Practical approaches to hygiene problems and sustainable health
By Thomas Kagera
The Community-Based Environmental Health Promotion Programme (CBEHPP) was created 17th December 2009 after realizing that the percentage of under-fives dying of diarrheal diseases annually was 11.3 percent while the prevalence is 14 percent. This was in addition to identifying that the ten leading causes of morbidity and mortality are caused by infectious diseases and that over 90 percent of consultations at the rural health facilities include malaria, acute respiratory tract infections, diarrhea, skin diseases, HIV/AIDS, STIs, tuberculosis, typhus, cholera, meningitis and intestinal parasites.
Under the Ministry of Health, CBEHPP is based at the communities organized right from the village level focusing on facilitating the households to think, act and change their hygienic behaviours. At the Village (Umudugudu) level, residents are organized into Hygiene Clubs. A Hygiene Club is a tool that brings together households to identify health and hygiene problems in their communities and devise ways of getting solutions.
CBEHPP intervention point is providing hygienic empowerment among communities to guarantee behaviour change and therefore attain sustainable hygiene. One of the ideals of Vision 2020 is to have households that will “have mastered and be practicing hygiene and waste disposal.”
By the end of 2012, CBEHPP will have significantly contributed to the reduction of the debilitating national disease burden that currently exists and, in so doing, will contribute significantly to poverty reduction outcomes. When a people’s health improves, their man-hours to work and their quality input significantly get better. Even healthy pupils’ grasp of class work and general appreciation of the environment goes up. According to the CBEHPP Coordinator Joseph Katabarwa, by 2009 25 per cent of school children were suffering from intestinal worms and 44 per cent in 2007 were suffering from amoebiasis).
The Environmental Health approach
Those aspects of human health, including quality of life that is determined by physical, biological, social and psychological factors in the environment constitute environmental health. It involves assessing, correcting, controlling and preventing those factors in the environment that can adversely affect the health of present and future generations.
The sub-components that are being accentuated are; promotion of safe drinking water, hand-washing, safe disposal of excreta, hygienic use of latrines/toilets, food safety and nutrition, indoor air pollution elimination, vector control and safe disposal of solid and liquid waste.
It was therefore decided that a Community-Approach be used in handling hygiene and related diseases since the Hygienic Community Clubs can be an effective tool to share knowledge and experiences of the causes and mechanisms of disorders having an environmental etiology, reduce adverse health outcomes through innovative intervention strategies and policy change, and address the environmental health concerns of communities.
Sustainable hygiene in view
The programme is being implanted in three phases two of which have already been done i.e. putting management structures and start-up districts. In the second phase, the Environmental Health Officers were trained to train the 60,000 Community Health Workers. In phase 3, the CBEHPP is in the process of scaling up to all the thirty districts of the country which will be attained by 2012.
The Ministry of Health, as the implementing institution of CBEHPP, has hired a consultant to elaborate the tools to be used by Community Hygiene Clubs (CHCs) and developed the implementation Roadmap both in English and Kinyarwanda, with brochures in large quantities. The Environmental Health Desk was commissioned to develop guidelines which were disseminated to all districts.
The CBEHPP was rolled-out in five start-up districts of; Rulindo, Ngoma, Muhanga, Bugesera and Nyabihu which were selected by the Provincial Governors. These are being used as laboratory districts from which others can learn, using a very short time to demonstrate behavioural changes, after which the programme will be scaled-up to the whole country. The Hygiene and Sanitation Presidential Initiative (HSPI) has been of great value in aiding the enhancement of this programme.
After the Hygiene and Sanitation Presidential Initiative, the guidelines were developed and CHCs formation was started in November 2010. Training of Trainers workshops on the formation of Hygiene Clubs have been organized, bringing in fold the District Environmental Health Officers and Vice Mayors in charge of social affairs in all the districts.
It is important to note that the Hygiene Clubs have been rolled out, and out of the 15,000 Villages in the country, about 20 per cent have formed these clubs. Training tools and manuals for Environmental Health Officers and Community Health Workers too, have been developed and pre-tested. The District and Sector Environmental Health Officers will train the CHWs and Club Executives, who will in turn train the Hygiene Club Members.
The Executive Committee and Community Health Workers (the mentors) will arrange for training sessions for the CHCs members in which they will explore hygienic principles and sanitation, behavioural change and a plethora of advantages to be reaped from best hygienic practices. Through this peer dialogue, members will accumulate and share knowledge, experiences and skills. Hygiene Club members will have this dialogue on health, hygiene and sanitation topics for two hours per week for six months.
A training tool which demonstrates 426 hygienic behaviours to be discussed in the six months has been developed. Certificates will be issued to every Hygiene Club member.
How Community Hygiene Clubs work
A Community Hygiene Club (CHC) is a discussion group of peers from the same locality, who meet, identify their sanitation, hygienic and health problems, and, through dialogue and using stimulant tools, they get engaged in identifying solutions—together.
The CHC approach appeals to an inane 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 will originate from the members and be implemented by them. The government will, however, always come out to give technical support and guidance.
The Community Health Workers do help in facilitating the formation of CHCs in every village. The programme also targets institutions such as clinics, schools and prisons. Each CHC is comprised of about 100-150 households. Every member is issued with a card which carries 20 topics discussed in the Club and the corresponding homework as shown below. (Note: There are also 426 hygienic behavioural practices to be discussed in six months).
Example of a Membership Card with 5 selected topics and homework
No. Topic Date Signature Homework Signature
1 Safe water chain Safe storage and use of water
2 Safe food chain Pot rack, hanging basket, etc
3 Hygienic kitchen Fuel efficient stove and ventilation
4 Skin/eye disease Bedroom and personal hygiene
5 Home-based care Community project
In the homework section, individuals or groups may come together to make a simple hand-washing facility, a composite manure pit, a bathing shelter etc.
The Community Hygiene Club approach will as well strengthen social capital and build trust and cohesion among communities. The CHCs will, in addition, empower communities, especially women, to take responsibility for village level operations, maintenance and management of water and sanitation facilities such as gravity systems, hand-pumps, protected springs, piped supplies and collective latrines.
These CHCs will help members gain the health, strength—therefore productivity, confidence, food security and improved nutrition. The clubs will also be used to solve the problem of lack of health and hygienic data required for baseline evaluations of the available and required facilities/services/conditions. A digitalized method of collecting data using mobile phones has been introduced, where the Environmental Health Officers or Community Based Workers send an SMS to the Central Server, to help in identifying which geographical area and or hygienic concern require more or immediate attention.
Through these Clubs, members will be taught how to make soap that can be used in their households to improve hygiene. The popularity of the CHCs has meant that even in those districts where CBEHPP has not rolled out, communities have already formed the clubs. Kayonza District, for example, has created 424 CHCs, Musanze 432, and Rubavu 525.
The CBEHPP in June 2011 set in motion the National Water Drinking Water Surveillance Project. District Environmental Health Officers are given motorcycles to facilitate their mobility to all parts of the country. Water testing kits have been secured. These are used in testing and identifying contaminated water sources, and then test water in the households that use the said source, to formulate lasting solutions. Treatment of water at home, especially, is encouraged and promoted.
The usage of hand-washing devices will be enforced in all restaurants around the country, as they will be marketed to the households. Another campaign that will be intensified is the improvement of traditional latrines and their cleanliness. Some latrines are, instead, a source of infections because they are not built according to standards—at least 4 meters deep, a slab, structured enclosure, a roof, and a simple door—at least for every household. For those that can afford, the Ventilated Improved Pit Latrines are encouraged because they combat flies and the bad odor.
The programme promotion will go on up to 2020, and if well implemented, diarrheal diseases will be brought to naught. Today, government spends at least RwF10 billion on de-worming twice a year. When CBEHP implements its programmes to the dot, then the government will be saving billions of francs. Quality child-learning will improve, productivity will soar, and sustainable health realized.
The key partner ministries are; MINALOC, MININFRA, MINEDUC, MINELA, and MINAGRI. To this effect, 1500 teachers are to be trained as TOTs of their fellow teachers.
The MINALOC has been very supportive in the mobilization and initial stages of implementation. Schools will be encouraged to revive/create the hygiene clubs so that students are not left out in this salient exercise. The international partners that work with the Ministry of Health to enhance the values of CBEHPP are WSP/World Bank, UNICEF and Water Aid in technical and financial support.