tines and Heather
MacDonald for commenting on an early draft. We are also very grateful to
Anna Girling for copy editing this document.
There were many donors to the PHAST initiative, including the Swedish
International Development Cooperation Agency (Sida), the Danish Inter-
national Development Agency (DANIDA), UNICEF, CARE International in
Kenya and the government of Norway. Their generosity and faith in the
project were crucial to its success.

Mayling Simpson-Hebert,
WHO, Geneva
1, What is PHAST?
P articipatory
H ygiene
A nd
S anitation
T ransformation
. . . is an innovative approach to promoting hygiene, sanitation and
community management of water and sanitation facilities. It is an
adaptation of the SARAR methodology of participatory learning, which
builds on peoples 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 promot-
ing health awareness and understanding which, in turn, lead to en-
vironmental and behavioural improvements.
PHAST uses methods and materials that stimulate the participation of
women, men and children in the development process. It relies heavily
both on the training of extension workers and on the development of
graphic materials (sets of which are called tool kits) that are modified
and adapted to reflect the actual cultural and physical characteristics of
communities in a particular area. The production of PHAST materials there-
fore requires trained artists as well as trained extension workers.

Trainer s participating in a PHAST

development workshop.

SARAR stands for Self-esteem, Associative strengths, Resourcefulness, Action-planning, and Responsibility. It was developed
during the 1970s and 1980s by Dr Lyra Srinivasan and colleagues for a variety of development purposes (see Annexe D). The
major work describing the methodology for the water and sanitation sector is entitled Tools for Community Participation, A
Manual for Training Trainers in Participatory Techniques. PROWWESS/UNDP Technical Series Involving Women in Water and
Sanitation, New York, 1990.

1
Health awareness and understanding - a basic premise
An underlying principle of the PHAST initiative is that no lasting change
in peoples behaviour will occur without health awareness and under-
standing. People must believe that better hygiene and sanitation will
lead to better health and better living.
It is often argued that people will not change their water, sanitation and
hygiene behaviour as a result of health awareness. Some argue that peo-
ple who have never heard that germs cause disease cannot understand
the connection between their behaviour and subsequent illness. Even if
they are taught, the argument goes, they will not care. It is said that such
people have traditional beliefs about the causes of disease and that these
will prevail no matter what is taught. Others argue that people may un-
derstand health messages but they will change only through a desire to
acquire status, prestige, convenience or privacy, and that hygiene and
sanitation should be promoted only on these bases.
The PHAST initiative challenges this view. Firstly, it does not deny that
people have traditional beliefs about the causes of disease. Some of these
may be consistent with modern scientific theory, some not. Others may
be found to be valid if scientifically tested. People everywhere do rely on
traditional beliefs to explain the causes of and cures for diseases, but are
not incapable of also understanding other explanations. Secondly, people
may be persuaded to change a habit or build a facility for reasons other
than health (such as status or privacy), but the idea of improved health
may also be a motivation. The PHAST initiative recognizes that much of
the great shift in health-related behaviour in the last century has been
due to education and a recognition of the relationship between public
and private sanitation facilities, behaviour and disease transmission routes.
There is no reason to believe that people everywhere cannot acquire the
same knowledge and act upon it. Thus PHAST has proceeded on the
premise that people can understand and that behaviour will only mean-
ingfully change and be sustained when people understand and believe in
health concepts. Belief underlies all enduring behaviour change and, with-
out it, changes soon fall back into old behaviour patterns. If this is the
case, then why have health education messages largely failed to result in
behaviour change? The practitioners of PHAST have observed that con-
ventional health education messages are widely known and largely un-
derstood, but that these messages do not enable people to implement
change. In fact, there are few messages on how to create a credit scheme,
how to convince your husband that he must help carry more water to the
home, or how to persuade your mother-in-law that you need to attend a
planning meeting. The objective of PI-MT is not only to teach hygiene
and sanitation concepts (where needed) but, more importantly, to enable
people to overcome constraints to change. It aims to do this by involving
.a11 members of society - young and old, female and male, higher and
lower status - in a participatory process involving: assessing their own
knowledge base; investigating their own environmental situation; visu-
alizing a future scenario; analysing constraints to change; planning for
change; and finally implementing change.

2
 Community members working
together using a PHAST activity to
stimulate discussion and the
exchange of ideas.

Health-related community development principles of PHAST

The main underlying health-related community development principles
of PHAST are as follows:
n Communities can and should determine their own priorities for disease
prevention.
n People within a community collectively possess an enormous depth
and breadth of health-related experience and knowledge. Within most
African (and developing world) communities there already exists a rich
knowledge base that includes both traditional and modern wisdom.
n Communities are capable of arriving at a consensus regarding the hy-
giene behaviours and sanitation systems most appropriate to their spe-
cific ecological and cu.ltural environment.
n When people understand why improved sanitation is to their advan-
tage, they will act.
4 All people, regardless of their educational backgrounds, are capable of
understanding that faeces carry disease and can be harmful, and can
learn to trace and describe the faecal-oral route of this disease trans-
mission within their own environment.
n There is a manageable set of barriers that can help to block this trans-
mission. Communities can identify appropriate barriers, based on their
own perception of effectiveness and according to local resources (cost).
These principles are derived from the collective experience of the authors
and close colleagues who have worked with communities around the
world, some using participatory methods for development and others car-
rying out anthropological studies.

3
 New principles on hygiene and sanitation promotion
The PHAST initiative has also built on some of the more recently devel-
oped principles on how to promote sanitation more effectively. Some of
these were expressed in WHO Informal Consultations held in 1992 and
19932, and have since been expressed and affirmed elsewhere3. The pro-
motional principles built into the PHAST methodology are as follows:
n Any sustainable improvement in hygiene and sanitation must be based
on a new awareness of the complex interaction between behavioural
and technological elements.
n The best way to achieve sustainable improvement is to take an incre-
mental approach, starting with the existing situation in a community
and building up a series of changes.
n Improvement in hygiene behaviour alone has been shown to have a
positive health impact whereas improvement in sanitation facilities alone
may not bring health benefits. Therefore, greater emphasis needs to
be put on improving hygiene behaviour, but the ideal situation would
be one where improvement in both behaviour and facilities can take
place simultaneously.

SARAR -the underlying methodology

The PHAST initiative uses SARAR as its underlying participatory method-
ology. A basic principle of SARAR is the recognition and affirmation of
peoples innate abilities. The system aims to help people recognize these
talents within themselves and to use them. Two main principles are:
W People will solve their own problems best in a participatory group
process.
n The group collectively will have enough information and experi-
ence to begin to address its own problems.
Other important principles of SARAR include:

Principles on learning
n Sustainable learning best takes place in a group context, which helps
to produce a normative shift and, eventually, a change in behaviour
that is sustainable because i is socially accepted or endorsed.
n An appropriate learning environment can provide an opportunity for a
group to make a collective review of existing information and experi-
ence, thereby arriving at a deeper level of understanding and a clear
course of action.
n Concept-based learning is more effective in bringing about sustain-
able change than message-based teaching.

2 WHO/CDD/CWS Informal Consultation on Improving Hygiene Behaviours for Water and Sanitation, May 1992; WHO/CWS Informal
Consultation on New Directions for Hygiene and Sanitation Promotion, May 1993.
3 See, for example, UNICEFs Report from the Eastern and Southern African Region Workshop on Sanitation, Harare, 25-30 October
1994 and the Report of the Water and Sanitation Collaborative Council Working Group on Promotion of Sanitation, October 1995.

4
 n Compared to the message-based approach, new concepts allow more
new information to be assimilated and processed.
n The clustering of concepts provides the basis for a normative shift,
which becomes a model for future behaviour.
n Literacy, formal schooling and hygiene and sanitation messages are
not prerequisites to making effective decisions.

Principles on decision-making
n The people closest to a problem are those best able to find the solution
(this applies equally in programme and community contexts).
n Those who create decisions will be committed to following them through
- hence sustainability.
n The community understands its own situation best. Their involvement
will result in a higher level of effectiveness and sustainability than
could be expected from externally imposed solutions.
H Communities are capable of accurately describing their present situa-
tion and problems and of visualizing possible future improvements.
n The more of their own material and financial resources people invest
in change, the greater will be their commitment to following it through.
n Self-esteem is a prerequisite to decision-making and follow-through.

Principles on mechanisms for information exchange and discovery

n Information exchange and discovery raises individual and group self-
confidence.
n When people know that they are responsible for finding a solution
they start to demand information. Such demand opens the way for
information exchange and dialogue.
n By helping people to learn from each other, communities come to rec-
ognize their own knowledge base.
n Through a creative learning approach based on active discovery, indi-
viduals can evaluate and change their own behaviour, and communi-
ties can choose and initiate their own development.
n Technical information is best provided in response to needs identified
by the community, following its own process of problem identification
and analysis. External intervention with technical information and sup-
port too early interrupts the process and has a negative effect.
w Applying SABAB at both community and institutional levels releases
creative energy which will help sustain programme momentum and
stimulate thinking about new goals and aspirations.

Key factors needed for effective participation

The participatory process will work only if there exists: respect for peo-
ples knowledge and ideas, with clear recognition of their individual and

5
collective inputs; faith in the creative potential of people and in the synergy
of the participatory process; a minimum of structure, a maximum of par-
ticipation; loyalty to the group; and a commitment to creating opportuni-
ties for people to express themselves.
To sum up, SARAR is a growth-orientated (rather than a top-down, mes-
sage-focused) approach. It is an individual-centred learning approach
which systematically seeks to draw on deep-seated human capacities for
self-motivated creative change and to channel these transformational
forces through group processes.
In order to assure maximum success, these basic principles of empower-
ment should be applied consistently, fairly and at all levels. Where this
does not happen there is a significant chance of not achieving the origi-
nal objectives or a danger of having the process degenerate along the
way. Thus, it is important to identify the factors that enhance effective
participation, as well as to recognize and avoid those factors that inhibit
it.
The PHAST initiative has been able to put these principles into operation
at international, inter-country, national and community levels.

6
2. How PHAST began
Building on a shared belief in the principles outlined in the previous sec-
tion, the United Nations Development Programme/World Bank Regional
Water and Sanitation Group - East Africa (RWSG-EA), under the
PROWWESS Project4, and the Rural Environmental Health Unit (REH) of
WHO in Geneva joined together to develop and test a new approach.

Working principles of the partnership

From the outset, it was decided that WHO, PROWWESS and all their part-
ners at field level would themselves follow a participatory learning proc-
ess in the testing of the African PHAST initiative. The development of
methods and materials and the training of trainers would be based on the
same learning principles that were to be applied at the community level.
For example:
H Maximum local adaptation and innovation should be encouraged.
n The initiative should apply an adaptable learning-process approach,
rather than lay down a prescriptive set of tools to be followed. This
recognizes that those running the initiative do not have the answers
and that the project should be experimental and creative.

A local artist, hard at work,

creating a set of locally
appropriate graphic tools for
the PHAST initiative.

4 PROWWESS stands for the Promotion of the Role of Women in Water and Environmental Sanitation Services. During the Interna-
tional Drinking Water Supply and Sanitation Decade, PROWWBSS, a special project under the UNDP, adopted the SARAR method-
ology as its primary strategy for promoting participation and the involvement of women in water supply and sanitation projects,
During the past decade PROWWESS has provided training and programme support to programmes in almost 20 African countries,
The work in anglophone Africa, in particular, was intensified in 1990 when PROWWESS began to merge with the UNDP/World
Bank Water and Sanitation Program and a SARAR specialist was assigned to work with the eastern and southern Africa Regional
Group based in Nairobi. In partnership with the World Bank International Training Network (ITN) centres - NETWAS in Nairobi
and IWSD in Harare - PROWWESS focused on developing national teams of training and participatory development specialists.

7
 n There should be common ownership of the methods and materials pro-
duced, with due recognition of the contributions of the various part-
ners in subsequent phases and applications.
n There should be wide sharing among the partners of the lessons learned.
n There should be a core team for each country to coordinate activities,
seek financial support and distil the lessons learned.

The selection of countries

Having achieved a meeting of minds and a decision to work together,
WHO and PROWWESS identified five pilot countries according to the fol-
lowing criteria:
n The existence of a cadre of trained PROWWESS individuals.
q At least two or three on-going projects with strong government and,
preferably, external donor support.
n Significant opportunity for involvement by nongovernmental organiza-
tions (NGOs).
n Commitment to being involved in a carefully documented, collabora-
tive learning project for at least a year, and probably longer.
Kenya, Uganda and Zimbabwe met all of these criteria. (PROWWESS had
been active in Kenya since 1985, Zimbabwe since 1986, and Uganda,
more recently, since 1992). Although there had been no previous
PROWWESS training in Botswana, in response to a strong demand from
the Botswanan Ministry of Health, the United Nations Childrens Fund
(UNICEF) and the Swedish International Development Cooperation Agency
(Sida), it was also invited to participate in the pilot phase. Ethiopia origi-
nally intended to participate but was unable to organize a pilot activity due
to decentralization of government services. Pilot activities were therefore
carried out in only four countries: Botswana, Kenya, Uganda and Zimbabwe.
The 18-month, regional pilot programme was implemented in collabora-
tion with the governments of these countries and in close partnership
with UNICEF (particularly in Kenya, Zimbabwe and Botswana) and vari-
ous regional and national NGOs (for example CARE, KWAHO, WaterAid).
The World Bank International Training Network centres (ITNs)~ played an
important role in preparing, coordinating and monitoring the participa-
tory hygiene promotion activities.
Core funding was provided by Sida, through WHO, and by Norway, through
a participatory development fund grant to the UNDP/World Bank Water
and Sanitation Program. In addition, UNICEF helped sponsor a number of
participants to the regional workshops and continues to play a very sig-
nificant role in the project. Various donors, including the Danish Interna-
tional Development Agency (DANIDA) and Sida, assisted with the funding
of activities at country level.

5 The International Training Network for Water and Waste Management (ITN) is a component of the UNDP/World Bank Water and
Sanitation Program. ITN centres provide training, disseminate information and promote local applied sector research on low-cost
water supply and sanitation options.

8
 In order to encourage maximum national and project-level ownership of
the process, the sponsors agreed to fund only the regional and inter-
country activities. Participants were expected to generate their own funds
for activities within their countries. Although WHO and PROWWESS/
RWSG-EA provided ongoing technical support to the process, they tried
to maintain sufficient distance so as to encourage a maximum degree of
initiative and leadership from their regional and national counterparts. As
a consequence, strong core teams emerged, with people from various
institutions and sectors collaborating to coordinate country training work-
shops and field implementation.

Two creative workshops

The PHAST programme officially began in September 1993 with a one-
week pre-planning workshop held in Nyeri, Kenya. The 12 participants
at the workshop included regional and international specialists with an
excellent understanding of epidemiological and methodological tools, coun-
try-level representatives and artists.
This creative workshop was designed to develop a core set of concept-
based tools, methods and materials, which integrated basic epidemio-
logical concepts with SARAR methodology. Seven of the key tools used
during the workshop are described here.

Trainers working together

to become familiar with
PHAST methodology.

Contamination
routes: Based on the F-diagram (see next page), this activity
uses a set of posters depicting the different steps or carriers of faecal-oral
contamination, to help communities analyse and organize their know-
ledge of diarrhoeal disease transmission. This activity also provides a
framework for assimilating new ideas and concepts about faecal-oral
contamination6.

6 This tool was originally developed by PROWWESS [Ron Sawyer and William Samson) in 1987 for the Rural Sanitation Programme
in Lesotho. Prior to the PHAST initiative, adaptations of the tool had been used in Zimbabwe by the countrys Ministry of Health
and UNICEF (blocking the routes), by the Yacupaj Project in Bolivia and by the Kumasi Health Education Programme in Ghana.

9
 F-diagram: transmission of diseases from excreta

hand cleaning

( faeces \ I ( food -b new host )

traditional
latrine

VIP or flush latrine

Source: Wagner & Lanoix 19.58, modified by Winblad 1993 [unpublished]

Barriers matrix:
Following on from the contamination routes exercise de-
scribed on the previous page, this activity includes a set of pictures of
common barriers (both technological and behavioural) that can be used
to block any of the principle transmission routes of faecal-oral disease.
The matrix includes two variables for classifying the barriers according to
their effectiveness and practicality (that is, ease of application). At the
community level the matrix can be substituted by an incremental process
of elimination, by first identifying the most effective barriers and then
prioritizing these according to their relative applicability?.
Sanitation ladder: This
set of posters was designed to help community mem-
bers to identify their own situation on a scale of various sanitation op-
tions and to determine the relative merit and feasibility of varying levels
of improvements. The activity is taken one step further by identifying
possible obstacles to implementing the proposed sanitation improvements
caused by attitude or behaviour.
Three-pile sorting:
This powerful SARAR tool has been readily adapted to
the PHAST initiative. It provides a set of pictures or photographs of
hygiene and sanitation-related situations which are sorted according
to whether they are considered to be good, bad or in-between.

7 The use of the matrix was introduced specifically for PHAST at the pre-planning workshop. Each of the programmes in turn
modified the tool according to their own specific purposes, During the December 1994 PHAST review workshop, WaterAid/
Uganda made a particularly useful demonstration of the use of the tool for needs identification. The activity was further modified
as a tools matrix for use in training workshops to analyse the appropriateness of the various SARAR-PHAST participatory
techniques and materials.
8 This activity was designed by Josiah Omotto during the pre-planning workshop in order to address the concept of incremental,
situation-specific improvements - steps in the Sanitation ladder - which has been promoted by the Swedish architect Uno Winblad.

10
 An example of the
Contamination routes activity
created by a group.

A community group
carefully considering the pictures
included as part of a Three-pile
sorting activity,

In addition to stimulating a very high degree of community involvement,

this activity has proved particularly useful in revealing the depth and breadth
of local health-related knowledge and in providing a context for arriving at
consensus on appropriate behaviour and sanitation technologies.
Pocket chart: Thepocket chart is an investigative tool. In the workshop, it
was used to tabulate where people defecate or from where they collect
water. It can be used as an evaluation tool as well. Tabulations from two
different points in time can be compared, such as where people def-
ecated before a hygiene and sanitation project began and then one year
later.
Dr Akili Sana:
This activity helps communities to appreciate the difference
between illnesses requiring curative attention from health-care providers
(either traditional or modern) and health problems which should be ad-
dressed through a preventive strategy initiated by the community

11
 members themselves. Water, sanitation and hygiene-related problems
generally lie within this latter categoryg.
Community mapping:People are encouraged to draw a picture of their com-
munity showing its water-supply sources and sanitation facilities. They
will often include various environmental problems, such as poor drainage
and open refuse. This activity is sometimes used to help communities
visualize their overall situation and the situation to which they aspire.

Two trainers becoming familiar

with Community mapping
by making a map of their own.

The Kenya pre-planning workshop was followed by a training-of-train-

ers workshop held in Mukono, Uganda, in October 1993. Participants in-
cluded experienced trainers of extension workers from the four countries
involved. By the end of the workshop the participants had developed
their own plans for field application, adaptation and assessment of the
hygiene promotion methods. They had also identified the potential for
support, in the form of funds or backing from institutions, within each
country.

Field testing
Participants at the Uganda workshop returned to their respective coun-
tries, organized national and district training workshops, further adapted
the methods and tools to local situations, and field tested them in at least
six sites within each country.
E In Botswana, the approach was piloted in seven districts and 72 exten-
sion workers were trained.
n Six districts in Kenya participated and a total of 4 071 community mem-
bers and extension staff were exposed to PHAST methodology.

9 This activity was introduced by Keith Wright, a participation specialist, during the pre-planning workshop and has been success-
fully adapted to various cultural contexts by changing the name of the doctor.

12
 n Uganda involved six districts and successfully included a total of 14 400
community members and extension workers.
n Zimbabwe extended its pilot to seven districts, training close to 1 000
extension workers and 3 285 community members.
Not unexpectedly, this adaptive (as opposed to prescriptive), learning-
process approach has yielded distinct hygiene-promotion programmes in
each of the participating countries, as well as enormous momentum and
commitment. Synopses of experiences in pilot countries are provided in
Annex A.

School children totally engrossed

in a PHAST activity.

Monitoring and evaluation

A central feature of the PHAST initiative was the mechanism put in place
for monitoring progress and lessons learned. The system evolved gradu-
ally. It included the use of outside documentation specialists as well as
inter-country consultations to share progress. By the time of the final
workshop to discuss results, only a year later, all of the countries had
produced well-documented evidence of the projects impact at commu-
nity level and of lessons learned for future projects and programmes. See
the diagram on page 14 for a summary of the stages involved in the PHAST
initiative.

13
The PHAST initiative - a summary

February 1993 February-August 1993 September 1993

PHAST initiative is born Selection of countries: Initial PHAST 1 week

Botswana pre-planning workshop -
Partners
UNDP/World Bank Water and
Kenya Nyeri, Kenya
Uganda Participants
Sanitation Program
Zimbabwe
WHO - Regional/international
PROWWESS specialists
- Country-level representa-
tives
- Artists

October 1993 December 1993 - November 1994 December 1994

PHAST workshop for Country level field projects Review workshop -

training-of-trainers - Harare, Zimbabwe
Activities
Mukono, Uganda -Presentation of written case-
-National and district level
outputs study reports
training workshops
-Plans for field application -Evaluation of progress
-Development of country
-Sources for funding and specific methods and tool -Modification where required
back-up support identified kits and continuation of field
initiative
-Field testing in 6 or more
sites within each country

November 1996 Future Activities

Publication of the PHAST -Proposed external review of

initiative report summarizing 4 pilot PHAST initiative
the outcome and the lessons projects
learnt from the 4 field projects
-Publication of a PHAST step-
by-step guide and tool kit
for working with communi-
ties, and a managers guide
-Production of a PHAST video

14
3. The impact on communities
All four countries participating in the field test gathered in December
1994 at a PHAST review workshop in Harare, Zimbabwe to report and
pool their results. As there were many field sites, only a selection of ex-
periences is presented here. However, responses from pilot communities
were very positive. The following comment from an 84-year-old Kenyan
woman captured the feelings generated. All my life people have been
coming here and telling us what to do. This is the first time anyone ever
listened to what we think.

Examples of impact
In one rural community in Zimbabwe, in the space of eight months, 24
latrines which had been left unfinished were completed and 18 family
wells were upgraded. In addition, the local environmental health techni-
cian noticed that almost twice as many people were attending the meet-
ings he arranged to discuss water, sanitation and hygiene in the village,
and they stayed longer than in the past. In fact sometimes he was late for
his next appointment because the discussion was so lively and the com-
munity members wanted to raise new issues, such as meat hygiene and
house construction.
In a school in Botswana a latrine block had recently been built by the
government. Hand-washing facilities were provided, but no soap. Teach-
ers and parents decided that this was not acceptable and created a fund
to buy soap dispensers and keep them filled with soap. The majority of
parents contributed the small sum necessary to make the improvement.
The teachers introduced hand washing into their teaching, particularly
with the youngest pupils, and helped the children to arrange a cleaning
rota to ensure that the latrine block stayed clean.
In a low-income peri-urban artisan community in Uganda, within six
months of an initial visit by one field worker, the community built la-
trines, organized the operation and maintenance of neglected communal
drains, collected tariffs to pay for maintenance workers for drains and
water points, and organized their own system of monitoring community
sanitation. The community adopted the graphic materials and discussion
techniques of the field worker in order to continue the process of commu-
nity development in her absence.
In a village in Uganda the community decided to make a map to track the
growing number of family latrines and improved water sources. They
asked a local artist to draw their village, marking each household which
had built or arranged for the building of a latrine and also showing the
water and sanitation problem areas in the village. The map hangs in the
headmans office and is brought out for meetings of the village committee
and visits by officials or guests.
In Zimbabwe, one community spontaneously submitted a report to the
government department on their water and sanitation situation. They knew.
that many homes lacked latrines and that the village water sources were

15
 almost all unprotected. They decided they wanted help to change. In the
past they had waited for the government extension worker to come, tell
them what needed to be done and offer them subsidies, usually in the
form of bags of cement. This time they knew what they wanted to do and
they were not prepared to wait.
In Kenya, one community held a water and sanitation meeting in the
absence of the community extension worker, who had failed to turn up.
On her previous two visits the extension worker had used a new method-
ology to help the community to identify their problems. Now they wanted
to go on, with or without her, and they decided to try some of the tech-
niques she had used during her visits.

Common achievements of the pilot phase

The programme participants from the four countries involved identified a
specific set of results that seemed to be fairly uniform in all of the commu-
nities exposed to PHAST:
n They all have self-esteem: a belief in their own ability to solve their
own problems. They do not wait for others to find the solutions. They
know that what they can do themselves with their existing resources
is enough to make a significant improvement to their health and their
environment.
n They all have a basic understanding of the health implications of poor
water supply and sanitation. They know how some of the diseases
they have experienced most frequently are linked to excreta. They un-
derstand why these diseases can only be reduced by getting excreta
(even childrens excreta) out of the environment, by keeping water
safe from contamination and by washing hands.
n They all have a sense of common purpose and a way of planning change
in their communities.
n They all have a committed and positive extension worker who is trying
to allow them to plan their own future. The extension worker does not
have all the answers to a communitys problems but now, can under-
stand how to help communities find the answers. The extension worker
finds the work more rewarding and can see its impact. This means a
higher level of job satisfaction and a happier worker than ever before.
It should not be forgotten that these communities are in four different
countries, speak different languages, are in both rural and urban areas,
have a variety of beliefs about health and about water and sanitation,
and, while most have low incomes, they have different income levels.
Yet, despite their differences, everyday they faced the same problems.
Only one year ago they shared:
n An inadequate supply of safe water close at hand.
n Poor sanitary conditions.
n Hygiene practices which represented a risk to health.
w A common belief that their own poverty or ignorance inhibited them

16
 from making changes to their water and sanitation situation and that
someone else should take this responsibility for them.

The impact on extension workers

The impact of PHAST on extension workers has been one of the most
rewarding aspects of the project.
Participants in the pilot phase have reported that:
n The extension workers respect the community and believe in them-
selves.
n They have a set of graphic materials that help them to relate to the
community in a non-directive way. The community can tell its story
and begin planning improvements.
n The one basic workshop they attended gave them the confidence to
begin to use and adapt these tools.
n They have opportunities to interact with other extension.workers and
project staff who share a common vision and have a willingness to
learn from common experiences and gain further confidence.
n They have a sense of support from their supervisors, who allow them
to explore their own skills, design their own interaction with the com-
munity and be involved in the monitoring of this interaction.
All of these positive elements give them the motivation to adopt this new
approach, despite receiving no additional remuneration or incentives -
other than greater job satisfaction. The extension workers who took part
did not want to go back to their former methods of working.

17
4, The lessons learned
On behaviour change
The SARAR methodology aims at personal growth and participatory de-
velopment. When applied to sanitation and personal hygiene, it worked
well in promoting sustainable behaviour change and community man-
agement.
While the SARAR methodology was used in this project to focus on hy-
giene behaviour change, it also prompted latrine construction and other
physical environmental improvements in communities. It encouraged com-
munities to set up their own systems for operation and maintenance, for
payment of services and for monitoring household and community be-
haviour using indicators identified by themselves. Thus, the lesson we
have learned is that when people understand the relationship between
their environment and their health and well-being, they identify and take
the necessary steps to improve the situation. They do not necessarily
wish to limit themselves to the behaviour change promoted by the pro-
gramme. In fact, the programme enables them to move beyond hygiene
behaviour by giving them the techniques for improved participation, visu-
alization and communication. As one village chief said: Before you came,
our panga (machete) was dull. Now you have helped us to make it sharp
again. As a result of the programme, people have acquired the generic
skills necessary to take their own development forward. Focusing on hy-
giene behaviour and sanitation, therefore, seems to be a good starting
point for stimulating community interest in general environmental im-
provements and in the factors necessary to sustain improvements, such
as operation and maintenance, cost recovery, self-monitoring and evalu-
ation.
The SARAR methodology encourages free, uninhibited expression and
enables outsiders to listen better to what communities have to say. Com-
munities know more than outsiders usually give them credit for. The SARAR
approach helps outsiders to respect community intuitiveness and resource-
fulness.
SARAR works especially well in an environment where resources are
poor. It allows communities to decide their own cost-benefit ratio. It helps
them determine what they really need and are prepared to pay for, in
terms of money, resources and time. Subsidies, we have learned, tend to
work as a disincentive to local contributions and initiatives.

On the requirements for success

A participatory programme, aimed at community empowerment, requires
certain factors not commonly found in typical water supply and sanitation
programmes. These factors are essential for initiating, sustaining and ex-
panding a participatory approach. They can be grouped into three areas.
The insiMional environment: An appropriate institutional structure must be
established to support a participatory approach. Incentives and rewards

18
 for field workers and engineers must reflect the objectives of the pro-
gramme. For example, instead of taking the number of hand pumps or
latrines installed as the criterion for achievement, success should be judged
on the number of communities organized and active in setting and achiev-
ing their own goals. The institution will need personnel trained in the
PHAST (SARAR) methodology. These people need to be given ample time
to work with communities. It should also be recognized that some com-
munities need more time than others to describe their problems, visualize
what they need, reach consensus and initiate changes.
Resources: A participatory programme needs more than just a sufficient
number of personnel. Other essentials include: an assured means of trans-
port or money for fares on public transport; per diems for extension work-
ers spending many nights in communities; and full sets of learning mate-
rials. In the field, workers will need funds for paying artists and resources
such as paper and photocopiers for duplicating materials. The budget for
a programme needs to include an allocation for training workshops on
methodology, field travel, artists and materials.
Policy commitment: Most importantly, a participatory methodology requires
a policy commitment from the very top. Without this commitment, it is
unlikely that such an unusual approach, with all of its unique features,
can succeed.

On how to start
Experience has shown that it is best to begin a PHAST programme with a
small pilot project. The PHAST approach requires a period of learning for
both programme personnel and the institution involved. Different institu-
tions will be more or less ready for PHAST. For example, some may have a
structure and management style that permits and encourages field-worker
initiative and experimentation. Others may have a more authoritarian hi-
erarchy.
In terms of materials and personnel, it is possible to make use of existing
resources when setting up a PHAST programme. Existing hygiene educa-
tion materials can be modified or adapted to create graphic tools for com-
munity discussion, provided they are culturally appropriate. It is best to
plan, at some stage, a small workshop to train a cadre of artists to work in
the programme. While it is not necessary to hire new personnel, existing
personnel will need training in the methodology. It is also necessary to
determine whether the numbers of personnel are enough to cover com-
munities in a reasonable period of time. The PHAST approach does not
necessarily require a newer or bigger budget than previous programmes,
but it may require shifting budgets from hardware to software. Once
done, the communities take a far greater share of the cost of the project
than they would have done before.

On how to sustain
Backup is most important. Community field workers can sustain a partici-
patory approach once they feel completely comfortable about using it.
Until that time they will need periodic visits from supervisors who will

19
 listen to their problems and try to meet their needs. This support is essen-
tial for anywhere from three months to one year after the start of the
project. Continual monitoring and periodic evaluation of community ac-
tivities and improvements will provide valuable lessons for sustainability
of the approach.

On how to expand
Any expansion of a participatory programme must take place slowly, per-
haps one district at a time, making sure that each district can sustain
what it has achieved before moving on to the next one. Expansion re-
quires political commitment and inviting district political leaders to visit
successful sites is usually a good way to achieve this.

Requirements for successful community management of water supply and sanitation using the PHAST methodology

to adopt a participatory
strategy Ongoing monitoring and
evaluation of progess
and impacts
Institutional structure
supportive of a Back-up support from trainers and
participatory approach supervisors until extension workers
feel confident in the PHAST
approach
Adequate resources
(not necessarily additional Pilot projects for
resources) the development of
perhaps re-organization country specific
of existing resources materials

PHAST may require a policy shift among decision-makers. Experience

shows that lack of support from supervisors and policy-makers who have
not been exposed to the methodology has been the single most difficult
obstacle to initiating, sustaining and expanding PHAST. An excellent way
to stimulate policy changes is to take decision-makers to pilot sites.

20
5. The future and the potential of PHAST
The three organizations involved in the development of the PHAST initia-
tive feel that the pilot phase has been very successful and would like to
see an expansion of the approach. A step-by-step guide for working with
communities and a prototype tool kit using the PHAST methodology are
being prepared. A managers guide and a set of detailed case studies
from the four countries involved in the pilot phase are envisaged for the
near future. In 1997 an external review of the four pilot countries is planned
to evaluate the impact and sustainability of the approach. It is hoped that
these further documents will enable countries not yet exposed to the ap-
proach to try it more easily.
The four countries involved in the pilot phase have developed tool kits
which can serve as models for new countries wishing to try the approach.
Trainers within those countries are available for future training work-
shops. The two ITNs involved, the Institute for Water and Sanitation De-
velopment (IWSD) in Harare and NETWAS in Nairobi, are able to offer
training courses in PHAST.
The PHAST approach can be adapted to any culture and can be used
equally well with school children in classrooms, in non-formal education
classes and in community meetings. Problems with the methodology arise
more often from poor training, supervision and support from institutions.
The production of artwork can also create a bottleneck. Artists must be
identified, trained and paid during an intensive phase of materials devel-
opment.
To sum up, the future of PHAST depends on inspiring commitment from
countries, donor agencies and international organizations. Once begun, it
often generates great enthusiasm among those trained, who usually do
not want to go back to their former ways of working. Personnel at all
levels can observe with great satisfaction the changes brought about as a
result of their personal efforts. Thus, while PHAST requires particular ef-
forts to achieve policy shifts, budget shifts, new training methods and
new types of educational materials, it appears to bring about the sought-
after results and should be considered for future investments.
For more information on PHAST, contact:
WHO
1211 Geneva 27, Switzerland
Tel (41-22) 7912111
Fax (41-22) 7910746
UNDP/World Bank RWSG-EA UNDP/World Bank Water and
PO Box 30577 Sanitation Program
Nairobi 1818 H Street, N.W., Room S4-055
Kenya Washington D.C. 20433
Tel (254-2) 338868 United States of America
Fax (254-2) 338464 Tel (l-202) 4736917
Fax (l-202) 4770164,5223228

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NETWAS
PO Box 15575
Nairobi
Kenya
Tel (254-2) 890555/58
Fax (254-2) 890554
IWSD
University of Zimbabwe
Box NIP422
Mount Pleasant
Harare
Zimbabwe
Tel (263-4) 303288
Fax (263-4) 303280
SARARTransformacih S.C.
A.P. 8, Tepoztlh
Morelos 62520
Mexico
Tel/Fax (52-739) 50364

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