Association for Applied Health Education And Development » Latrines

Comparing CHC to CLTS

africaahead — Wed, 28 Dec 2011 15:17:10 +0000

The debate about the pros and cons of different strategies that are being used to mobilise communities and induce them to change their behaviour rolls on and this well reserached paper can add some factual information to the discussion. It summarises the outputs of latrine construction in three different projects areas in Zimbabwe. The CHC programme is our own project in Chiredzi run by Zimbabwe AHEAD which is compared to a CLTS programme run by PLAN International. They are then compared to an area where both strategies of CHC and CLTS have been used.

” CHCs were significantly more effective than CLTS in two key respects. Firstly, more people disposed of their faeces by some method other than OD (92% versus 77%), and secondly, the number of people who owned a HWF was far greater in the case of CHCs (64% versus 10%, p,0.0001). In terms of sanitation, only 26% of CHC respondents owned a latrine, although all of them had been built since the intervention started. A large number therefore (66%) claimed to practise cat sanitation; 44% of CLTS respondents owned a latrine, and it is interesting to note that 57% also shared their latrine with others, as opposed to 0% in the case of CHCs.”

The authors note the following:

Firstly, the CHC sample was a much poorer group and as they points out, building a latrine is strongly related to cash flow of the household. However despite lower income, 26% of the CHC households had built latrines since the project started with no subsidy. With another 66% practicing cat sanitation, there is a 92% sanitation coverage in CHC areas, with only 8% still defecating in the open. In the richer areas where CLTS was sampled, 57% claimed to share a latrine but this as this isrreported rather than observed, it is doubltful whether this is in fact the case, they are likely to be embarrased to admit they are using the bush! Although there was a better coverage of latrines in CLTS, none of them had been build since the triggering, so surely this is the point: CHCs have resulted in action, CLTS has not.

The second point which is in this paper is that whilst CLTS has a negligable effect on handwashing with only 10% with a handwashing facility, the CHC areas show a 66% improvement in handwashing, which goes a long way in blocking the fecal-oral route. The use of a latrine on its own, does not decrease diarrhoea effectively as there are so many other routes for germs to spread.

Finally, it is worth remembering that the building and maintainence of latrine and hand washing were the only two indicators that were compared in this research. Although this is the sum of the CLTS outputs, there are a wealth of other behaviour changes which have been achieved in the CHC Project. There is no mention at all about the immaculate kitchens and compounds, the management of solid waste and the cleanliness of the beneficiaries themselves because the research is narrowly focused on WATSAN issues in order to stay within the limited length and scope of a Masters Thesis.

Neither does ithe paper attempt to discuss the ethical aspects of the two approaches and there is little focus on whether the approaches are appropriate for the culture of the area.

However with more and more stories about the appaling way in which some community leaders in India have been assert their authority in order to coerce villagers into ODF, many planners are going off the quick fix that is the CLTS approach. They are beginning to look for a less contentious methods, which are in line with cultural values in Africa for equity and respect for elders. ‘Naming and Shaming’ may be acceptable in the caste-ridden culture of Asia, but in Africa to expose ones mother-in-law to shame because her turd was identified near her home is tantamount to an outright insult and could damage family relations permenantly. Perhaps this sensitivity is one of the reasons so many African countries are trying to find an alternative to CLTS, despite the hard sell by the proponents of the approach, who have been touring Africa in an agressive attempt to sell their dubious product. This is a pity as there are other more beign and more sustainable ways of achieving a demand for sanitation.

This paper provides a scientific rationale for using the more holistic CHC approach which uses positive, rather than negative peer pressure, to persuade people rather than embarass them into changing their traditional behaviour. Why have a narrow programme which goes only for sanitation with the limited CLTS approach when you can get the whole raft of public health measures achieved, and be sure to not only minimise diarrhoea but also malaria, bilharzia, skin disease, and worms all for the same cost. Its a no brainer, but it has needs research of this type to provide the proof. So here it is!

Give this a read: link http://africaahead.org/publications/2011_Whaley_CHC.pdf

Towards EDPRS ideals: Water access, hygiene and sanitation in Rwanda give new hopes and opportunities

africaahead — Mon, 05 Sep 2011 08:37:40 +0000

SUNDAY TIMES, KIGALI.

Friday September 2, 2011 by Thomas Kagera

Rwanda has committed itself to reaching very ambitious targets in water supply and sanitation, with the vision to attain 100 per cent service coverage by 2020. The importance of adequate water supply and sanitation services as drivers for social and economic development, poverty reduction and public health is fully acknowledged in Rwanda’s flagship policy documents and political goals. But by the look of things and according to the Permanent Secretary Ministry of Infrastructure, Marie Claire Mukasine, the sanitation coverage as a sub-component is likely to be 100 per cent by 2012.

“Even though our country is among the four sub-Saharan African countries that will meet the MDG on sanitation, we have our own targets and goals. We are planning 100 percent improved sanitation coverage countrywide by 2012,” the Permanent Secretary is quoted as having noted in one of the preparatory meeting for the AfricanSan3 that was recently concluded. The other countries are Angola, Botswana, and South Africa.

Access to improved sources of drinking water has reached about 74 per cent (rural: 71 percent, urban: 88 percent), according to the national inventory. Sanitation levels have evolved to write numbers from 38 per cent to 56 per cent. Coverage is currently rising at a rate which is close to the value needed to stay on track towards the flagship targets (EDPRS, MDGs, Vision 2020). However, to meet the targets it will have to continue to rise for another 4 percentage points every year. Given that population growth partly compromises the efforts to raise coverage this is equivalent to supplying on average 460,000 additional people every year (until 2012). Total latrine (or toilet) coverage in Rwanda is 96 percent.

Today, 32 per cent of Rwandans use piped water, but only 3.4 per cent have access to it within their house or plot (urban: 17 per cent, rural: 0.9 per cent). On average, households – women and children spend 29 minutes per day on fetching water in rural areas (9 minutes in urban areas).
By 2012, it is planned to increase the proportion of the rural population living within 500m of an improved water source from 64 per cent to 85 per cent, and to raise the proportion of the urban population residing within 200m of an improved water source from 69 per cent to 100 per cent.

Special efforts have been made to provide water services in grouped settlements in rural areas; Imidugudu and small towns or trading centres. The Electricity, Water and Sanitation Authority (EWSA), as a major partner in the cleaning and distribution of water, has engaged the services of cooperative movements in the supply of water. Of the 800 water supplying systems in the country, 30 per cent of these are operated and managed by Small and Medium Enterprises that have formed cooperatives.

Open defecation has practically been eradicated and most of Rwandan households have already financed and built their on-site private sanitation premises, and are now being encouraged to match them with the international standard definitions of an improved sanitation facility.
The excreta are disposed with waterless latrines, which is a rational solution considering the scarcity of the average water supply.

Major hotels, hospitals and some industries have installed their own (pre-) treatment systems. A conventional sewerage and treatment system for Kigali’s centre is in the planning process.

Rwanda’s schools benefit from the HAMS (Hygiène et Assainissement en Milieu Scolaire (School Sanitation) program since 2000, which focuses on behaviour change in hygiene practice including considerations for menstrual hygiene. The Community Based Environment Health Promotion Programme (CBEHPP) is particularly focusing on the communities to impart the values of and create the demand for behavioural changes.

In managing solid waste, the major towns are undertaking considerable efforts to maintain the urban environment clean. Plastic bags are forbidden within the bounds of the country. Sector harmonization is making significant progress and has prepared the ground for a Sector-Wide Approach (SWAp).

There is a very strong government commitment for sanitation exemplified by a sanitation community service day, at the last Saturday of every month. Well elaborated environmental health policy is also in policy and the Ministry of Health takes the lead in household sanitation and hygiene promotion, of course with a strong collaboration with the Ministry of Local Government.

Strategies

Private investments in Water and sanitation infrastructure have been encouraged and supported. The Ministry of Infrastructure is considering options to leverage private capital investments by providing low-interest loans, through output-based aid (OBA) or co-financing. Community management has continued to be the most common approach to ensure the organization and management of point water sources, such as protected springs and boreholes equipped with hand pumps. Communities and User Committees are supported and supervised by the Districts, with technical assistance from the Ministry of Infrastructure.

The concerned sector institutions – the Agency, RURA and the Ministry of Health – will cooperate to develop and implement a system for rural water quality control. This involves the clarification of responsibilities, the definition of standards, the development of viable operational procedures and the creation of decentralized laboratory capacities. The costs of urban water services are fully covered by user fees, in order to redirect public funds to extending service coverage (or, if need be, to rural areas where financial viability is more difficult to achieve).

Investments are funded by a mix of public grants, loans and internal cash generation as per a financial model. While external aid accounts for a large share in the short and medium term the EWSA will endeavor to access loans and increase the share of investment financed by internal cash generation.

A firm, permanent framework of cooperation has been established to coordinate the interventions of the different government institutions involved in sanitation and health promotion – essentially the Ministry of Health, the EWSA and the Districts. The Ministry of Health will continue to be the lead in the promotion of individual sanitation at the community level, essentially through its national Community Based Environmental Health Promotion Programme (CBEHPP).

The EWSA on the other hand, will be responsible for the development, evaluation and support of adequate technical sanitation solutions. Sanitation and hygiene components shall also be incorporated in each water supply project. The Water and Sanitation Fund (WSF) will be one of the sources of funding of the joint programme.

Ownership and behaviour change are critical steps for sustainably increasing sanitation coverage and improving hygiene practices. Government institutions therefore focus on promotion and facilitation, while households remain the main investor. Well designed sanitation programs have shown leverage ratios of up to 1:10 between public and private investments.

The demand for improved sanitation shall be promoted through a combination of; awareness campaigns related to visible and non-visible health impacts of poor sanitation and aiming at behaviour change, marketing the sanitation offer, targeting on people’s expectations and preferences such as comfort, status, health benefits, value or safety and education and training in schools and universities;

Other measures include the provision of limited material incentives or subsidies to accelerate the improvement, construction or replacement of sanitary facilities and using the provision of water supply services as an incentive and opportunity to improve sanitation facilities.

Rwanda homegrown initiatives that augment sanitation and hygiene

The government of the Republic of Rwanda has crafted a number of initiatives to extricate Rwandans from the depredations that emanate from poor hygiene and sanitation. Most of the interventions hinge on changing people’s mindset, but there are others in which considerable sums of money have been sunk.

The government’s resolve to eliminate grass-thatched houses (Nyakatsi) in the country is one such initiative of improving the living domestic environments. The plan has succeeded in getting people out of scattered grass thatched houses to decent houses in planned villages (Umudugudu). The government has taken advantage of local initiatives like community work, Army and Police week, Youth and Women week to engage in activities aimed at helping the vulnerable get decent housing.

The establishment of grouped settlements (Imidugudu) makes it easy and less costly to connect such areas to the national electricity and water grids, as the cost per individual connection substantially goes down. The use of clean renewable energy, is not only hygienically rewarding, but is as well environmentally friendly and sustainable. Through community work (Umuganda) that takes place every month, the general cleaning, tree planting and other activities all ensure a clean, green, inhabitable and hygienic environment.

The Step and Wash (Kandagira Ukarabe—being implemented by the Community Based Environment Health Promotion Programme under the Ministry of Health), is a campaign that has widely been commissioned across the country and embraced by Rwandans.

The use of local materials such as silt and cow-dung for the final coating and finishing of rural homesteads for those that cannot afford cement, has also improved the state of sanitation and hygiene among the populace.
Currently, the government is working with AFRITANK, to provide mobile toilets, as well as toilet slabs, all in effort to provide clean hygiene and sanitation facilities and services.
The government also mobilizes through radio and TV drama programmes such as Urunana, booklets and posters. Besides, after the community work that takes place at the last Saturday of every month, people are advised on the best hygiene and sanitation practices.

The Ministry of Health has trained Community Health Workers that number to over 45,000—three per village—who participate in peer education and collection and dissemination of health-related data. A lot of useful information on sanitation and hygiene is also compiled by the Community Health Workers and Environmental Health officers who remit it the Ministry of Health, which is then routed to respective ministries concerned for action.

The government of Rwanda through the Community Based Environment Health Promotion Programme, under the Ministry of Health, has encouraged the establishment of Community Hygiene Clubs (CHCs). A Community Hygiene Club (CHC) is a discussion group of peers from the same locality, who meet, identify their sanitation, hygienic and health problems or needs, and, through dialogue and using stimulant tools, get engaged in identifying solutions—together.

The CHC approach appeals to an inate need for health knowledge which is then reinforced by peer pressure to conform to communally accepted standards of hygiene, thereby creating a ‘culture of health.’ Members can, for example, decide that after two months, all members shall have built a drying rack, or a standard latrine or a bathing shelter. The ideas and concepts originate from the members and implemented by them. The government however, always comes out to give technical support and guidance.

Discipline and mindset change are some of the tenets that the government has fervently emphasized to ensure clean hygiene and sanitation. The government emphasizes upholding the dignity of every Rwandan, and sanitation and hygiene are some of the components that the leadership of President Paul Kagame has relentlessly put to the fore and, actually, helped implement.

CHCs take off in Vietnam

africaahead — Tue, 19 Apr 2011 14:35:44 +0000

April, 2011

Vietnam is the first country in Asia to pioneer the Community Health Club (CHC) Model of development to bring about hygiene behaviour change and improve sanitation coverage, adapting it to suit local cultures. If sucessful, Vietnam could lead the way as a powerful change agent for sound development in Asia ensuring that CHCs are as cost-effective as they have been in Africa for the past 15 years. Out of 48 CHCs established since 2009, six were assessed in the three Provinces of Son La, Phu Tho and Ha Tinh over a 10 day period. In each district a structured interview of provincial, district and commune MoH officials was conducted by the consultant to verify the CHC report for 2010. Existing MoH data from a pre and post intervention household inventory of all CHC members were used to measure knowledge and levels of behaviour change. Standard monthly reported cases in each Commune Health Centre Changes were examined to see if there was a pattern of disease reduction. The findings of this evaluation should provide lessons inform more effective replication and scaling up through the National Target Programme, now entering its 3^rd phase.

Under the Hammer and Sicle Muong Bu Community Health Club is thriving

There is clear evidence that the training in the CHCs, in 24 sessions spread out over the past two years has improved knowledge of health issues and that peer pressure within the CHCs is leading to very significent levels of behaviour change. For example there was a 42% increase in Ha Tinh and a 59% increase in Son La in good knowledge of how to make Sugar Salt Solution. Changes in hygiene behaviour are highly significant with a 58% increase in hand washing with soap in Ha Tinh . There has been a great effort at improving sanitation in the CHC areas, as demonstrated in Son La where 387 households (70% of the CHC members) improved their sanitation facilites, without any subsidy, and the household inventory showed that only 4 families out of 1,036 were found to still practice open defecation. Phu Tho Health Centres in CHC communes have recorded a sharp decrease in diarrhoeal disease since the CHCs started, by 90%, 93% and 59%. Although all communes in Thach Ha district (Ha Tinh Province) were targeted with the same IEC materials, diarrhoeal disease cases decreased by 35% in two CHC Communes but actually increased 18% and 31% in two non-CHC Communes. The CHC programme can be measured for cost per beneficiary at only US$1.30 for one year. This is remarkably cost–effective by any standards and compares well with similar projects in Africa. As one MoH official from Ha Tinh remarked the CHC Model is ‘low cost- high impact’.

Achievements in all three provinces were made despite the fact that the CHCs were started without using membership cards, an incentive which has always been a draw card for joining CHC. With the training material complete, there is little doubt that the CHC Model will be replicated easily, scaling-up by using recommendations and lessons learnt. The Pilot Project has demonstrated that the CHC model can improve sanitation coverage and with very little subsidy, significantly reduced diarrhoea within two years, simply by harnessing the power of peer pressure to ensure safe hygiene standards. Within an emphasis on group consensus, the CHC Model resonates with cultural norms in Vietnam, whilst the training enables Village Health Workers to run CHCs at very little extra cost within their duties. This pilot project should provide the NTP3 with a sound methodology that can be predicted to achieve the Millennium Development Goals in CHC districts.

WASH Response to Humanitarian Crisis in Zimbabwe

africaahead — Mon, 07 Feb 2011 10:19:52 +0000

Masvingo Community Health CLlub Project

Goal:

To reduce the vulnerability of at-risk rural populations in rural Masvingo to Water and Sanitation Related Disease (WSRD) transmission.

Objectives:

1) To increase levels of Water, Sanitation and Hygiene (WASH) knowledge, attitudes and practices through Community Health Clubs and School Health Clubs so as to decrease vulnerability to WSRD transmission.

2) To increase access to sufficient quantity and quality of water for drinking and domestic purposes through the rehabilitation of existing boreholes for communities in rural Masvingo affected by severe water shortages.

Introduction

A lot of activities were undertaken during the reporting period since the last meeting. It is our great pleasure to inform the house that there were no cholera cases in the project area. However we remain vigilant in the face of reported cholera and H1N1 cases in other parts of the district and nearby disticts with which we share boundaries. (221210 MoHCW WHO Zimbabwe Epidemiological Bulleting Number 88 Week 48).

CHC, SHC and CBM activities are running in earnest as the report will show.

Public Health Promotion

A community driven baseline inventory was conducted at 3872 households by the 33 CBFs prior to PHHE sessions with the following results:

Many of these practices have beeen recommended by other projects that have been implemented here in the last few years as shown by the high pencentage of refuse pits pot racks, covered water storage containers, individual cups. In addition it appears that many kitchens are decorated and there are many nutrition gardens. There is also a high percentage with knowledge of how to mae Sugar Salt solution. However there is still a gap where hand washing, water sources, use of ladle, sanitation coverage, and malaria prevention and control are concerned. The project will focus on these gaps and will seeks to redress the knowledge and this will be evaluated at project end.

Community Health Clubs

The project has now exceeded its project CHC target of 108 CHC as it now stands at 119 and still counting due to popular demand. Club membership stands at 5120 (360 to reach target) with sex aggregation at 1185 males (23%) and 3935 females(78%). Male participation is encouraging this part of the project as compared to other areas we have worked before. It will be interesting to find out what makes this difference.

School Health Clubs

9 SHC are running with a total club membershipof 1,115. They have just reopened after the holiday and more info will be available in the next meeting as they are settling down at the moment.

9 School headmasters participated in a day long WASH in schools capacity building workshop we conducted and this was also attended by the District Education Office.

Global Hand Washing day Commemoration

98 CHCs (then) in the 6 wards were mobilized to commemorate hand washing day. The occassions were marked by public health promotion in the form of hand washing demonstrations, dramas, poems, songs and dance. ZimAHEAD distributed IEC materials sourced from UNICEF in the form of 400 t-shirts and thousands of pamphlets and posters.The objective was to completely cut out WSRD during the festive season and this was achieved as none were reported.

Water Supply

WPUC (Water Point Upgrading Committee) trainings have started with ward 30 where 21 WPUC were established . The other wards will be trained in due course. Rehabilitation will start once the WPUCs are trained. VPM (Village Pump Mechanic) tools sets were delivered from Oxfam and ZA is chasing the variances.

NFIs

ZimAHEAD has procured the NFI (Non Food Items) vouchers and 3 suppliers have been identified as well as 1,700 beneficiaries drawn from the OVCs, the elderly, the chronically and the very poor as defined by the communities themselves. We hope to round up the process soon. What is left is the procument of soap. Close consultation with Oxfam is being maintained given the shooting prizes of soap on the market.

Notes from the Field

Regis Matimati, Director of Programmes Zim AHEAD

February 2011.

“The trip was fantastic. I drove with the Directors of Ministry of Health and Department of Infrastructure down to Chiredzi. We got to the village to a gathering of about 40 club members. I can’t start to describe the immaculate home and surroundings at the venue of the meeting. The kitchen, launch, temporary toilet, the flowers around the homestead, the infectious singing and dancing by other club members and the high KAPB. both the Directors Mr. Goldberg and Sibanda could not help but heap praise on ZA and the community for taking the CHC method up.

….

We then toured another household picked at random and there we saw a self initiated permanent toilet which was constructed following CHC participation. The club member, an elderly male was so proud of his home and ZA. His wife stays in Chiredzi town to be close to the hospital as she has a bad case of arthritis but the home looked so clean that one would think their was a maid doing the chores there but when asked the Sekuru (uncle) said “…..how can I leave in dirt when I am a club member? …… I attended the club to learn and after the lessons I can’t go back to dirt…” This bowled over both our visitors. The Sekuru’s children had even laminated Sekuru’s graduation certificate!

…

The next day we started by visiting the PMD (Provincial Medical Director) who was not in the office but we then met the PEHO Provincial Environmental Health Officer) and the Chief Hygiene Officer (CHO) and his team. The CHO, a

very charismatic man gave an update of ZA’s work in Masvingo. After that we went into the locations where we saw 3 clubs including a new one.

…

The Garikai club was a delight to see and the club leader gave a splendid over view of the project. We then toured their area.

Everyone was impressed by the urban CHCs as they thought it was impossible for urbanites to form a strong community like that.

Uganda IDP Case Study – pdf download

africaahead — Wed, 20 Jan 2010 11:10:55 +0000

In 2005 Community Health Clubs were started in IDP Camps in Northern Uganda, where numerous NGOs had been trying to introduce safer sanitation for the past 18 years in one of the worst ongoing conflicts in Africa. Inspite of much sceptism that nothing could be done to aleviate this chronic public health situation, the 120 CHCs managed to achieve unheard of changes in the camps, with the most convincing indicator being the construction by the community of over 11,000 latrines in eight months, not only meeting but exceeding ambitious targets. If ever there was a proof of the effectiveness of CHC to create a demand for sanitation this case study is it!

Uganda IDP Case Study

Uganda

africaahead — Mon, 18 Jan 2010 06:55:58 +0000

READ THE LATEST NEWS FROM UGANDA – (click here)

COMMUNITY HEALTH CLUB PROJECTS

1. CARE International (funded by Gates Foundation)

In 2003, Africa AHEAD provided training for 23 facilitators from HIDO, a local NGO and a PHAST Toolkit was developed specifically for the IDP Camps. Trainers were then posted into 15 Internally Displaced People’s camps in Gulu District. Within a month over 116 Community Health Clubs with over 15,000 members, had been registered and weekly sessions were held for six months. By this time over 11,256 latrines, as well as 11,709 pot racks, and 2127 hand washing facilities had been constructed. This record breaking number of latrines highlights the power of the CHC Approach to create a strong demand for sanitation even crowded IDP camps, in an emergency setting within a short period of time.

2. Malaria Consortium – HIDO (funded by Unicef):

The approach was then taken to Pader District, also a refugee area in Norther Uganda, by HIDO (in partnership with Malaria Consortium). Another 35 health clubs were established with 2,599 members in 8 IDP camps and within 5 months 51% (1,318 members) had built latrines as well constructed 400 rubbish pits, 1,644 pot racks and 810 bathrooms.

3. Lutheran World Federation:

Based on recommendations in an evaluation (by Cranfield University), Community Health Clubs were started in Katakwi by Lutheran World Federation. In October 2006, a local EHD trainer who had co-facilitated with Africa AHEAD in the Gulu Trainer successfuly trained LWF field staff in PHAST and the CHC approach. By March 2007 there was a 40% uptake of sanitation. This was important as it shows how replication does not depend solely on Africa AHEAD, and points the way forward as to how Uganda can scale up CHCs without external consultancy.

4. WaterAid and partner NGOs pilot CHCs:

In May 2008, Africa AHEAD provided training for WaterAid local partners to enable them to start up Community Health Clubs in various areas of Uganda: Busoga Trust in Southern Uganda, whilst SSWARS and AEE operate mainly in Kampala. WEDA, another highly successful implementing partner is currently conducting a successful program in Katakwi using Clusters rather than health clubs and will be integrating some of the CHC ideas into their home grown health promotion methodology.We await an update on how these organisation have adapted the CHC Approach to their own contexts.

Accredited CHC Trainer: Justin Otai (MoH); Victor Kwame (HIDO)

Africa AHEAD Consultant: Dr. Juliet Waterkeyn

PRACTISING ORGANISATIONS:

CARE International; HealthIntegrated Organisation for Development (HIDO); Malaria Consortium, Unicef; WaterAid; UWASNET, Lutheran World Federation; WEDA; SSWARS; AEE; Busoga Trust

TRAINING MATERIAL: MoH PHAST Training Manual (available in country from EHD-MoH)

REPORTS: Waterkeyn. J. (2008) Africa AHEAD Scoping Study: Community Health Clubs in Uganda. Part 1. WaterAid Uganda.

PUBLICATIONS

UWASNET: Uganda Water and Sanitation NGO Network, Members Directory 2007-8

UWASNET. Group Performance Report for 2007.

Okot, P., Kwame, V., and Waterkeyn, J. (2005). Rapid Sanitation Uptake in the Internally Displaced People Camps of Northern Uganda through Community Health Clubs. Kampala. 31st WEDC Conference

Mpalanyi.J. and Mukama.D. (2007) Documentation of best practices (BOP) in hygiene and sanitation in districts of Uganda. WSP – AF.

Joint Annual Review supported by WSP

In November 2004 at the 10th ‘Joint Health Sector Review’ government officials and development partners resolved to commit themselves to an ‘Undertaking for Sanitation’: to work together to integrate and coordinate existing resources towards implementation of best practice in hygiene promotion and sanitation, and to ensure that by October 2005 every administrative district in the country will have work–plans, budgets and active district water and sanitation committees. Anthony Waterkeyn has been appointed onto the secretarial committee that is developing the ‘Health Sector Strategic Plan’ for the period 2005 -2010 where a new emphasis on preventative health and the importance of hygiene and sanitation, are being given added prominence. In September 2004 the 4th ‘Joint WSS Sector Review’ agreed on 12 key sector undertakings for the next year. These included advancing sector reforms; support to districts for sanitation planning and coordination; and, sector wide investment planning. WSP-AF will play a role in promoting good practices and sanitation resource flows assessment at the district level.

For full article click here

Contact: Anthony Waterkeyn, WSP-Africa, awaterkeyn@worldbank.org; WSP-Africa, wspaf@worldbank.org

Hygiene & Sanitation Strategies in Uganda: How to Achieve Sustainable Behavior Change?

Waterkeyn, A. (2005). Hygiene & sanitation strategies in Uganda: How to achieve sustainable behaviour change? Kampala, 31st WEDC Conference.

Abstract: Breaking the faecal:oral disease transmission route is a vital first step towards overcoming preventable disease and, ultimately, poverty. Simple knowledge transfer, whatever methodology is employed, does not automatically result in changed or improved behaviour. There is growing consensus that to achieve behaviour change in hygiene and sanitation practices communities, both rural and high-density peri-urban, need to be supported in ways that will stimulate social cohesion and result in group decisions being taken. Such cohesion and the building of social capital can ensure that peer pressure comes to bear and poor hygiene practices can thus be challenged. This paper considers several approaches to Hygiene Promotion and Sanitation that are currently receiving attention. It attempts to tease out some of the common threads that appear to be stimulating social cohesion and peer pressure towards achieving behaviour change that will be sustained and also considers the current hopeful situation in Uganda.

For full article in pdf, click here: Hygiene and Sanitation Strategies in Uganda: How to Achieve Sustainable Behavior Change

Hygiene Behaviour change monitored in Umzimkhulu

africaahead — Mon, 18 Jan 2010 06:40:57 +0000

BACKGROUND

Umzimkhulu Municipality in Sisonke District of KZN was selected by the Department of Water Affairs to pilot this project that was initiated as part of the IWRM (Integrated Water Resource Management) programme being funded by the Danish Embassy (DANIDA). Umzimkhulu was part of the Eastern Cape until it was recently absorbed into Kwa Zulu Natal. The area has one of the lowest levels of development in KZN as demonstrated in this base-line survey which highlights that safe drinking water supply is a major challenge with only 15% of households having access to a safe water source whilst the remaining households have to use open ground water, usually in the form of unprotected springs. As this surface water is open to contamination it needs to be treated or boiled before consumption. Sanitation usually consists of a household pit latrine and although the coverage is high at 90%, around 50% are unhygienic, smell and attracted flies which would account for the high levels of diarrhoea in the area. Most social scientists would agree that changing people’s hygiene habits is notoriously difficult, and there are few good case studies to-date. Africa AHEAD was commissioned as service provider to introduce a health promotion campaign in the 1st phase of an holistic development package that would build the capacity of the community through health clubs, with the objective of developing a community-led demand for improved water and sanitation. Although Africa AHEAD has initiated Community Health Clubs in informal settlements, this is the first pilot project in South Africa to be implemented in a rural community.

THE COMMUNITY HEALTH CLUB APPROACH

It has been shown in a review of over 100 studies that Health Promotion alone can reduce diarrhoea by 33%, while hygiene changes such as ensuring safe drinking water can diminish diarrhoea by 15%, safe sanitation by 35%, and safe handwashing with soap by 47% (Esrey, 1991). As the Community Health Clubealth promotion campaign in nine wards of Umzimkhulu. In February 2009, worki
Approach is known to be capable of achieving high levels of behaviour change (Waterkeyn & Cairncross, 2006) it was chosen as the strategy for a hng with the Umzimkhulu Municipality and local councillors, a Community Health Club was started in each ward. Africa AHEAD trained facilitators from the community in how to conduct health promotion sessions using PHAST participatory activities to promote hygiene behaviour change. Almost 1,000 members were registered and weekly sessions were held in all nine wards. Attendance rates varied according to the proficiency of the facilitator, but although most members attended some sessions, there were 550 hard-core members who completed all 24 health topics within six months. Certificates were awarded at a Graduation Ceremony in September 2009, attended by district and provincial representatives which marked the end of the pilot project. In the next phase, relevant government departments are planning to use these well mobilised communities to improve water, sanitation and quality of life through agricultural and income generating activities.

RESULTS

The levels of behaviour change as a result of this project are exciting, with an overall average of 20%. In the post intervention survey (September 2009), it was found that 76% of all registered members are now following the recommended practices promoted during the weekly health promotion sessions. Whereas before the project only 18.1% had safe water, there is an 41% change. Although the water source is still not safe, 51% now treat their water,86.1% store it safely and 87% take it using a ladle, so minimizing contamination. Sanitation has improved by 14%, from 71.1% with no open defecation to 87.8% of members having ZOD (Zero Open Defecation) defined as clean covered latrines with no faeces. In addition, whereas only 29% of member households had dedicated hand washing facility near their latrine at the beginning of the project, 70.1% have now constructed a simple facility that allows them to wash their hands immediately upon exiting their latrine. Even more impressive is the use of soap for hand washing that has risen from 40.1% in February to 68.4% six months later. An observable indicator is an 18% drop in Ringworm seen in CHC households, a disease caused by infrequent washing and lack of soap, 87.7% mother can now prepare SSS correctly, so saving babies that might have died from dehydration. There is little doubt that family health has been improved where health clubs have been established in Umzimkhulu, and demand to scale up this programme to all other wards is high. Meanwhile the self-motivated improvements that some HealthClubs have already made contingency measures to protect their water sources.without any external financial or technical assistance. Each CHC now has a trained building group, now constructing safe latrines on demand for members. This display of self reliance validates the CHC Approach, which aims to empower communities so that they manage their own health and utilize existing resources more effectively, at least until government can provide the required services.

RESEARCH METHODOLOGY

METHOD

Study Type: Intervention Study
Sampling: Purposeful
Technology: Mobile Research Platform
Enumerators: Seven local CHC facilitators
Health Clubs: Seven
Total Membership: 1000
Hard Core membership: 550
Sample Size Baseline: 469
Sample Size Post Intervention: 538

Demography of the CHC Respondents

Total Female Male
Total Number of Respondents 251 311 60
Median Age 40 38.5 39.2
Married 45% 45% 45%
Single 22% 50% 36%
Widowed 24% 3% 13%
Household size 5 4 4.5
Christian Denomination 46% 48% 47%
Christian Apostolic 53% 43% 48%
Traditional Religion 0.4% 5% 2.7%
Education & employment
No schooling 7% 4% 5%
Primary only 37% 33% 35%
Secondary 38% 35% 36%
Matric + passed 18% 28% 23%
Unemployed with Matric + 70% 56% 63%
No formal income 51% 58% 54%

Prior to the training a base line survey was conducted in all nine wards, with most Community Health Club members being interviewed. Each month, this ‘household inventory’ was redone, and hygiene changes as represented by the 12 observations in household inventory were tracked by the community facilitators. There are more respondents in the post intervention as members increased. Two of the facilitators failed to complete the surveys correctly and the data was rejected. Although preliminary finding in were higher in Round 5, (August 2009) the data in this poster shows the final round 6 data using only 7 out of 9 CHCs to ensure correct claims (September 2009). One observation ‘pour to waste’ hand-washing method was ignored as it was obsolete when members adopted the hand washing facility which was a more reliable indicator , being more observable.

TECHNOLOGY

Most household surveys are conducted on paper, and this leads to much human error and spoilt forms. To speed up data collection and collation and minimize human error, an innovative tool has been used in this research. A standard mobile phone was issued to each facilitator with the Household Inventory installed. Responses could be keyed eliminating human error, and data sent like an sms to a central website where results were updated automatically and instantaneously. This eliminated manual computer entry, and thus much time and error was saved. The monthly monitoring with cell
phones gave facilitators a more glamorous role, and the members responded to this monitoring (Hawthorne Effect) by making changes
that were recommended. Thus the monitoring has contributed as much as the methodology to the high rates of behaviour change.

Observed Home Hygiene changes before and after 6 months of weekly health promotion training sessions

Baseline Post Increase
Treated Drinking Water 18.1 59.3 41
Use of a Ladle 73.3 87.7 14
Safe Water Storage 78 86.1 8
Safe Food Storage 79.7 92.4 13
Use of Pot Rack 72.1 89.4 17
Zero Open Defecation 71.1 84.8 14
Hand Wash Facility 29 70.1 41
Use of Soap 40.9 68.4 28
Use of Rubbish Pit 74.2 86.6 12
No Ringworm 72.3 89.6 17
Make SSS 69.3 87.7 18

Average Increase in behaviour change 20%

Recommended Practices p>0.001

Active Members of CHCs

Baseline n=469 Post Intervention n=538

Purposeful sample of 3 wards

Demography of the CHC Respondents

CONCLUSION

The hygiene practices of Community Health Club members have been significantly improved as a result of the health and hygiene promotion using the CHC approach.

There is a high demand for safe sanitation (Ventilated Improved Pit latrines) & safe water sources (protected springs)

As the faecal-oral transmission route has been broken in all CHC areas by safe water, food, sanitation (Zero Open Defecation), and hand washing with soap, diarrhoea should be effectively minimised in Umzimkhulu.

Umzimkhulu Base Line Survey

africaahead — Mon, 18 Jan 2010 06:39:05 +0000

March 2009. J. Rosenfeld & J. Waterkeyn

The base line survey has been completed for Umzimkhulu and provides some guidelines as to the most pressing gaps in health knowledge that can be filled and hygiene behavior that can be changed by the Community Health Clubs. Based upon the results of this report, and given that the three selected villages are representatives of the whole of Umzimkhulu, it would appear that the CHC Approach can make significant differences in the lives of the participating communities. The three selected villages represent a high, medium and lower living standard and it is reasonable to assume that the rest of the district will fall somewhere in between. It would also appear that the topics to be done in health promotion sessions are indeed appropriate for the target communities, and that the training can proceed without alteration to the training materials. If the 24 health sessions are completed as planned we can expect that there will be significant improvement in health knowledge and behavior, and would predict an average of between 20-30% change in most hygiene behaviours.

: 80% of households that were in the three case study areas in Umzimkhulu still rely on open water sources such as this ‘spring’

The training intends to focus on water usage and storage, safe disposal of human faeces and solid waste, as well as diseases that can be prevented by poor hygiene such as diarrhoea, scabies, ringworm, and intestinal worms. This report highlights that there is indeed room for improvement in all these areas. 80% of the households that were surveyed in the three villages still use unprotected water, and 51% have dirty latrines, 60% had a fly problem in kitchens of with only 43% of those with left over food making any to protect food from flies. 55% of households reported rats were a problem and with 74% reporting a rubbish problem and with 54% of households having solid waste within close proximity, these are areas that can be improved significantly. Handwashing probably provides the best opportunity to impact on the prevalence of diarrhea as only 8% households use soap regularly. As regards levels of health knowledge there is little doubt that the programme will register a significant rise in good health knowledge from the average of 18.6% for the six topics which were asked.

It is also clear that the district of Umzimkhulu is an ideal area for a pilot project as the level of safe water supply, sanitation and general hygiene is decidedly low as compared to more developed areas in Kwa Zulu Natal. This low base line will enable a clear measurement of impact using the proxy indicators that have been carefully linked to the training and the recommended practices which are expected to be put into place within the next six months. Given the current low provision of safe water supply and adequate sanitation, this base line report should to circulated to service providers of water and sanitation to alert the relevant authorities that within a few months there will be a sudden demand as a result of this training programme, and that planning to deal with this demand should be already in place to ensure a seamless transition from demand creation to improved living conditions in Umzimkhulu.

Now that the base line survey is complete, the Community Health club training will start in 10 wards. the facilitators have been selected from the community and are being trained in bi-weekly sessions. They have already mobilised their communities and initial response is very encouraging. There are estimated to be an average of 75 members per club and one club has even exceeded 150 people all looking forward to the future training. Most facilitators have already done five sessions and will be finished within another five months.

Start up has been delayed by two months due to slow uptake by some councillors but reports are now coming in that the councillors are excited about the initial activities and those that were slow to apply for the project are now regretting the fact that they missed the deadline. At present this project is supported by Danida and IWRM until June 2009 through the Department for Water Affairs and Forrestry but given the demand there is likely to be a viable programme in Umzimkhulu for many years to come and support is being sought for the scaling up of this novel approach that holds such promise for the poorer areas of KwaZulu-Natal.

Beautiful Bhutanese Bathrooms

africaahead — Mon, 19 Jan 2009 15:49:30 +0000

The Directors of Africa AHEAD, Juliet and Anthony Waterkeyn have recently been on a combined consultancy to Bhutan at the request of SNV, which is the leading development agency supporting Government in this extraordinary hidden Himalayan Kingdom.

The objects of the consultancy were twofold:

1. Anthony to assist in developing an appropriate design for Bhutanese sanitation;

2. Juliet to design a base line survey for measuring the effectiveness of the future two year health promotion programme.

BASE LINE SURVEY OF HOME HYGIENE

The survey took place in the southern Geog (District) of Nangong, a two day drive from the capital of Thimphu in the far west- over the most massive mountain ranges and through the spectacular scenery to Permagatshel (Place of the Lotus) in the south east. This was not the end of the journey. The twelve enumerators and SNV staff then shouldered their rucksacks and set off on a four hour trek up another few mountains, while Juliet was provided with a long suffering mule to ferry her to the hidden mountainside where the survey was to take place. Ten days later the survey of 146 households had been done and the preliminary results were available.

SANITATION DESIGNS FOR BHUTAN

Anthony Waterkeyn had meanwhile been criss-crossing the country visiting schools and monasteries and households in the poorest settlements to assess the current problems with sanitation. Although Bhutan has made massive strides in the provision of water and sanitation to over 80% of its tiny population of roughly 650,000 scattered through this isolated Kingdom, the decrease in disease has been disappointing. Although latrines do exist in high numbers, there are many that are not used, and those that are used are poorly maintained, and seldom very inviting.

The current thinking in the health sector of Bhutan is that a strong health promotion campaign is needs and Community Led Total Sanitation has been proposed as a method, based on its success in neighbouring Moslem communities of Bangladesh. However this approach can be misused and become a top down drive by local leaders which may not be appropriate in these gentle Buddhist communities, where rats cannot be killed as they too are sentient beings. Africa AHEAD is proposing the use of the CHC Methodology as there is little doubt that it would be culturally appropriate given the national value for Gross National Happiness.

Another outcome of this consultancy has been the design of a Beautiful Bhutanese Bathroom (BBB): this combines the effectiveness of the VIP latrine in reducing odour and flies, with a shower room, so that washing is encouraged given the added privacy. The squat hole is designed so that it can accommodate a pour flush system, and the squat hole can be exchanged for a seat for the infirm or disabled. The external design of this versatile latrine matches the houses of Bhutan, one of the most beautiful styles of building to be found in an underdeveloped nation. The latrine is constructed of local wood which is used for the traditional houses. The forests of Bhutan are some of the most extensive in the region and are well regulated by the government in this eco-conscious nation. The idea is that toilets should not be an object of disgust but rather a status symbol: every bit as beautiful as the home. At the King’s request all the houses in Bhutan are in the national style of architecture which demands much painting with intricate religious symbols and even an un-Bhuddist eye can marvel at the most humble of dwellings. So the BBB design is not only practical but also in keeping with National values contributing to the unique concept of Gross National Happiness. It is hoped that the BBB may contribute towards the household’s everyday happiness by providing an appealing sanitary retreat, perhaps even a place of quiet meditation where one can escape from daily chores to enjoy a quiet moment to attend to one’s ablutions!

Creating demand for sanitation and hygiene through Community Health Clubs:

africaahead — Sun, 17 Feb 2008 10:40:38 +0000

Waterkeyn, J. & Cairncross, S. (2005). Creating demand for sanitation and hygiene through Community Health Clubs: a cost-effective intervention in two districts of Zimbabwe. 61. Social Science & Medicine. p.1958-1970.

Abstract: Unless strategies are found to galvanise rural communities and create a demand for sanitation, we cannot achieve the Millennium Development Goal of halving the 2.4 billion people without sanitation by the year 2015. This study describes an innovative methodology used in Zimbabwe – Community Health Clubs – which significantly changed hygiene behaviour and build rural demand for sanitation. In one year in Makoni District, 1,244 health sessions were held by 14 trainers, costing an average of US$0.21 per beneficiary and involving 11,450 club members (68,700 beneficiaries). In Tsholotsho District, 2,105 members participated in 182 health promotion sessions held by 3 trainers which cost US$ 0.55 for each of the 12,630 beneficiaries. Within two years, 2,400 latrines had been built in Makoni, and in Tsholotsho latrine coverage rose to 43% contrasted to 2% in the control area, with 1,200 latrines being built in 18 months. Although Zimbabwe has historically relied on subsidies to stimulate sanitation, this intervention shows how total sanitation could be achievable; the remaining 57% Club members without latrines in Tsholotsho all practised faecal burial, a method previously unknown to them. Club members’ hygiene was significantly different (p < 0.0001) from a control group regarding 17 key hygiene practices including hand washing, showing that if a strong community structure is developed and the norms of a community are altered, sanitation and hygiene behaviour are likely to improve. This methodology could be scaled up to contribute to ambitious global targets.

For full article in pdf, click here: Creating Demand for Sanitation and Hygiene Through Community Health Clubs