This learning brief will explore experiences of water, sanitation and hygiene (WASH) system strengthening during the COVID-19 pandemic, through drawing on content from Hygiene Hub case studies and discussions with Hygiene Behaviour Change Coalition (HBCC) partners, as well as evidence and practice from numerous WASH and health stakeholders. We explore the different types of system strengthening activities implemented, common challenges encountered and key lessons and action points, before reflecting on cross-cutting challenges and lessons. This document, although drawing on WASH systems thinking, focusses primarily on water and hygiene. We also include two case studies from Amref and WaterAid which provide in-depth examples of system strengthening activities.

There are numerous roadmaps which can be followed when conducting WASH system strengthening. Activities are explored using an adapted version of WaterAid’s WASH system framework (image 1). For building block frameworks, there is a focus on examining all blocks to ascertain where the strengths and weaknesses lie, so that we can identify the block (s) with the greatest potential for improvement. When reading this brief it is crucial that we don’t lose sight of the larger picture, as all blocks must be functional across all levels to achieve a strong WASH system.

We have incorporated institutional arrangements and capacity with co-ordination and integration. Before reading this brief, we recommend that you read our resource which outlines the basics of system strengthening. You can also view WaterAid’s System Strengthening Toolkit for more insight.

In this section, we explore the various system strengthening activities implemented throughout the pandemic from 2020-2023, with a focus on hygiene behaviour change but also the wider WASH portfolio and vaccines, which were central to the COVID-19 response.

From the outset, effective and efficient government leadership is critical to ensure appropriate, context-specific and durable strategies to achieve WASH systems which are inclusive, well-financed, responsive and adaptive. Strong government leadership also ensures that programmes are aligned with national policy and regulation. It is also crucial that citizens trust governments during outbreaks; trust influences the degree to which citizens embrace information, adhere to guidelines and engage with health systems, as well as influencing risk perceptions.

The pandemic presented numerous challenges, including – mistrust in government, which created barriers to health seeking behaviour and adherence to guidelines. Others grappled with governments under prioritising COVID-19 due to more pressing demands e.g., natural disasters and conflict. Government transitions, diversities between actors, cumbersome bureaucratic processes, unsystematic collaboration and insufficient data management and warning system capacities, also hindered responses.

Governments positively led responses based on evidence and guidance from the World Health Organisation (WHO), what they were seeing and hearing on the ground and interactions with other governmental counterparts. Hygiene behaviour strategies commonly included – mask wearing, hand hygiene (HH), physical distancing, vaccine uptake, and cross border efforts (e.g., hygiene infrastructure at border crossings and movement restrictions). Some governments were more stringent on certain preventative behaviours than others, depending on policies (e.g., mask wearing). The following provides national and international level insights into government led action with a range of stakeholders.

National

International

Lesson 2: Outbreak responses require harmonised, cross-sectoral approaches which unite a range of actors under a shared vision, enabling actors to play to their strengths and mount integrated hygiene behaviour programmes.

Strong coordination and integration / institutional arrangements and capacity are central in mounting an effective outbreak response. This typically includes the integration of WASH into existing government programmes and the alignment of agencies behind united goals, strategies and policies, as well as there being necessary institutional capacity with clear roles and responsibilities.

Common challenges during the pandemic included evolving priorities, budgets and commitments of different parties, particularly during humanitarian crises, elections, and political unrest. Power dynamics within ministries also presented challenges, as did undefined roles and responsibilities and fragmentation, driven by insufficient frameworks and accountability measures. Programmes were also hindered by inadequate coordination of stakeholders, impacting timelines and effectiveness.

Despite these challenges, actors formed novel partnerships, drawing on each other’s expertise and institutional capacities to mount integrated programmes. Below we explore several examples of strengthening activities.

Action point 2: Prioritise inclusive collaboration and integration through forming multi-sectoral partnerships. Ensure key stakeholders are included, priorities and capacities are mapped, and that structures and processes are in place to strengthen accountability and transparency. Use existing public health programmes as an entry point where possible.

Lesson 3: Robust, adaptable financing is essential in mounting effective hygiene behaviour programmes and because each context has unique financing systems, capacity and challenges, there is no silver bullet. The process requires considerable investment in preparation and planning.

Strong financing, characterized by accurate costing plans, fiscal decentralization, private sector investment, flexible funding, district channelling of external funds and accurate lifecycle costing, is fundamental from the outset of any outbreak response, including COVID-19.

Finance strengthening efforts encountered various challenges, including unreliable external support, characterized by inflexible, “stop-start” funding and misaligned donor priorities, favouring short-term efforts over long-term strengthening activities. Similarly, there were competing priorities, impacting investment in WASH generally, with government WASH expenditure also proving difficult to track, due to fragmented budget coding practices. Efforts were also hindered by inadequate financial accountability, costing challenges (in terms of tools and technical capacity) and economic challenges e.g., inflation and fuel crises.

Actors overcame challenges through forming novel partnerships, diverting funds to COVID-19 programmes, strengthening national capacities and designing tools to optimize available funds. Below we explore examples of finance strengthening interventions.

In the Philippines, general operational and maintenance (O&M) costs of facilities are the responsibility of the MOOE (Maintenance and Other Operational Expenses), which sits within budget lines of schools and can be used for maintenance, however it is difficult to accurately cost O&M of WASH facilities and activities. These costing gaps became increasingly challenging during the pandemic, when there was an unprecedented demand on WinS. In response, GIZ launched the O&M mobile app in 2021. The application enables schools to input context-specific details (e.g., number of school days per year, number of toilets and classrooms, with the cost of locally available materials), to produce an annual budget estimate which complies with global recommendations from the WHO and UNICEF. The budget details the annual cost per student and school, as well as the quantity of tools and materials required per annum. This information is vital to developing the School Improvement Plan and Annual Implementation Plan, supporting mobilisation of resources from stakeholders and ultimately identifying areas for cost cutting.

Action point 3: Invest in the preparatory phase, to ensure there is clarity on rationale, objectives and scope of WASH finance strategies. Safeguard finance strategies by presenting a combination of policy actions that, together as a package, aim to ensure the financial sustainability of hygiene behaviour and WASH programmes. Establish financing modalities which enable scaling of programmes through diverse partnerships.

Lesson 4: Whilst timely, mass implementation of water sources and hand hygiene infrastructure is undeniably important, the long-term sustainability and resilience of such hardware and software should never be overlooked.

Environment and water resources are a crucial during any infectious disease outbreak which typically introduce unparalleled WASH demand. In a durable system, there would be coordinated management of water resources, including protection and management policies. Robust systems also include water resource threat monitoring which feeds into resilience planning, and ample infrastructure and supplies to support behaviour change interventions.

Efforts to strengthen environment and water resources were hindered by climatic variations, market and financial challenges. For instance, there was a lack of effective procurement processes due to market and financial failings (e.g., inflation and lockdowns restricting functional markets) causing implementation delays. The financial viability of utilities was also overlooked and there was a hesitancy towards simple, low-cost infrastructure, given the unknown magnitude and timeframe of the pandemic.

Actors overcame challenges through partnering with national governments and utilities to implement low-cost hand hygiene infrastructure, provide free water and strengthen operation and maintenance (O&M).

Action point 4: Prioritise sustainability through strengthening O&M, local markets, governance and accountability mechanisms. Include government, regulators, utilities, communities and other stakeholders in water and hand hygiene infrastructure plans and strengthen technical and financial viability. Strengthen climate change resilience through supporting local monitoring and analysis of seasonality and water source data.

Lesson 5: Harnessing existing strategies and policies can improve the efficiency and sustainability of WASH responses – foster what has worked rather than reinventing the wheel. Incorporating renewed capacity assessments is essential when planning and implementing appropriate hygiene behaviour programmes which meet local needs.

Strong policy, strategy and planning which ensures universal access to sustainable and resilient WASH services and hygiene behaviours is essential. To achieve this, thorough formative research which aligns programmes with the needs of affected populations is key.

Strengthening efforts were hindered by numerous challenges including a lack of defined roles and responsibilities, ever-evolving priorities and budget re-allocations and insufficient stock of key supplies e.g. soap and vaccines. Despite this, actors and governments successfully collaborated to harness existing policies and strategies and developed appropriate WASH and behaviour change programmes.

Action point 5: Focus on assessing local capacity (especially absorptive) and follow up to ensure that implementation aligns with agreed strategy, plans and budgets. Keep tools and processes simple and ensure hygiene behaviour interventions are locally led and aligned with national and international guidelines. Ensure appropriate policies and strategies are in place to strengthen design, implementation and evaluation of hygiene behaviour change programmes.

Lesson 6: There is a wide range of populations and contexts which may be more vulnerable to COVID-19 and each situation is unique – hence, gender and inclusion must be embedded from the get-go.

WASH and hygiene behaviour change programmes must be equitable and respond to the specific needs of different types of populations, including groups who may be more vulnerable to COVID-19, such as women, older people and people with disabilities, minority groups, indigenous populations, people with pre-existing conditions and care givers. Effective and accountable gender and inclusion necessitates actively involving these key populations in decision-making, having group members occupy leadership positions and collecting disaggregated data. For further information on inclusion, see our resource on defining vulnerability and our learning brief on identifying who may be vulnerable.

Challenges to strengthening gender and inclusion were largely related to prioritisation and accessibility. There was inadequate prioritisation from actors and donors, marked by insufficient engagement with populations who may be vulnerable, potentially due assumptions that the pandemic would be short lived. Actors also experienced challenges in accessing populations who may be vulnerable, finding accessible locations and designing and implementing programmes which reached groups affected by the digital divide. As the pandemic progressed and the stark inequities became ever-more apparent, actors began focusing on strengthening the inclusivity of programmes – see below for some examples.

Action Point 6: Ensure that equity and inclusion is embedded from the start and individuals and or groups who may be vulnerable to COVID-19 are actively engaged throughout the programme cycle to achieve tailored hygiene behaviour responses.

Empowered communities are central to any WASH system. Programmes should empower communities, including marginalised groups, to demand their human right to WASH services and behaviour change and actively engage in the project cycle, to ensure that services meet their needs. For an in-depth exploration of community engagement in COVID-19 response programming, see our resources on community engagement, developing materials and choosing delivery channels.

The pandemic presented numerous challenges associated with remote engagement, like overcoming the digital divide, effectively using social media and ensuring mass and digital media was accessible and engaging. Others experienced difficulties engaging certain groups, with strategies proving ineffective in certain populations. Competing priorities, myths and misconceptions, vaccine hesitancy and message fatigue all contributed to awareness-action gap due to limited adherence, complacency and disrespect of government policies.

Despite this, actors successfully mobilised and empowered populations through community engagement, capacity strengthening and making the right choice the easy one. Subsequently, preventative behaviours were enacted and promoted by societies and communities united to support one another, vocalise their needs and demand change.

Action point 7: To empower communities to adhere to hygiene preventative behaviours and overcome COVID-19 fatigue, community engagement approaches must be informed by thorough pre-existing and or new research which includes evaluation of trusted and appropriate delivery channels. Hygiene behaviour campaigns must be tailored to local populations and use multiple channels to disseminate creative, nuanced and positive messages that promote community spirit and collective action.

Effective service delivery and behaviour change is key in ensuring that COVID-19 preventative behaviours are adopted. Effective responses are characterized by ample coverage and post-implementation support, institutional and community capacity strengthening and the use of multiple, tailored touch points.

One of the most significant challenges was that responses typically prioritized hardware over behaviour change, contributing to the awareness-action gap. Even when behaviour change interventions were implemented, they were not always tailored, and theory based. There was also a misconception that because SARS-CoV-2 was a novel pathogen, we had to reinvent the wheel. Moreover, long-term investments in financial and human resource were typically lacking. Gaps in water access due to water scarcity and or insufficient durable water infrastructure also impeded HH interventions. Market access and affordability of soap was also an issue.

Actors overcame these challenges through collaborating closely with other actors and adopting novel approaches to service delivery and behaviour change interventions. See below for some examples.

Image 12: Hygiene promotion messages on bread packaging. Source: Hygiene Hub

Image 13: WaterAid’s Handwashing on Wheels. Source: Hygiene Hub

Action point 8: Prioritise the behaviour change dimension of WASH interventions through implementing tailored, immediate to long-term interventions which are embedded in behavioural frameworks. This includes investing resources to identify which behavioural determinants to target and how.

Lesson 9: Disease outbreak responses need government-owned monitoring systems which collect reliable, trusted, and timely data aligned with national and global standards. This will achieve sustainable, adaptable systems which support evidence-based learning and accountability.

Robust monitoring systems are vital to any disease outbreak response, as they support coordinated planning, adaptability, evidence-based decision making, accountability and community empowerment. Monitoring should begin prior to implementation, continue after programme completion and demonstrate learning.

Challenges included difficulties attributing engagement to behaviour change (exacerbated by remote data collection methods), scalability and sustainability. Short-sighted responses (at least initially) prioritised acute responses over implementing sustainable monitoring systems, culminating in inadequate data, impeding responses. Moreover, numerous novel frameworks and information synthesis tools, coupled with a desire to use the latest tools, resulted one-off data collection exercises with different baselines, feeding into isolated systems. Whilst the development of institutionalized frameworks, embedded in existing government structures, is key in enhancing sustainability, it is a long, resources intensive process which requires sustained political will and close collaboration with numerous actors. Similarly, updating national indicators to align with international standards requires coordination and buy-in and from all stakeholders, making it time consuming.

Actors overcame challenges through collaborating with local actors, strengthening local capacity, developing improved indicators and creative, community-led data collection systems. See below for some examples.

Action point 9: Ensure that monitoring systems are integrated into national structures and provide local capacity strengthening if required. If indicators do not align with national standards (including disaggregation), work with governments, JMP and UNICEF to update them. Integrate quality validation measures and where possible, avoid self-reported data. Depending on whether quality or coverage are priority, involve communities in data collection to strengthen coverage and adherence (at potential detriment to the quality). Generate evidence to inform current and future programmes and assess effectiveness.

Lesson 10: It is essential that WASH and hygiene behaviour programmes are accountable to affected populations, governments and donors, and that programmes align with national and international regulations.

Accountability and regulation are characterised by mutual accountability from governments and actors, institutionalised accountability mechanisms which harness feedback to inform programmes, accountability of duty bearers to civil society and operationalisation of national WASH guidelines.

Challenges included corruption, inadequate accountability in fragile contexts, insufficient resource management and mistrust among key national stakeholders. Moreover, because inadequate regulation and accountability is typically due to political representation and judicial processes, it can be difficult to address. Some programmes were also unresponsive to certain communities (e.g., informal settlements), resulting in inequitable responses. Everchanging government priorities and regulations and unclear roles and responsibilities also hindered programmes, as did the short-sighted approach to the pandemic.

Actors strengthened accountability and regulation through investing in formative research, designing creative and accessible remote solutions, aligning programmes with government regulations, and implementing novel tools to strengthen accountability. See below for some examples.

Action point 10: Ensure that accountability and regulation are embedded in organisational processes from the get-go. This includes using accountability frameworks, regulatory frameworks and capacity strengthening regulatory actors and includes ensuring accountability for sustainability. Strengthen accountability to affected populations through inclusive feedback structures and promoting two-way communication, with a focus on engaging people who may be more vulnerable to COVID-19.

Below, we synthesise cross-cutting challenges and make clear recommendations for how to address them when designing and implementing WASH system strengthening activities for hygiene behaviour programmes.

Misalignment between acute outbreak response and long-term outlook, resulting in unsustainable responses - a tendency for actors and donors to prioritise timely, short-term responses over focusing on sustainability and resilience, impeding system strengthening efforts across the WASH system and contributing to the lack of system strengthening visibility in general.

Recommendation: Broaden efforts to focus on building sustainable, government-led programmes with resilience to future outbreaks and climate change, embedded in a systems approach. Where possible, draw on existing structures (including local business and service providers) and strategies and harness local staff and community volunteers to increase reach, sustainability and local ownership.

Vaccine hesitancy and COVID-19 fatigue, fuelled by misinformation, inadequately designed behaviour change interventions and challenges associated with remote engagement, feeding into overarching issue of behavioural intention-action gaps, as well as insufficient engagement of youths.

Recommendation: Embed interventions in behaviour change theories, invest in using pre-existing data sets and conducting formative research, use multiple channels and deliver interventions at a high frequency and intensity, include positive motivational content/assets supported by engaging activities, and tailor to specific groups and contexts. Use a mix of face to face and low-cost learning platforms to reach wider populations and ensure material is engaging through using videos, radio, TV, interactive voice recordings (IVR) or WhatsApp peer-to-peer learning groups. Always ensure that interventions and communication channels are tailored to specific populations.

Numerous financing challenges, including unreliable and inflexible donor funding, a lack of prioritisation and funding for the WASH and more specifically for hygiene as a standalone, insufficient capacity and over complex costing tools, as well as a tendency for funds to be reallocated without close follow-up.

Recommendation: The cylindrical, context-specific nature of system strengthening requires an adaptive approach and flexible funding - advocate for flexible donor funding and investment in hygiene as an equal to water and sanitation in WASH or more. Support mobilisation of government funds. Focus on assessing financial capacity, building technical financing skills and implementing simple financing tools.

External challenges, including climate change, economic crises, political dynamics and humanitarian crises, causing logistical challenges, market variations in prices and availability of key basic needs commodities and shifting priorities and budgets.

Recommendation: continue focusing on building sustainable and resilient systems, integrate COVID-19 efforts with other parallel emergencies, provide capacity strengthening on using epidemiological, climate change and market monitoring data.

Lack of harmonised monitoring and technical capacity – an excess of novel monitoring tools and frameworks, resulting in a lack of harmonised efforts and generalisable data. Additionally, not all national indicators comply with JMP and the process of updating them is convoluted and lengthy. Finally, there is a lack of local data management capacity (data collection and analysis) in some settings.

Recommendation: JMP and other relevant stakeholders should develop and support countries to achieve harmonised monitoring systems which require relatively low technical capacity and collect disaggregated data, as well as implementing cross-country learning initiatives to deliver capacity strengthening. For hygiene, JMP should consider introducing feasible indicators beyond facilities as these proxy outputs do not necessarily reflect behaviour.

Lack of collective goal and vision amongst governments, actors and affected communities, all with different priorities and budgets, being driven by inadequate stakeholder coordination.

Recommendation: harness the 10 building blocks of the WASH system frameworks presented by WaterAid to develop a collective goal and vision amongst all stakeholders. Ensure a diverse range of stakeholders, including groups who might be particularly vulnerable to COVID-19. Systems thinking puts people on the same page, but strengthening approaches must balance agility and practicality – the need for long-term strategic planning with the need to implement change quickly.

Installing and maintaining sustainable hygiene infrastructure, due to inadequate O&M training and SOPs, a lack of clear roles and responsibilities, inadequate water supply and a desire for expensive or temporary infrastructure.

Recommendation: develop clear roles and responsibilities supported at the local and national level with an O&M plan, obtain buy-in from utilities and local artisans and provide capacity strengthening to respond to demand, draw on local resources/markets and use permanent or semi-permanent infrastructure.

Inclusion is not being prioritised in a compelling way, especially those with limited access to remote communication channels, infrastructure and markets.

Recommendation: inclusion structures must be embedded in programme design, including initial mapping and needs assessments, and key groups must be engaged throughout, including in design of infrastructure and accessibility audits must be conducted to ensure that infrastructure is inclusive. Disaggregated data must be collected, and representative groups should be engaged to reach populations with appropriate interventions.

Numerous coordination and collaboration challenges within and between governments and key actors, including navigating power balances and political dynamics, inadequate prioritisation of wider collaborations through sector/cluster and taskforce meetings, a lack of clear roles and responsibilities, in part due to absence of clear guidelines and SOPs and competing priorities and budgets.

Recommendation: focussed efforts and structures like TWGs are key to building rapport with a diverse range of stakeholders to develop guidelines and SOPs which clearly outline roles and responsibilities. To achieve efficient TWGs, ensure working groups embed structural processes (e.g., elect leader) and encourage engagement with other key collaborative groups, such as sectors/clusters and taskforces. Encourage joint sector reviews and monitoring. Additionally, support engagement with cross-country learning and focus on obtaining buy-in from government.

Challenges of strengthening government leadership, including delays due to bureaucratic processes and review of materials, stretched capacities and SOPs/guidelines, aligning priorities and navigating playing a facilitative role, but also expressing expert opinions when you believe that mistakes are being made.

Recommendation: to achieve long-term change, sustainability and local ownership, national governments and organisations need to be in the driving seat – international actors should play a facilitative role, supporting national actors to identify weaknesses and solutions which harness local systems and actors. Gauging absorptive capacity is also vital – programmes must be realistic and align with local capacities.

This learning brief was written by India Hotopf with support from Jenny Lamb, both part of the Hygiene Hub. Valuable inputs were also provided by Bella Monse (GIZ), Marvin Marquez (GIZ), Rogers Moraro (Amref), Joanna Esteves Mills (WHO), Tara Vernon (WSUP), Om Prasad Gautam (WaterAid), Hannah Crichton-Smith (WaterAid), Ian Gavin (WaterAid), Catherine Grasham (University of Oxford), Katrina Charles (University of Oxford). Editing support was also provided by Meriel Flint-O’Kane (LSHTM) and Fatima Ahmed (LSHTM).

Published on August 25, 2023

The COVID-19 Hygiene Hub is housed at the London School of Hygiene and Tropical Medicine (LSHTM) and developed in partnership with Center for Affordable Water and Sanitation Technology (CAWST) and Wash’Em.

The Hygiene Hub is funded by the Foreign Commonwealth and Development Office (FCDO).

This project was made possible by UK aid from the UK government, however the views expressed do not necessarily reflect the UK government’s official policies.