Tag Archives: indicators

Why is it so hard to measure handwashing with soap?

As Global Handwashing Day approaches, the WASH Results MV team explores the challenges of verifying changes in handwashing behaviour.

Hygiene has tended to be the Cinderella of WASH (Water, Sanitation & Hygiene): relegated to the end of the acronym and with hygiene promotion often having been treated as an afterthought in larger water and sanitation programmes. But good hygiene is recognised as an essential component in addressing the burden of disease, and hygiene promotion can be a cost-effective way of improving health outcomes. In linking payment milestones to sustained handwashing behaviour the WASH Results Programme is breaking new ground, and pushing against some of the limits of understanding in the sector. The programme has faced key challenges in how to establish what reasonable handwashing outcomes might look like, and the most appropriate way to measure them. This post draws on discussions within the Monitoring and Verification (MV) team on some of these issues, and resulting internal briefings.

What is a good handwashing outcome?

Across the WASH sector there is little established knowledge on the sustainability of WASH outcomes. Whilst the well-known (and well-resourced) SuperAmma campaign saw a sustained increase in handwashing practice of 28% after 12 months, it’s still an open question as to what level of behaviour change it might be reasonable to expect across differing countries, contexts and projects. This matters, because in a payment by results (PBR) context, payment is linked to achieving targets. Set targets too high and suppliers risk being penalised for failing to reach unrealistic expectations. Set targets too low and donors risk overpaying.

How do we measure handwashing?

Compounding the uncertainty over what reasonable targets may be, is uncertainty on how to measure achievement against those targets. There are several commonly accepted methodologies, but they all involve compromises. At one end of the scale there is structured observation of household handwashing behaviour. Considered the gold standard in measuring behaviour change, this can provide a wealth of data on the handwashing practices of individuals. But it’s also prohibitive to undertake at scale – the most rigorous designs can involve hundreds of enumerators making simultaneous observations. The feasibility of conducting such measurements regularly for a PBR programme is questionable.

A much simpler (and on the face of it, more objective) indicator might be the presence of handwashing facilities (a water container and soap). This is used by the Joint Monitoring Programme (JMP) to measure progress against SDG 6.2 because it is the most feasible proxy indicator to include in large, nationally-representative household surveys which form the basis for the Sustainable Development Goal monitoring (and typically collect data on WASH as just one of several health topics). However, these observations tell us nothing about individuals’ handwashing behaviour, or if the facilities are even being used.

Setting indicators for handwashing outcomes

Within the WASH Results Programme, the suppliers have tended to define handwashing outputs in terms of the reach of handwashing promotion (though evidencing how a programme has reached hundreds of thousands or even millions of beneficiaries leads to its own challenges). They have defined outcomes in terms of:

  • knowledge of handwashing behaviour,
  • self-reported behaviour, and
  • the presence of handwashing facilities.

The suppliers have taken different approaches to considering these indicators separately or as part of a composite indicator to attempt to reach a reasonable conclusion on what the sustained change in handwashing practice has been. Each of the indicators has drawbacks (self-reporting, for example, has been shown to consistently over-estimate handwashing behaviour), but by considering all of them, a more reliable estimate may be reached.

Where this process has become particularly challenging for the WASH Results programme, is in attempting to measure outcomes at scale and across highly diverse contexts. All too often the devil is in the detail and small details in how indicators are set and measured could lead to huge variations in results, in turn leading to major differences in what suppliers get paid for. For example, we may wish to define a standard for the presence of a handwashing facility as a water container and soap, but very quickly some of the following issues arise:

  • In some countries, ash is commonly used instead of soap: national governments may actively promote the use of ash, and in some areas, it’s almost impossible to even find soap to buy. But at the same time there is evidence that using ash (or soil, or sand) is less effective than using soap: and for this reason, handwashing with soap is the indicator for basic handwashing facilities for SDG 6.2. Should payment targets follow national norms, or would this be a case of paying for lower-quality outcomes?
  • In other areas households choose not to store soap outside because it can be eaten by livestock or taken by crows (a far more common problem than one might imagine). Do we adopt a strict definition and record that there is no soap (so hence no handwashing facility) or is it acceptable if a household can quickly access soap from within a building? Do we need to see evidence that this soap has been used?
  • Local practice may mean that handwashing facilities do not have water in-situ, instead people carry a jug of water to the latrine from a kitchen. Recording a handwashing facility only if there is water present may risk a significant underestimate of handwashing practice, but how can we determine if people actually do carry water? And does this practice adversely impact on marginalised groups such as the elderly or people living with disabilities?

And this is just for one indicator. Across all three (knowledge of handwashing behaviour, self-reported behaviour, and the presence of handwashing facilities) the complexity of the methodology for measuring the results can quite quickly become unwieldy. There are tensions between wanting to adopt the most rigorous assessment of handwashing possible (to be more certain that the results do reflect changed behaviour), what data it is feasible to collect, and what it is reasonable for the suppliers to achieve. The answers to these will depend on what the programme is trying to achieve, the results of baseline surveys, and the costs of measurement and verification of results.

There may not be an easy answer to the question of how to measure handwashing outcomes, but the experience of the WASH Results Programme suppliers has provided useful learning on some of the aspects that need to be thought through. As the programme progresses, the suppliers are continuing to refine their understanding of how best to approach this issue in the countries and contexts they work in, and iterate the indicators they use. What’s next? Well, exploring how the various handwashing indicators relate to improved public health could be interesting…

What can we learn from the Government Outcomes Lab?

Our Learning Advisor, Catherine Fisher, investigates a new research centre on outcomes-based commissioning and finds plenty of interest for the WASH Results Programme.

You know an idea has traction when the University of Oxford sets up a research centre to investigate it. This is the case for outcomes-based commissioning (aka Payment by Results), which is the focus of the new Government Outcomes Lab (GO Lab) based at the University of Oxford’s Blavatnik School of Government.

The GO Lab focusses on the interests and experience of government departments in procuring services in an outcomes-based way, rather than those of contractors (or suppliers, in WASH Results terminology) in providing them. It is a collaboration between Blavatnik School of Government and Her Majesty’s Government. The focus of the research centre is on outcomes-based commissioning that uses Social Impact Bonds (SIBs), a model in which external investors provide the initial investment for programme implementation which is repaid on achievement of outcomes. However, the GO Lab will also look at other models, presumably including that used in the WASH Results Programme in which the suppliers themselves provide the upfront investment.

The rationale for the GO Lab is as follows: “While numbers of, and funding for, outcomes-based approaches have increased over recent years, research has not kept pace with this speed of growth. Much is still unknown about whether outcomes-based commissioning will meet its promise….Through rigorous academic research, the GO Lab will deepen the understanding of outcomes-based commissioning and provide independent support, data and evidence on what works, and what doesn’t.”  (GO Lab FAQ) .

So far, the GO Lab has organised three “Better Commissioning” events looking at outcomes-based commissioning in different sectors in a UK context, namely Children’s Services, Older People’s Services and promotion of Healthy Lives.

A quick skim of the interesting post-event reports suggests that outcomes-based commissioning is seen as a way of promoting a greater focus on outcomes by providers (who may not already think in this way), of prompting innovation in service provision and of transferring the risk of new approaches from commissioners to socially-minded private enterprises. Similar themes occur in Results Based Aid discussions, although I’d suggest that the international development sector places a slightly greater emphasis on incentivising delivery, value for money and accountability to commissioners.

One aspect of the GO Lab work that caught my eye is their interest in the creation of Outcomes Frameworks which were discussed at each event: “Developing an outcomes framework is a key part of any SIB or outcome based contract, but accessing data and articulating robust metrics that can be rigorously defined and measured is often seen as a challenge by commissioning authorities.”  (Better Commissioning for Healthy Lives: a Summary Report, p 13).

This process of articulating appropriate metrics and identifying indicators has been a key area of learning within the WASH Results Programme and continues to be discussed. It was reassuring to see others grappling with similar challenges in different sectors, such as challenges of creating indicators that:

During this, the outcomes-focused period of the WASH Results Programme, we will be following the progress of the GO Lab with interest, and hope to find opportunities to exchange learning with them, and others researching innovative funding approaches. Our team is particularly interested in contributing to, and benefiting from, learning around:

  • independent monitoring and verification of outcomes-based contracts;
  • creating outcomes frameworks that reflect sustained outcomes in areas such as behaviour change (e.g. handwashing behaviours) and institutional change (e.g. ability of district stakeholders to manage water systems);
  • streamlining metrics and indicators while balancing needs of all parties: beneficiaries, service providers, commissioners and, in the case of international development programmes, national stakeholders and global commitments such as Sustainable Development Goals.

Catherine Fisher, Learning Advisor, WASH Results MVE Team

If you have any ideas or observations about this topic, we encourage you to Leave A Reply (below), or email us

Measuring progress towards SDGs: a Payment by Results perspective

Attending the 2017 WEDC Conference prompted our team members to share their reflections on measuring progress towards SDGs from a Payment by Results (PBR) perspective.

Some of the e-Pact Monitoring and Verification (MV) team recently attended the WEDC Conference – an annual international event focused on water, sanitation and hygiene (WASH), organised by the Water, Engineering and Development Centre (WEDC) at Loughborough University. One of the key themes this year was the Sustainable Development Goals (SDGs): what they are, how close we are to achieving them, and how we are going to monitor them. The SDGs are important for PBR programmes because they influence what programmes aspire to achieve and how they measure their progress.

The recent publication of the first report (and effective baseline) on SDG 6, covering drinking water, sanitation and hygiene, marked a watershed. With the shift to understanding universal and equitable access, the inclusion of hygiene and a focus on ‘safely managed’ and ‘affordable access’, the breadth and depth of data we aspire to have on water and sanitation services is unprecedented. But the first SDG progress report also highlights a yawning data gap: for example, estimates for safely managed drinking water are only available for one third of the global population, and we are only starting to get to grips with how to measure affordable levels of service.

As part of the WASH Results Programme, the three consortia are constantly grappling with how to objectively measure complex outputs and outcomes linked to water, sanitation and hygiene. At the same time our MV team is trying to understand how we can verify such measures, and if they are sufficiently robust to make payments against. How do the SDGs influence this process? We have three reflections from our experience of verifying results under the WASH Results Programme:

Reflection 1: the relationship between the SDGs and PBR-programming can be mutually beneficial.

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The SDGs help PBR programmes to set ambitious benchmarks

It’s clear that to track progress against the SDGs, the WASH sector is going to have to become a lot better at collecting, managing and analysing an awful lot of data. One of the learning points from the WASH Results Programme is that the verification process requires the consortia (and in-country partners) to take data far more seriously.

Compared to more conventional grant programmes, Monitoring and Verification functions take on the importance of financial reporting. One function of this, is that everyone has more confidence that reported results (whether access to water, number of latrines built or handwashing behaviour) accurately reflect reality. As such, PBR programmes can help focusing peoples’ attention on improving service levels.

Conversely, the SDGs help PBR programmes to set ambitious benchmarks and provide an orientation on how to measure them. This is proving important under the WASH Results Programme, which has, at times, struggled with aligning definitions, targets, indicators and how to measure them.

Reflection 2: some of the SDG targets are hard to incorporate into a PBR programme
Embed from Getty ImagesPhysical evidence of a handwashing facility doesn’t guarantee use at critical times

Measuring hygiene behaviour change illustrates this point neatly: the simplest way to understand if people are washing their hand with soap may appear to be just to go out and ask them. Yet self-reported behaviour indicators are notoriously unreliable. Looking for physical evidence of a handwashing facility (with water and soap) is the approach currently suggested by the WHO/UNICEF Joint Monitoring Program (JMP), but there is no guarantee that people use such facilities at the most critical times, for example, after defecation or before handling food.

Under a PBR programme (where implementers get paid against pre-defined results) the temptation to take the shortest route to success, namely focusing on getting the hardware in place, may be high. Therefore, it may be important to complement this indicator with a knowledge-related indicator to also capture behaviour change albeit in a crude way. This brings along another challenge: how to agree on appropriate, payment-related targets in a situation where experience on how to accurately measure behaviour change is still in its infancy?

Reflection 3: keeping indicators lean is challenging when faced with the breadth and depth of the SDGs

Hygiene behaviour change is just one indicator. Attempting to robustly measure changes across three consortia, eight result areas and two phases (output and outcome) has resulted in the MV team reviewing a large amount of surveys, databases, and supporting evidence since 2014.

Under the WASH Results programme, the sustainability of services is incentivised via payment against outcomes: people continuing to access water and sanitation facilities and handwashing stations for up to two years after they gained access to improved services. In the meantime, between the final MDG report, and the initial SDG report, the number of data sources used by JMP to produce estimates for the water, sanitation and hygiene estimates has more than doubled[1]. Instead of more traditional household surveys, increasingly, data is obtained from administrative sources such as utilities, regulators and governments.

How to marry these new data ambitions with the necessary goal to keep the number of indicators manageable under a PBR programme will be an interesting challenge going forward.

Katharina Welle and Ben Harris, MV Team, WASH Results

[1] Progress on drinking water, sanitation and hygiene: 2017 update and SDG baselines (p50) https://washdata.org/reports 

Is it time for Results 2.0?

Catherine Fisher reports back on a Bond Conference panel discussion about the origins and future of the ‘results agenda’.

Aid should generate results. On the face of it, an indisputably good idea, but the ‘results agenda’ is anything but uncontroversial and can spark “epic” debates. In the WASH Results Programme, this agenda is manifest in the funding relationship – Results Based Financing (RBF) – a form of Payment By Results (PBR) through which DFID makes payments to Suppliers contingent on the independent verification of results. As the Monitoring, Verification and Evaluation (MVE) providers for WASH Results, we’re keen to exchange the programme’s insights with those of other people who have first-hand experience of the results agenda.

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Credit: Bond/Vicky Couchman. Jessica Horn and Irene Guijt sharing their views on the ‘results agenda’ at the Bond Conference 2016.

One such opportunity arose this week at the Bond Conference, in a session entitled ‘How to crack Results 2.0’ chaired by Michael O’Donnell, Head of Effectiveness and Learning at Bond and author of ‘Payment by Results: What it means for UK NGOs’. The session considered the origins and implications of the results agenda and looked ahead to the next version. Catherine Fisher, Learning Advisor for the WASH Results MVE team, reports on a lively discussion about how results agendas could be aligned with work on social transformation, enable learning and reflection within programmes, and provide value for money themselves.

Looking back to the origins of results approaches in DFID

Opening the session, Kevin Quinlan, Head of Finance, Performance and Impact at DFID explained how, in 2010, DFID encountered two opposing forces: increased funding in order to meet the UK’s legal commitment to spending 0.7 percent of national income on Overseas Development Aid alongside the introduction of austerity measures that required cuts in, and increased scrutiny on, public spending. Results and transparency agendas were DFID’s response to those competing demands and made a shift towards delivering results now in comparison with systems strengthening for results in future. This implied a corresponding shift to talking about the results DFID is going to support rather than the activities they would support to achieve results in future. Six years on, DFID is reassessing its approach.

Can results approaches be reconciled with the “art of transformation”?

Earlier that day, Dr Danny Sriskandarajah, Secretary General of CIVICUS, told conference delegates that INGOs had become too focused on the “science of delivery” (which he described as the achievement of impact by any means) as opposed to the “art of transformation” – the work of bringing about social change. This theme re-emerged during the ‘Results 2.0’ discussion: how could the focus on hard results, embedded in results frameworks, be reconciled with the messy business of social transformation that is at the heart of struggles for equity and rights?

Jessica Horn, Director of Programmes at the African Women’s Development Fund, noted that results frameworks do not acknowledge power or monitor how it is transformed. Consequently she and her colleagues resort to what she called “feminist martial arts” – twisting and turning, blocking and jabbing to defend the transformative work they do, from the “tyranny of results”.  Often, Jessica argued, the politics of the process are as important as the politics of the outcome and asked “how does the results framework capture that?” Yet as Irene Guijt, newly appointed Head of Research at Oxfam GB, argued, being forced to think about results even in the social transformation context helps to make things clearer. Between them, they had some suggestions about how it could be done.

Irene contended that there needed to be greater differentiation of what kind of data we need for different reasons, rather than a one-size-fits-all approach to accountability. She argued that “results” are too often about numbers and we need to bring humans back in and tell the story of change. Irene recommended using the tool SenseMaker to bring together multiple qualitative stories which, through their scale, become quantifiable. Jessica shared some frameworks for approaching monitoring and reporting on social transformation more systematically and in ways that consider power, such as Making the Case: the five social change shifts and the Gender at Work Framework.

Does focusing on monitoring results for accountability squeeze out reflection and learning?

This criticism is often levelled at results-based approaches and their associated heavy reporting requirements. Irene commented that “learning and data are mates but compete for space”. To align learning and reflection with results monitoring, she advised focusing on collective sense-making of reporting data, a process that enables evidence-based reflection and learning. She also suggested streamlining indicators focussing on those with most potential for learning, a point echoed by Kevin from DFID who emphasised the need to select indicators that are most meaningful to the people implementing programmes (rather than donors).

Do results agendas themselves demonstrate value for money?

This question resonated with the participants, triggering musings on the value of randomised controlled trials and the cost of management agents from the private sector. One point emerging from this discussion was that often what is asked for in results monitoring is difficult to achieve. Indeed, this has at times, been the experience of the WASH Results Programme, particularly in fragile contexts (see for example, the SWIFT Consortium’s report [PDF]) . Both Irene and Jessica talked of the need to use a range of different tools for different purposes and Irene made reference to her recent work on balancing feasibility, inclusiveness and rigour in impact assessments.

What is the trajectory for DFID and the results agenda?

Kevin Quinlan took this question head on, agreeing that this is something DFID needs to decide in the next few months. He suggested that some of the areas for discussion were:

  • Getting to a more appropriate place on the spectrum between communication (to tax-payers) and better programme design; results are part of communicating to tax-payers but not the only part;
  • Reducing standard indicators in favour of flexible local indicators; each project would need at least one standard indicator to allow aggregation but there should be more local indicators to enable learning;
  • Alleviating the torture of results – “rightsizing” the reporting burden and reducing the transaction costs of results reporting; thinking about what results can do alongside other tools.
  • Adopting a principles-based approach rather than a set of rules.

Meanwhile the Evaluation Team for WASH Results is investigating some of the issues raised during the panel such as examining the effect of results verification on Suppliers’ learning and reflection, and seeking to explore the value for money of verification.

So it sounds like there will be more interesting discussions about the results agenda in the near future and we look forward to contributing insights from WASH Results*. Whether Results 2.0 is on the horizon remains to be seen.

* Please email the MVE Team if you would like us to let you know when our evaluation findings are available.