Example 4: Elevating Local Policies: A Ministry of Public Health and Sanitation Policy

This example was contributed by Ithar Hassaballa through a World Health Organization (WHO) Health Promotion Internship (summer 2012).

BACKGROUND ON THE PROBLEM OF SANITATION IN KOMO:

Contaminated drinking water resulting from improper sanitation has become cause for concern in Komo. Residents in the area, particularly young children, have been suffering from diarrhea and other waterborne illnesses. Many homes in this community do not have toilets and most residents live far from public restrooms. As a result, children often relieve themselves outdoors, creating unsanitary environments for others in the area. The negative consequences for those directly affected by sanitation issues range from diarrhea and worms to polio and even death.

As part of the monthly Community Dialogue Day (CDD), community members raised the issue of sanitation in the area and proposed policies that must be created, implemented, and enforced in Komo to assure a clean environment for all. This is an example of how a rural community in Kenya thought of policies that would assure a basic necessity (a toilet) and a clean environment for residents in the area. The Ministry of Public Health and sanitation not only put the policies into place, but they also elevated these policies as national policies in Kenya/

STATE WHY A POLICY NEEDS TO BE DEVELOPED OR MODIFIED.

A policy needs to be developed because:

• Basic health sanitation practices are being ignored in Komo.
• Education about sanitation is limited in farm towns.
• Several of the current laws on sanitation are not enforced.
• Existing environmental conditions pose a threat to public health and safety.

STUDY THE ISSUE OR PROBLEM A POLICY CHANGE WOUL AFFECT.

Outline the facts, myths, and values associated with the issue:

• Those who are affected by the issue believe that it should be illegal to relieve oneself in the environment (e.g., on the grass, behind the tree, outside the home, etc.)
• The residents of Komo also believe that there should be serious consequences for those who pose a threat to the environment and other residents.
• People of Komo believe that everyone must have a bathroom in their home, or within close distance to where they live, work, and play.
• People believe that there are several factors maintaining the problem:
  • Physical barriers (long distances to public bathrooms)
  • It is more convenient for people to go behind the bushes (the response cost is less)
  • Developing new behaviors (using the toilet); residents do not have a history of using bathrooms
  • People’s limited sanitation knowledge and skills also maintain the problem
  • Rainy conditions increase the prevalence of malaria and increase waterborne illnesses during the rainy season

List who or what is affected by the current state of affairs:

• The residents of Komo are affected by sanitation problems. A large percentage of residents, mainly children are at risk of suffering from diarrheal illnesses, worms, polio, and even death.
• To lessen the problem, children should be taught to use the bathroom regularly and should be rewarded for doing so.
• Adults should model the behavior of interest (using the bathrooms) correctly.

Define the issue or current policy in neutral terms and generate possible policy related solutions.

• There are too many children of local farmers who do not have access to bathrooms; there should be a policy that guarantees that all children receive an adequate place to go to the bathroom. There should be a second policy that assures the correct use of bathrooms and those who do not use or misuse the bathrooms will be fined.

BASED ON KNOWLEDGE ABOUT THE ISSUE OR PROBLEM AND WHO IT AFFECTS, INDICATE THE TYPE AND CONTEXT OF POLICIES TO BE DEVELOPED. 

• A local ordinance to assure public health safety and sanitation for all Komo residence will be presented to the chief.
• A district law that seeks to protect water quality and imposing penalties for waste or toxins will be introduced to the Ministry of Public Health & Sanitation in Thika West District.
• An executive order will be sought by the Komo Chief to set a community service day during the monthly Community Dialogue Day (CDD) for all community members.
• An organizational rule to permit Community Health Workers (CHWs) to be mentors for local children will be presented to the Board of Directors of the Ministry of Public Health and Sanitation.

STATE WHAT YOUR GROUP WILL DO TO INFLUENCE EACH OF THE STAGES OF POLICY DEVELOPMENT. 

[Agenda Setting Stage]

• The Ministry of Public Health and Sanitation will assure a policy debate on the issue of sanitation for all during CDD. The Ministry will also develop and secure consideration of policy options for extending water safety and sanitation to include preventive services.

[Policy Adoption Stage]

• The Ministry will provide materials and support to build toilets where people live, work, and play. The CHWs will educate community members about the cost and benefits of water safety. Community Health Workers will also train the residents on how to use the restrooms.

[Policy Implementation Stage]

• Assure that regulations for water safety and sanitation are strictly enforced. Community Health Workers will communicate consequences for not using or misusing toilets.

[Policy Evaluation Stage]

• Examine whether policies to assure water safety and sanitation have reduced instances of diarrheal diseases and worms amongst children through pre-intervention (before) and post-intervention (after) data.

IDENTIFY RESOURCES AND ASSETS TO BE USED FOR POLICY DEVELOPMENT.

• There are 50 CHWs who are available and committed to working on the problem or issue by providing education, skills training, support, etc.
• The financial resources that are currently available are from the Kenyan Ministry of Public Health & Sanitation, USAID, and APIA Plus Kamili.
• Other assets that can be used to support the effort are the relationships and ties to other organizations that aim to reduce this issue in Kenya. People of Komo have done a great job improving their health, and have been nationally recognized for their efforts.

INDICATE POTENCIAL ALLIES AND OPPONENTS OF POLICY DEVELOPMENT EFFORTS.

Identify allies:

Most members of the community who are affected by the issue are allies. Important allied include CHWs who are health promoters in the area. Other allied include elected and appointed officials (e.g., the Chief, representatives from different ministries, CHWs, CHEWs, etc.). Organizations who share related efforts are also allied (e.g., WHO, APHIA Plus Kamili, USAID, and others).

Identify likely opponents and how they might resist the effort because of the consequences of the proposed policy:

Likely opponents may be a few of the residents living in Komo. During the CDD, there were disagreements about ways of approaching the sanitation problem, but everyone agreed to create laws pertaining to a clean environment. There were no opponents seen. If there were opponents, they may use a tactic to hinder the efforts. The tactic to be used is delaying the planning and implementation of the new policy. While efforts are usually slower in Africa, setting goal dates and continually checking that everyone’s doing his or her share can speed up the process.

IDENTIFY TARGETS AND AGENTS OF POLICY CHANGE AND THIER ASSEST AND INTEREST.

Identify targets of change:

The targets of change are the Komo residents, mainly the children. The first policy will require ministry of health to contribute aid community members to build bathrooms. The second policy will require those living in Komo to correctly use the bathrooms and keep a clean environment. For those who break these law, they must report to the court and must pay a fee. If the offense is repeated a second time, they must pay two fees, if the offense occurred three times by the same person, the offender may get jail time including an additional fee: this approach was developed by community members during CDD.

Describe potential agents of change:

Community Health Workers (CHWs) are the main agents of change because they are the link between the Ministry of Health and the local people. They serve as health ambassadors by understanding health information and health behaviors as well as a deep cultural knowledge of the people. They support the planning, implement, and evaluation processes of local programs and policies. Another agent of change is the area Chief’s; his support is key to the success of these policies because chiefs are highly respected in society. The community listens to the chief when he speaks because he or she is considered knowledgeable and always attends to the community’s needs. Other agents of change include the Ministry of Public Health and Sanitation and other organizations who care about the issue.

Prepare answers to anticipated questions:

Why they should support your proposed policy or position?

• This will make the environment healthier and will improve health outcomes by preventing disease.

How do local people benefit?

• They will prevent many diseases. Increase health and wellbeing for community members and spend less money on hospital visits.

How the issue affects them or those they care about?

• This issue affects adults and children; less sanitation brings more waterborne illnesses.

How this stance could cost them?

• Taking sanitary measures is cost effective in that people spend less money, time, and effort going to Thika Hospital (15km far). They will also gain health “Afya ni mali” “Health is wealth.” The people of Komo will also be more productive in their daily activities when they are healthy.

DEPENDING ON THE BROAD GOAL OF YOUR POLICY DEVELOPMENT EFFORTS (SEE #3), CHOOSE THE STRATEGIES AND ACTION PLAN TO BE USED.

Policy research and investigation:

• Performed by the Ministry of Public Health and Sanitation.
• Study the issue through CDDs, home visits, and CHW observations
• Gather data on public opinion during CDDs
• Request accountability from both the community members and elected officials
• Document complaints of residents

Relationship building and education of decision makers:

• Give personal compliments when a person meets their goal
• Arrange celebrations during CDD when new bathrooms are built in the area
• Refine the policy being implemented (arrange a CDD to listen to feedback from residents about the policy change affecting the community)
• Request participation of residents during the CDD
• Prepare fact sheets by compile data on the use or misuse of bathrooms before and after the policy is implemented, using the monthly logs.
• Offer public education by make brief presentations/training at local forums or CDDs to increase the knowledge and skills of the local people

Mobilize public support:

• Sponsor a public hearing by arranging a public forum or CDD to discuss sanitation issues and the new policies proposed

Make your presence felt:

• Initiate legal action by pursuing legal action against those who pose environmentally hazardous practices that may harm others in Komo.

REVIEW WHETHER THE PLANNED POLICY GOALS, STRATEGIES AND ACTIONS FIT THE SITIUATION.

• The policy goals use available resources from the Ministry of Public Health and Sanitation. The policy will be enabled by the CHWs who are health advocates within their community.
• The group members are comfortable with the approach because the approach was their idea and they have a sense of ownership in solving the problem.
• The policy goals are likely to work because the community is determined to end sanitation related illness.

CREATE AN ACTION PLAN TO CARRY OUT YOUR POLICY EFFORTS.

ACTION PLAN 

ASSESS THE EVALUATION OF THE POLICY DEVELOPMENT EFFORT.

Clearly state what indicators will signify "success":

After adopting the policies, there will be a significant decrease in sanitation-related illnesses. Success will be if children used the bathroom regularly and most importantly, when all residents have a restroom within close proximity to where they live, work, and play.

Describe how measures of success will be obtained:

The Chalkboard that is used by the community to track illnesses—pre and post policy implementations will provide a picture of whether the policies are making significant improvement. Other ways to measure success are CHWs observing the environmental changes. If people report satisfaction with the clean environment, that is also a measure of success.

Community members track their indicators on a chalkboard near the CDD meeting place

RESOURCES AND ACKNOWLEDGEMENTS:

• Kenya’s Ministry of Public Health & Sanitation (Miss Ruth)
• The community of Thika West (Komo)
• WHO office in Nairobi, Kenya