2004  WSP-EA/World Bank. 

Waterkeyn, A. & Waterkeyn, J. 


The current concern over the lack of cost-effectiveness of PHAST in East and Central Africa prompts us to enter the debate to argue that PHAST should not be abandoned as it can be very effective if it is taken the extra mile. The programme described below is a variation of the PHAST Methodology and was implemented by Zimbabwe AHEAD, a local NGO, during the same period as the national PHAST training was taking place through the Ministry of Health in Zimbabwe. The NGO was working closely with UNICEF in the initial phase of  the PHAST programme and was a major contributor to the National PHAST Tool Kit which was used throughout the country for training. The PHAST programme in Zimbabwe was substantial with over 9,000 trainers introduced to PHAST, but in the long term this did not translate into community programmes except in two districts. However, the cost-effectiveness of hygiene behaviour change could not be assessed accurately as the target audience was ill-defined and the outputs were unspecified and unmeasurable. In view of this, the NGO sought to  ‘add value’ to PHAST by developing a system of monitoring and evaluation that is able to quantify levels of behaviour change.

This methodology  sought to use the standard participatory training method of PHAST but within a more structured programme i.e. ‘structured participation’. Health promotion is the entry point into a four stage process which has become known as the AHEAD Approach (Applied Health Education and Development). Community Health Clubs are the ‘vehicle’ for hygiene promotion with the benefit of having a consistent membership who attend health sessions weekly and who are monitored using membership cards. The concept of the ‘club’ is a subtle but important difference between this approach and standard PHAST interventions. In addition, a structured ‘syllabus’ of health information is followed with standardised recommended hygiene practices for each member.  Thus PHAST is ‘repackaged’ into a methodology that has now shown itself to provide the missing ‘social’ link that is needed if we are to persuade people to change their behaviour. (Waterkeyn,1999, 2000, 2003) To evaluate the cost-effectiveness of the AHEAD approach, an extensive survey was conducted in three districts of Zimbabwe in 2001, with 1,250 health club members and a control of  260 non members, with spot observations of randomly selected households. 

Taking an average of the eighteen observable proxy indicators, there was a significant difference between health club members and non members of  50% in Tsholotsho, 18% in Makoni, and 7% in Gutu (p=>0.001).  Health Knowledge increased by 48% in Tsholotsho, 20% in Gutu and 8% in Makoni. In many cases particularly in Tsholotsho, the difference was highly significant with 92:3% for pouring method of handwashing, 95:46% use of ladle, 97:22% for use of individual plates and 86:10% use of individual cups, whilst cat sanitation increased from nil to 57%, with an increase of latrine construction of 40% (p=>0.001).   It has been calculated from detailed project records that in Makoni District where 14 trainers conducted 746 health sessions in seven months running 141 clubs with  10,620 members,  the project cost amounted to 43c (US$) per beneficiary. With the latest study of PHAST in Uganda estimated from US$16-24 per beneficiary, the Zimbabwe experience should be revisited.  With such immense investment in PHAST in the past ten years it would be wasteful to abandon the approach – rather it needs to more structured. The recommendation of this article, based on empirical evidence is this: situate PHAST within a Health Club structure and it will provide cost effective behaviour change. (Waterkeyn & Cairncross, 2004)