Creating demand for sanitation and hygiene through Community Health Clubs: A cost-effective intervention in two districts in Zimbabwe
Introduction
Every 15 s a child dies from diseases largely due to poor water, sanitation and hygiene (WHO, 2000). An authoritative review (Esrey, Potash, Roberts, & Shiff, 1991) found that sanitation can lower the rate of diarrhoeal diseases by 35% and good home hygiene by 33%, and that these two interventions alone are more effective in reducing diarrhoea than improvements in either water quantity (20%) or water quality (15%). One of the Millennium Development Goals (United Nations, 2002) is to halve, by the year 2015, the number of people who have no sanitation (currently 2.4 billion people, or two fifths of the world's population). This immense task relies not only on substantially scaling-up available funds (Terry & Calaguas, 2003) and using effective technologies, but also on the capacity of the unserved population to respond to this international effort. Whilst there is seldom resistance to improving water facilities in the rural areas of developing countries, there is usually less interest in making hygiene improvements and to date sanitation initiatives have attracted little support. It is clear that this demand can only be created if a more subtle strategy is used to persuade the target population of the benefits of safe faecal disposal. Sanitation coverage in sub-Saharan Africa has not kept pace with population increase, but has dropped from 60% in 1990, to 47% in 2000; in Asia it has fared little better (Cairncross, 2003). This trend needs to be reversed by creating a demand for sanitation. For this to happen, a proven model for community mobilisation is required that can be rapidly adopted and taken to scale. We document the effectiveness and costs of one such approach, which has been successfully implemented by government staff in two districts of Zimbabwe.
Participatory approaches were first used in the water sector in the 1980s as a means of community mobilisation (Srinavasan, 1990). By the mid-nineties, the local variant in East and Southern Africa known as Participatory Hygiene and Sanitation Transformation (PHAST) was widely acknowledged as good practice (Lidonde, 2000). By 1997 this methodology had became established in Zimbabwe and a ‘Toolkit’ of visual aids had been developed and distributed throughout the country to 800 Environmental Health Technicians (EHTs) stationed at rural health centres, and 48 out of 57 districts had been introduced to the approach, with an estimated 3800 extension workers trained. In the following few years, although the concept was well known it failed to become translated into well-supported programmes. In all but two districts, although training material had been distributed and district staff were conversant with participatory approaches, they failed to use this in their routine work. The activities were seen as labour-intensive and time-consuming and reliant on trainers with extrovert personalities if they were to be used creatively and with confidence. The lack of dedicated funding was also cited as a constraint. The 5 day training given to field staff was seen as too short, and conventional didactic methods too firmly engrained (United Nations Development Programme/Water and Sanitation Programme—East Africa, 1998). Thus PHAST remained largely an interesting concept rather than an applied programme and by 2001 the regional planners who had launched PHAST were losing interest. After nearly a decade, the PHAST approach had failed to produce empirical evidence of behaviour change as few practical objectives and indicators of change had been adequately monitored to convince donors to continue support.
Aware of the shortcomings of PHAST, but convinced of the ability of participatory approaches to achieve behaviour change through conscientisation (Freire, 1970), a small pilot project was set up by one of us in 1995 to address these issues (Waterkeyn, 1999). PHAST was taken a stage further: the exploratory dynamic of participatory activities was linked to achievable objectives with measurable outcomes. Health promotion became a campaign focused on a dedicated membership promoting inspired leadership rather than using conventional village gatherings controlled by traditional leadership. It also set out to provide indicators and monitoring systems that allowed cost effectiveness to be measured. The concept of a club is in line with traditional values of conformity in rural society (Gelfand, 1984) and builds on a long history of womens’ groups developed throughout the colonial period through the missionaries and philanthropic societies, when an archetype of the smart, club-going woman as a pillar of society developed in Zimbabwe (Burke, 1996).
Section snippets
Materials and methods
We measured effectiveness in terms of observable indicators of behaviour change rather than a health outcome, given the unreliability of health outcomes for operational evaluation (Cairncross, 1990). Given the evidence in the literature for the impact of clean water, sanitation and good hygiene practices on diarrhoeal and other diseases (Feachem, 1984; Esrey et al., 1991; Curtis & Cairncross, 2003), in this research we have used proxy indicators of safe practices to quantify effectiveness. To
Qualitative data
The success of the intervention in terms of community support is reflected in project reports, and anecdotal evidence given by the NGO and MoHCW officials. These indicated that the methodology had strong appeal for rural communities, and that participants enjoyed the sessions which were social events as well as informative and entertaining. This was indicated by large numbers who joined the clubs, which often had over 100 members. With 52% of members attending all 20 meetings (Table 1) and
Weaknesses and sources of bias
As elections were imminent in Zimbabwe in 2001 at the time, data collection was difficult for the enumerators who were sometimes suspected of opposition activity. With a real danger of physical intimidation, all enumerators were men and thus gender differences may have influenced respondents. In the control areas where the NGO was unknown, men were reluctant to let their wives talk and so in Tsholotsho fewer women were interviewed for the control. For the same reason control groups were smaller
Conclusions
This intervention has demonstrated that by altering the norms that direct activity, a ‘culture of cleanliness’ can be created that will direct all behaviour towards more effective control of family health. Regular health sessions provide a forum in which peer pressure can influence members to conform to newly established norms.
The response of the Community Health Clubs in Zimbabwe shows that with appropriate resources, this methodology could halve the number without VIP latrines in the project
Acknowledgements
This research was made possible by funding from Department for International Development (DFID), and the kind co-operation of the Rural District Councils, Ministry of Health and Child Welfare (MoHCW), the National Co-ordinating Unit (NAC), and Zimbabwe Applied Health and Development (A.H.E.A.D) Organisation, as well as members of the community in Tsholotsho and Makoni Districts, Zimbabwe.
The intervention was funded by DFID in Gutu and Tsholotsho, and by Danida in Makoni (1998–2001). Support for
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