2.  Central Cote d’Ivoire – 2009 - 2011  Ongoing Conflict and Political Instability  Water and sanitation systems neglected and/or overwhelmed  High levels of maternal and child morbidity and mortality

3.  Goal –  Reduce maternal and child morbidity and mortality  Objectives –  Increase access to protected water sources  Increase access to adequate sanitation facilities  Teach and encourage members of the target population to practice proper hygiene

4.  Phase 1 Hardware  36 villages in Tiébissou, Didiévi, and Sakassou  Rehabilitated 50 pumps  Dug 13 wells  Connected 4 HCs to village water supply networks  Constructed 148 demonstration latrines

5. Building on Lessons Learned – “Hardware” is necessary, but …

6. We need “software” … but what is “software”? Address behavioral factors that influence health outcomes Promote sustainability through community ownership and maintenance of hardware improvements

7. - Trained 222 members of 37 Water and Hygiene Committees

8. Qualitative Process Evaluation Objective : To explore community perspectives on the functionality and sustainability of water and hygiene committees

9. Methods Submitted for ethics review to JHSPH IRB and National Committee of Ethics and Research of the Ministry of Health and Public Hygiene of Côte d’Ivoire Evaluation conducted in 6 program villages in Didiévi, Tiébissou, and Sakassou Health Districts (2 villages / district) Qualitative research methodology to elicit community perspectives and community- identified solutions Research activities conducted in Baoulé

10. Methods Transect walks Focus Groups Committee Members Village Leaders Women Men In-Depth Interviews Committee Members

11. Analysis Digital recording Translated and transcribed focus groups and interviews from Baoulé to French Developed list of “codes” and “codebook” Applied codebook to transcripts using Atlas.ti qualitative data analysis software For each code or theme, identified important subthemes

12.  All committees remained active  Committees were engaged in activities such as:  Management of pump surveillance, cost recovery, and maintenance  Hygiene promotion  Reporting on committee activities and finances to community leaders and members

13.  Perceived improvements in health and hygiene, as well as management of water resources  Dedication to sustaining the work of the committees post-intervention: If IRC isn’t here anymore we will continue to work…because we know that as long as we do our work well and the pump is managed with the dues, we will still be able to repair the pump. The villagers will always have water because water is vital. It is because of this that we will not stop working.” President, Tiebissou 1

14. Focus on sustainability issues related to:  Selection of committee members  Time management and motivation  Cost recovery systems and maintenance

15.  In all but one village, traditional leadership played a central role in the choice of committee members, however full community participation (ex. democratic elections) was limited  Key Criteria for Selection  Good character, ready to work as volunteer  Representativeness (by akpassoua / extended family or neighborhood)  Availability  Gender  Permission from family  Because process led by leadership, often candidates were not aware of selection, but felt obligation to accept “work of the village”

16.  Impact of lack of participation/representativeness “They took them all from one neighborhood, yet the village has 5 neighborhoods. Because they come from the other neighborhood, we don’t see that they sensitize us. They sensitize the people in their neighborhood.” Leader, Tiebissou 2 “We know them, but we don’t know why they were selected or when.” Male Villager, Tiebissou 2

17.  Gender – Availability of women “When the elders got together, they preferred that we take only men… The women, when you choose them, they will maybe say tomorrow that they don’t have the time. And so the activities of the pump won’t be well managed... Because with women it’s bothersome since the women take care of the children in the morning and wouldn’t have the time to manage their activities well. Women also need to prepare meals in the evening.” Leader, Tiebissou 2

18.  Members generally felt that workload of committee was manageable  Sources of motivation:  Seeing improvements in health and hygiene  Noble self-sacrifice for “work of the village”, clear understanding of voluntary nature at outset  Appreciation for knowledge/skills gained in training  Hope that knowledge/skills would lead to employment

19.  Perceived improvements in health and hygiene “Before, we would drink water and we didn’t know that it would cause illnesses. When your eyes would see the water, you would think that the water was clean and yet it was doing us harm. Before, we had diarrhea, epidemics of diarrhea. Now, we don’t see these epidemics anymore. We are satisfied, very satisfied. We want the project to go far and to progress here.”” Village Mechanic, Sakassou 1

20.  Serving community, gaining skills The day before yesterday, the pump was leaking. My colleague called me to come and tighten it and we did it. If it were before, the smallest nut and bolt to tighten, they would have made us pay dearly. So this helps us.“ Mechanic, Didievi 2

21.  Members generally felt that workload of committee was manageable  Sources of motivation:  Seeing improvements in health and hygiene  Noble self-sacrifice for “work of the village”, clear understanding of voluntary nature at outset  Appreciation for knowledge/skills gained in training  Hope that knowledge/skills would lead to employment  Sources of discouragement:  Feeling that work deserved remuneration  Insults they received from community members while conducting activities and lack of behavior change  Wanting more recognition from community

22.  Lack of community support “Every day the committee goes into each courtyard to sensitize people, to tell them to cut back the plants, to make the village clean. There are people that do it; there are people, on the other hand, that don’t do it, and on the contrary give them the cold shoulder, insult them. But it’s not because of this that the committee will get discouraged.” Female Villager, Didievi 1 “You have to be brave to hold the position of hygienist because people insult us…There is a lot of verbal abuse. The chief endures it, and so does the president of the committee.” Hygienist, Tiebissou 2

23.  Community satisfaction with systems for cost recovery and management of funds

24.  “Now if the pump breaks down there aren’t any more dues to contribute that are the cause of disputes in households. Now the committee members that were put in place repair it and we hear that the pump broke down but that it was repaired. And we are very much in joy.” Leader, Tiébissou 1

25.  Community satisfaction with systems for cost recovery and management of funds  Increased transparency of repair process

26.  “ We didn’t know the price of the parts [for the pump] and IRC gave the prices to the committee mechanic. We can see on the paper the normal price and no longer have to dispute the price with the repairman. He can’t swindle us anymore.” Committee President, Tiébissou 2

27.  Satisfaction with systems for cost recovery and management of funds  Increased transparency of repair process  Limited revenues from sale of water (especially during rainy season), request income-generating activities

28.  “There was a breakdown, [the IRC field agent] came to see…and he said 200,000F. When we look in the savings box we can’t reach 100,000F, let alone 200,000. Like that, what are we going to do to spend the 200,000F? It’s because of this that I ask that you help us financially. Ask IRC to please help us, to face up to the needs of the pump.” Treasurer, Didievi 2

29.  Satisfaction with systems for cost recovery and management of funds  Increased transparency of repair process  Limited revenues from sale of water (especially during rainy season), request income-generating activities  Dissatisfaction with limited training of village-level mechanics

30.  “We ask IRC to help us so that we can work tomorrow when IRC is no longer here. Because if IRC isn’t there, our mechanics, we will be obliged to run and fetch the artisan réparateur. Today, if there is a breakdown, our mechanics don’t know the work well. But if [they have more training] we will no longer have the need to go far. They know that it is a voluntary thing – they won’t ask for money before they go to make the repairs.” Hygienist, Didievi 1

31. Discussion  Water and hygiene committees are a means for meaningfully engaging communities in key “software” elements such as hygiene promotion,,cost-recovery, and maintenance  However, a range of factors at all levels of programming contributes to ability of water and hygiene committees to achieve sustainability  Conducting qualitative process evaluation can help to engage communities and project staff to develop richer, contextual insight into these factors and adapt strategies accordingly

32. Limitations  Resource and security constraints limited the number of villages included in the study and the amount of time spent per village (~6 hours)  Potential for bias due to perceived need to report certain perspectives in order to maintain/increase investment from the IRC/donors  Post-electoral conflict from 2010-2011 limited ability:  to take a more iterative data analysis approach  to engage in more thorough member checking  to develop and more fully integrate recommendations into ongoing programming