An Overview Of Our Solution
Africa AHEAD pioneered the Community Health Club approach to public health in 1994 in Zimbabwe. The model has since been adopted and enshrined into national thinking in the National Water Policy (2013) and the National Sanitation and Hygiene Strategy (2011). The Community Health Club approach uses the same participatory activities as PHAST, but within a more STRUCTURED FRAMEWORK with ACHIEVABLE TARGETS in Community Health Clubs. Community Health Clubs serve as vehicles for change. The Community Health Club approach achieves behavior change because it uses POSITIVE PEER PRESSURE (PPP) and SOCIAL SOLIDARITY (SS) to influence people’s thoughts and actions. Members meet weekly using a membership card that lists all the identified public health and developmental needs of the specific community. Communities hold periodic peer reviews and a graduation at the end
- Population Impacted: 40,000
- Continent: Africa
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Context Analysis
Africa AHEAD works in rural and urban poor communities of Zimbabwe. Zimbabwe grapples with unemployment, a failing economy, floods alternating with drought, and diseases (crops, livestock, and humans). This myriad of challenges makes it difficult for resilience. Safe water coverage is around 80% while sanitation coverage is around 23%. Poor sanitation leads to contamination of the water drinking water supplies and periodically both rural and urban Zimbabwe grapples with typhoid, cholera, and dysentery. Unplanned urban settlements, inadequate water treatment chemicals, and aged water, and sanitation infrastructure results in open defecation and burst sewerage systems overflowing on the streets and vleis. Inadequate and poorly resourced environmental health personnel in rural areas also contribute to poor water and sanitation programming. The high cost of operations and maintenance activities (spares and equipment) also inhibits the early recovery of broken-down infrastructure.
Describe the technical solution you wanted the target audience to adopt
Despite adopting the Community Health Club approach back in 2011, Zimbabwe has paid lip service to this effective model. There hasn't been much government-sponsored ACTION in making sure the communities are mobilized into CHCs. Africa AHEAD proposes to enroll communities into CHCs so that we impact their behavior and promote self-supply water and sanitation initiatives and health-seeking behavior. Targeted subsidies will be availed to vulnerable community members while the rest will self-supply. The project will deploy motorbikes for environmental health officers monitoring the CHCs and supporting water quality monitoring and treatment. Low-cost water abstraction methods (rope and washer pumps) will be promoted. Incremental sanitation using the upgradable UBVIP will also be promoted to improve sanitation coverage and to reduce open defecation. Technical support will be offered to upgrade the Rural Water Information Management Systems (RWIMS) to monitor safe water availability.
Describe your behavioral intervention.
Communities everywhere like to participate in their own development. In the past government and donors would provide water and sanitation infrastructure for households but increasingly the funding has dried up in recent years. The need for self-supply has never been so imminent like it is right now. Participatory activities were very popular in the 1990’s. However now it is realized that although PHAST attracts a lot of interest from the community and is excellent at enabling people to talk and analyze, these activities alone do not often result in people changing their behavior. Surveys of PHAST activities (WSP, 2006) in a large program in Uganda and Tanzania (Bibby, 2005) have shown that behavior change is minimal. As the objective of health promotion is to get people to ACT it is clear that a more defined structure has to be given to ensure that participatory activities result in BEHAVIOUR CHANGE.
With DFID funding in Tsholotsho and Gutu Districts and Danida support in 20 wards in Makoni District all EHTs being trained in the CHC approach. Wherever Health Clubs were started they flourished and by 2001 there were over 600 health clubs in Zimbabwe with 300,000 direct beneficiaries, taking into account the families of health club members.
Importantly, many health club members have built their own latrines and family wells unassisted in the past decade, making the CHC approach a model of ‘Self Supply’ for safe water and sanitation (Matimati, R & Waterkeyn, J. 2015)
Behavioral Levers Utilized
As needed, please explain how you utilized the lever(s) in more detail.
People living in the neighbourhood are often not 'Community'; they do not necessarily have common unity. The Community health Club builds common-unity in communities by affording a platform to sit, chat, listen and discuss issues with neighbours in a friendly edutaining environment. Factual information about disease causality coupled with positive peer ressure and intertwined with social solidarity results in unity of purpose towards achieving set goals. Community priorities are redefined and in the case of water and sanitation, every villager becomes their brother/sister's keeper as they motivate and police each other on the water and sanitation ladder. Ways and means to achieve the ideals are clearly chatted and step by step communities push each other in a friendly rivalry to accomplish the water and sanitation hardware as well as adopting health-seeking behaviour. Outsiders (EHTs and NGO staff) stimulate and ensures the reinforcement of positive practices.
Describe your implementation
The CHC ensures community participation in community health and hygiene issues. A community-based facilitator is identified and trained. They are supported by the local Environmental Health technician/officer. Communities are mobilized into CHCs and they identify and prioritize their public health challenges. A suitable membership card is designed that covers their selected issues. A baseline mini-survey of the members' households is done collecting data on water and sanitation infrastructure and practices as well as water and sanitation related diseases. Data is collected and tables and graphs prepared by the technical support (EHTs/NGO staff. Feedback is given to the communities on their water and sanitation outlook. Members meet weekly at a set venue and time to review the previous week's issues, get feedback from their homework (tasks agreed the previous week to be done at home), and learn/discuss a new topic for the week. They agree on that week's homework. After about 2 months the community members go house to house to review the changes taking place in the homes and to observe behavior change uptake in the homes (positive peer pressure). Change begins to be noticed as every household likes to be identified with like-minded community members (social solidarity). Data is collected and tabulated once more. The community discusses the changes comparing with the baseline data collected. This instills community ownership, community control, community responsibility, and accountability for their own development. Champions emerge and they role models for others to emulate. Household competitions ensue the project continues with the public health promotion sessions. Water and sanitation infrastructure models are introduced and communities self-supply while small targetted subsidies are initiated to serve as demonstration sites as well. Around month 6 the community does an end-line survey to assess their developments and community graduation is held.
Describe the leadership for your solution. Who is leading the implementation?
The solution is led by predominantly women selected by the communities as water and sanitation champions for their specific villages. At times the leaders are young women below the age of 35 but oftentimes they are elderly women who are respectable, stable, and always available in the village. Often communities do not select the youth to lead them on voluntary leadership positions as they youth are seen as being at a high chance of leaving the community in search of greener pastures and that does not urger well for continuity. The model also deploys an out of school youth health club and these are typically led by the youths themselves.
The EHTs in the districts are predominatly middle aged and these are the ones who offer technical suport to the CHC leadership.
Share some of the key partners or stakeholders engaged in your solution development and implementation.
Africa AHEAD in driving the CHC solution to safe water and adequate sanitation partners government at National level ( Department of WASH) and sits in the various WASH technical taskforces at National level namely the National Water and Sanitation Coordination and Information Forum (WSCIF), the Emergency Strategic Advisory Group on WASH (E-SAG). At the subnational level, Africa AHEAD participates in the Provincial Water and Sanitation Sub Committee, District Water and Sanitation Sub Committee, and Ward Water and Sanitation Sub Committee. We also partner with the Waterpoint User Committees where we offer training, upskilling, and retooling as necessary. Africa AHEAD partners the communities themselves in the water and sanitation development planning and implementation. We also partner other development partners (NGOs, banks and other relevent pressure groups).
Who adopted the desired behavior(s) and to what degree? Include an explanation of how you measured a change in behavior.
In our programs, about 75-80% of the CHC membership adopt health-seeking behavior. These attain above 80% of all the health indicators on the membership card. This is measured at baseline, midway, and end-line looking at water and sanitation infrastructure changes/developments, observable practices like improved handwashing, and statistical evidence of reduced disease incidences as reported by the local health centers. We use a triangulation of observation, key informant interviews, and focus group discussions to measure the changes
How did you impact water pollution? Please be specific and include measurement methodology where relevant.
We deployed household water treatment using Bio sand filters, conducted water quality monitoring for biological and chemical analysis.
We promoted better water point siting in view of potential contaminants like toilets, livestock kraals and dumpsites
We promoted stormwater drainage away from water points, promoted water safety aprons at water points to avoid contamination
We also helped communities come up with drinking water safety plans
How has your solution impacted equity challenges (including race, gender, ethnicity, social class/income, or others)?
Women who are culturally the bearers of the water drawing task have found our interventions life-saving in view of the reduced time it takes to draw/fetch water, the reduced distance t the nearest water point leaving them time to do other chores or even to rest. Girls now do not need to miss school because they now have improved water access. Menstrual Hygiene Management is greatly impr0ved as girls and women of childbearing age need more water particularly related to menstrual management. There is a reduced conflict for water particularly GBV as women do not have to spend hours in queues or travel risky distances in poor light to collect water
What were some environmental co-benefits?
When communities have a unity of purpose they can achieve the SDGs together easily. Group cohesion results in planned livestock grazing thereby avoiding the need to cut down trees to make thorn and twig fences for nutrition gardens as livestock are a menace to household gardens that are not fenced. Informed siting and construction of water and sanitation infrastructure avoid contamination of watercourse/points. Open defecation is avoided with adequate infrastructure
What were some sustainable development co-benefits?
The CHC results in the attainment of the SDGs like improved livelihoods through improved Health and the avoidance of Disease. Sanitation goals will be achieved through zero open defecation campaigns and improved access to sanitation facilities. Nutrition is impacted positively through the availability of water for the gardens (productive water). Community Health and hygiene is improved through public health sessions that are sustained by the clubs. Women empowerment is also achieved.
Sustainability: Describe the economic sustainability of your solution.
Once the CHC is started it becomes self-perpetuating as the only capital outlay is the training of community-based facilitators and supplying them with the health promotion kit and membership cards. The support to EHTs remains the government's responsibility but they will need motorbikes to kick start the hygiene promotion and water quality monitoring consumables for water quality testing. After the first 6 months, the project should be able to run with minimum support.
Return on investment: How much did it cost to implement these activities? How do your results above compare to this investment?
Public health promotion costs about $3 per person per annum and this is an acceptable figure. Water and sanitation subsidies will add up to about $15 per person. Government policy on sanitation subsidies is that sponsors only give one bag of cement per sanitation facility and the individual contributes part of the costs in order not to create a donor dependency syndrome within the communities. Communities are encouraged to self-supply and to assist the targetted community members where they are severely disabled. The Community Health Clubs come in handy in that they build social solidarity and they stand together to help the vulnerable members amongst them.
How could we successfully replicate this solution elsewhere?
The CHCs started in 2 districts in Zimbabwe in 1995 and to date, there are over 3500 community health clubs countrywide started by Africa AHEAD alone and thousands of others started by other NGOs and government after we had trained and backstopped them between 2008 and 2012. The model has been taken up outside Zimbabwe in places like Rwanda, Zambia, South Africa, Namibia, Malawi where the Zimbabwean teams have gone up to train and setup.
In Zimbabwe replication is easier as there are look learn opportunities to see the best practices of the CHCs. We would require about $5,000 per district (there are 62 rural districts in Zimbabwe) to scale up the classic CHCs training to EHTs who in turn will train community-based facilitators in their local areas