Half an hour from the beautiful city of Cape Town, where a green ribbon of sophistication wraps around the famous Table Mountain, stretch the infamous Cape Flats, a flat grey carpet of chaos and crime where the less fortunate flock to seek work. The swelling numbers of migrants, mainly from the Eastern Cape, dwell in the squalor of 240 ‘informal settlements’, a flattering name for a shack-land of permanent squatters. The active City policy claims ‘We work for you’ but the lack of adequate sanitation is a critical issue, and beleaguered civil servants battle with limited staff to meet the promise of providing free sanitation facilities to all. With 600,000 in the Western Cape using poorly maintained chemical toilets, or even a simple bucket, the great un-served still have to defecate in the open. The problem is immense, and there is little chance that the target of eradicating the ‘bucket system’ by 2012 will be achieved as a never ending stream of migrants continue to pour into the Cape Flats.

Project Area

Africa AHEAD was asked by the City Health Department to start a pilot project using Community Health Clubs to minimise preventable disease and to help build a more responsible attitude to sanitation and the disposal of solid waste. The training started this month (10^th - 15^th March 2008) and the project is to operate in four main areas: Khayelitsha, Philippi, Eastern and Klipfontain. Apparently this is also the first project ever to combine the resources of the Health Department with the Water Department in Western Cape and will hopefully pave the way for more integrated programmes between the different sectors in the future.

Participants Produce Dramas Depicting Local Issues

The Participants

Accustomed to a more rural environment for training ‘the community’, the second floor of a smart office block in Bellville was an unusual venue for our Community Health Club Training. In addition, the challenge of turning community members into health workers in five days of training was indeed interesting. The majority of the participants had a limited education and had never been called upon to speak in public, let alone coordinate their neighbours in the sometimes rough areas in which they operate. Of the 24 participants, only three were trained Government Environmental Health Practitioners (EHPs) who are to supervise the health club facilitators once the clubs are active. Five others are Community Health Workers with basic training in public health issues and their experience immediately became apparent during the training. The balance of the participants are newcomers to facilitation and community mobilisation, being currently employed as sanitation attendants charged with monitoring the community use of water and sanitation facilities. Xhosa was the most comfortable language for most, with a few speaking a little English and Afrikaans. The Africa AHEAD team consisted of the Director of Africa AHEAD, Juliet Waterkeyn, Facilitator Jason Rosenfeld and Saviour Maqaloti, Xhosa Facilitator. The approach was simple: to build ‘common unity’ within a group through participatory PHAST activities to enable informed decision-making, in order to solve common problems such as poor use of communal water and sanitation facilities and risky hygiene behaviors.

The Training

The training manual, ‘Community Health Clubs in Informal Settlements‘, has just been published by Africa AHEAD after 18 months of development. Together with the 13 packs of illustrated cards, the participants were provided a simple and effective Toolkit for the participatory activities that we were to use during the week. The training covered all aspects of personal and home hygiene, in particular, relating to diarrhoea transmission, with a strong focus on water and sanitation. Well known PHAST activities such as ‘Blocking the Route’, Three Pile Sorting, and ‘Story with a Gap’ became familiar to the participants and slowly their reserve disappeared and the training became more relaxed. People who had never sung in public before were coming out of their shells.

PHAST Tools Developed by Africa AHEAD for Informal Settlements

Identifying problems

Participants were grouped into their operational areas, each having to form a miniature health club, provide a name for their hypothetical club, develop a health song, and rehearse a short play illustrating some of the issues they would be tackling. Just as would be the case in the community, the development of these plays and songs enabled team building during the week and the clubs presented their efforts at a ‘Graduation’ at the end of the week long training. The short dramas they produced were instructive and fun. A ‘good family’ encouraging a ‘dirty family’ plagued by enormous flies to join the club and reform their unhygienic ways was a familiar plot, and an amusing skit on how to deal with a drunken husband had everyone collapsed with laughter. However, the play which showed someone trying to report the dumping of rubbish to the local officer illustrated a problem unique to the informal settlements in South Africa, where so much is expected of government, and so little is done. Together we planned with participants how to mobilise the community, how to start up health clubs and how to implement the sessions. With the management, we planned how to set up systems for reporting, monitoring and evaluation.

Ms. Mapasa Receives Certificate from Amien Peterson, Health Promotion Coordinator

Graduation

On a Saturday morning, twenty four certificates were handed over in a touching little ceremony to mark the beginning of this innovative project. It was agreed that these certificates would be validated only once each participant had shown themselves capable of running a health club effectively in the community. We parted with a sense that the PHAST system of training had enabled a lot of bonding and bridging and there was no doubt that social capital within our group had been developed. We are looking forward to seeing whether this can be replicated in the more challenging rough and tumble of the Cape Flat shack dwellers. Watch this space for updates on the project.

Back: Sean Van Wyk, Werner Geldenhuys, Xolelani Dombothi, Jeanette Maselana, Jason Rosenfeld (AA), Rep Water Dept.  Middle: Zuziwe Balintulo, Miranda Flente, Nokwezi Noyakaza, Bukiwe Mapasa, Basil Maarman, Patricia Tunzi, Saviour Maqaloti, Ntombiziyeza Bhaqeka, Nonkosi Poza. Front: Armien Peters (Health) Juliet Waterkeyn (AA), Rebecca Leaka, Amanda Manyana, Nomxolisi Nyamankulu, Vuyakazi Ruiters, Amogeland Dioma, Desmond Fudumele, Nomfundo Memeza, Dorothy Brussels

At present there are an estimated 234 million open defecators (ODs) across the Africa continent, and only a handful of countries in Africa are on track to meet these ambitious MDG targets. However it is encouraging that one of the first stumbling blocks is being addressed, the lack of political will. To reverse this dire record of disinterest in the subject of open defecation, these 32 Ministers have pledged to return to their countries and produce Action Plans of their own by the end of July 2008. Given the cost-effectiveness of our approach, we hope that many of these plans will include the recommendation to start Community Health Clubs in their countries.

It is one thing to pledge support and provide the political will, but it is another thing altogether to find a successful plan of implementation which can convert these simple undertakings into reality. One key undertaking in this international Action Plan that is critical is the commitment to provide an enabling environment to ensure that the methodologies that can stimulate demand-led sanitation are given support.  There were a few main strategies cited to operationalise the scaling up of sanitation, two of which were discussed at some length at the Conference in the smaller groups. As not everyone had the chance to follow the debate which was focused on how best to trigger behaviour change, our perspective is summarised below.

Community Led Total Sanitation (CLTS)received a high profile at the Conference with the presence of the initiator, Kamal Khar, as well as the much acclaimed author on participatory approaches, Robert Chambers, in person. These two strong advocates provided a persuasive team for CLTS, a quick-fix system for  ensuring ODF (open defecation free) villages by shaming villages into compliance by disgust for excreta pollution of water. This ingenious method has caught on in Asia on a large scale; however, the question remains whether this method is culturally suitable for much of Africa, where political correctness often ensures that public criticism is swept under the carpet in favour of overt politeness. CLTS does provide a ‘sticking plaster’ to cover the open sore of  faecal contamination but it does nothing to address the underlying cause of diarrhoea disease, poor understanding that leads to risk practice.  People can be made to clean up the village for a time when the warden is on patrol, but is this a sustainable approach?  The authoritarianism reinforces existing village elites, mainly men, and may do little to provide women with a structure to challenge the status quo. Another question is important: what happens next after ODF? Can CLTS capitalise on the mobilisation achieved to clean up the village to move onto other initiatives? Is a structure created that provides  organisation on the ground to support ongoing ‘projects’ across a wide spectrum of behaviours related to prevention of other communicable diseases such as malaria, bilharzias, or water washed diseases such as scabies, ringworm, Trachoma, and parasitic worms that infect children due to poor hygiene. This is perhaps where CLTS could combine with the CHC (Community Health Club) Approach - community health clubs could be formed to achieve CLTS, and them move onto other projects, so providing ongoing monitoring and management of all diseases at community level.

Public Private Partnerships (PPPs)were given extensive time to explain a novel approach in which ‘strange bedfellows’ i.e. large multinationals (Unilever and Rentokil) and local implementing partners (community) link in a ‘win-win’ situation, in the effort to minimise diarrhoea.  Hand-washing with soap is encouraged by subliminal appeal to smartness, using established commercial advertising techniques.  The funding available from large companies of course is attractive as a means to an end, but one may question whether  the method of broadcasting a few simple key messages provides real  understanding of the  reasons for this smart new hand-washing practice. Again, does this simplistic approach give the poor adequate respect, by empowering them to control their own health though knowledge.  The term ‘Social Marketing’ was conspicuous by its absence, possibly indicating that the buzz may have gone out of the claims of a few years ago, that with massive spending on media, this is a cost-effective approach. Although it is now widely claimed that hand-washing can reduce diarrhoea by 47%, diarrhoea is caused by multiple hygiene malpractice and so the use of soap, as laudable as it is, is just another vertical and very shallow intervention to achieve limited behaviour change. If it is linked to philanthropic handouts from soap companies it is likely to endure as long as the goodies continue and no longer. For PPP to succeed the multinationals who wish to improve their ‘street credibility’ should rather support robust community development programmes with the human resources necessary to train communities in safe hygiene. The overt market-orientated could be tempered with the use of ‘pc’ label of some sort that would indicate that a certain percent of sales were used to support community projects. This may increase up market sales as is the case with the ‘fair trade’ label. 

Africa AHEAD has little issue with involvement of the Private Sector in the Public Good in a hand washing programme, provided there is a strong element of community empowerment and sustainability. An example of this is an innovative programme in the Informal Settlements of Western Province, South Africa, were health clusters (mini health clubs) were supported for a year before any products were distributed and no branding was allowed. The intervention was a research project where Brigham Young University (BYU) partnered with the makers of Dettol (Rickett Benkisser) to provide a case study that aims to establish whether the use of anti-septic products in shanty towns can decrease communicable diseases such as diarrhoea and acute respiratory illnesses (ARI).  Africa AHEAD provided the training in health promotion for the health clusters, which involved 70 facilitators holding a meeting each week with ten households for a year to discuss hygiene issues.  This provides a good example of combining strategies to achieve long term sustainable behaviour change based on assumptions which are core to the CHC approach.

Both CLTS and PPP focus on a very limited target, the reduction of diarrhoea; they are vertical programmes with a narrow spotlight on a small aspect of one disease.  Both seek no further than to achieve more than one direct change: either safe faecal disposal or the practice of hand washing with soap.  As laudable as these outputs may be, neither strategy as it stands can address the fundamental issues of poverty and ignorance that underpin the high prevalence of killer, preventable diseases.

Whilst we saw strategies that could contribute to reducing diarrhoea, we found no new methodologies on display at Africa San 2008 to rival the CHC Approach, in terms of cost-effective behaviour change to ensure demand driven sanitation. Not enough time was allowed for us to showcase our achievements in any detail, but many delegates sensitive to ‘horizontal’ broad development, understood our message and there were many new ‘converts’.  Those who were interested in the deeper and more sustainable version of hygiene behaviour change, based on a ‘culture of health’ rather than a ‘sticking plaster on the wounds, gravitated to our organisation.  Africa AHEAD has received many serious enquiries to start up health clubs in a number of new countries, notably Rwanda, Ethiopia, Namibia and Mozambique, whilst a large programme is soon to be launched in South Africa. 

This training manual is designed to be used for training community workers in informal settlements in South Africa who are preparing to develop and implement Community Health Clubs (CHC) using the participatory toolkit of visual aids. This manual is divided into three modules:

• Module 1: FEASIBILITY: This module provides rationale for the CHC Approach.
• Module 2: PLANNING: This module provides guidance on how to start a CHC project.
• Module 3: TRAINING OF TRAINERS: This module provides guidance on how to train community workers how to use the participatory toolkit of visual aids.

This manual is now available for download. Please follow the links below. Note: Currently this manual is not available as one pdf document. Each module is located in seperate zip files for download.

Training Manual: Introduction & Module 1

Training Manual: Module 2

Training Manual: Module 3 (3.0 - 3.12)

Training Manual: Module 3 (3.13 - 3.25) & References

Participatory Toolkit of Visual Aids

This toolkit is comprised of the 13 sets of illustrated cards found below. These visual aids are used to guide  the 24 CHC educational sessions and stimulate member participation.

1. South Africa: Personal Hygiene

2. South Africa: Skin Diseases 

3. South Africa: Oral Rehydration Treatment Guide

4. South Africa: Vendor Hygiene

5. South Africa: Water

6. South Africa: Drinking Water

7. South Africa: Community Management

8. South Africa: Hand Washing 

9. South Africa: Food Hygiene 

10. South Africa: Home Care  

11a. South Africa: Sanitation (Cards 1-10)

11b. South Africa: Sanitation (Cards 11-24) 

12. South Africa: Parasites

13. South Africa: Vector Control

Introduction:

“Woman’s place is in the Home, but Home is not contained within the four walls of an individual home. Home is the community.”
                                                                                                                -Rhetta Childe Dorr, 1910

Zimbabwe is a country in crisis. This is what the international news agencies tell you, and for the most part they are correct. As one moves around the country the signs that things are not well are everywhere: shops with little to nothing on their shelves or that have simply closed; long queues outside of supermarkets as shoppers hope to purchase half a loaf of bread; power fluctuations in Harare; no fuel available at the gas stations; and an inflation rate that has at last estimate surpassed 7,000%. However, not all is as it appears at first glance.

In fact, despite this apparent economic collapse, there are portions of Zimbabwean society that have thrived and increased their capital over the years. In the urban centers like Harare and Makoni, the amazing number of brand new luxury cars and SUVs show that the middle and upper class are thriving off of the black market that has supplanted the regular economy and now supports all life and commerce. In this Zimbabwe, people have clearly increased their access to financial, and in turn physical, capital. On the other hand, in some of the rural areas, even those considered to be the poorest and most vulnerable in all of Zimbabwe, communities are increasing their capital of another sort; social capital. Generally, social capital refers to the connections among individuals, including the social networks and the norms of reciprocity and trustworthiness that arise from them.

For the rest of the article, please go to: The Power of Participatory Education: Social Capital in Zimbabwe

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.

Summary: After years of debate, most people working in water and sanitation now agree that hygiene promotion is vitally important. But even now, many programmes and projects either ignore it or do it badly. This Field Note describes two African hygiene promotion programmes that have successfully used new approaches: Programme Saniya in Burkina Faso, and ZimAHEAD in Zimbabwe. They both concentrated on understanding how people actually behave and hence how to change that behaviour, and they both demonstrated ideas that can be applied at a larger scale. Changing human hygiene behaviour is a long process that is difficult to measure, and both of these programmes still have obstacles to overcome. However, this work indicates that systematic and carefully managed hygiene promotion programmes can achieve improvements in hygiene behaviour and hence reduction in diarrhoeal diseases.

* List of members in each health club
* Inventory of member’s facilities (eg. Latrine, hand-washing facility, pot rack etc)
* Attendance per health session
* Topics covered at each health session
* Number of health sessions per trainer
* Average attendance of members per year
* Number of members completing course of sessions.

This information is combined with the following project records:
* Cost per Trainer for transport, mileage, and allowances
* Cost per beneficiary
* Cost per health session.

Effectiveness is measured either:
* Before and after project implementation
* By comparison with a control group in terms of:

Levels of behaviour change as measured by proxy indicators such as:
* Clean, used latrine
* Used hand-washing facility with soap readily available
* Correct food storage and usage
* Correct water storage ad usage

Levels of health related knowledge are also tested by asking each member the causes, transmission, symptoms, prevention and cure of common communicable diseases (e.g. malaria, diarrhoea, bilharzia, skin and eye diseases, parasitic worm infestation, HIV/AIDS).

For examples of the outcomes of CHC Monitoring and Evaluation, please refer to Creating Demand for Sanitation and Hygiene Through Community Health Clubs & Cost Effective Health Promotion Through Community Health Clubs.

Finally, AfricaAHEAD is currently conducting exploratory research to facilitate the development of Social Capital indicators to be incorporated into normal Monitoring and Evaluation activities. Please return for more information regarding CHCs and Social Capital.

Health promotion programmes in which concrete achievements in behaviour change can be accurately quantified are more likely to attract financial assistance because they can be shown to be cost-effective. The A.H.E.A.D Model provides cost-effectiveness health promotion training at less than US$1 per beneficiary per annum (Waterkeyn & Cairncross, 2005). In one year in Zimbabwe, 1,244 health sessions were carried out by 14 trainers, costing an average of US$0.21 per beneficiary and involving 11,450 club members (~68,700 beneficiaries) in Makoni District. In Tsholotsho District, in a smaller project 2,105 members participated in 182 health promotion sessions carried out by 3 trainers, which cost US$ 0.55 for each of the 12,630 beneficiaries.

Abstract:

Although literacy rates in developing countries have improved substantially in the past few decades, vertical health promotion programmes for rural communities still tend to pitch their messages at a low comprehension level, promoting only a few simple key messages usually to prevent only one identified disease (Loevinsohn, 1990). The overall literacy level in Zimbabwe is around 86% (Unicef, 1999) although 50% of those over 60 are illiterate (Auret, 1990). A recent study in Zimbabwe (Waterkeyn and Cairncross, 2005) has piloted an approach using Community Health Clubs to promote a culture of health by improving health knowledge and hygiene behaviour. Interviews with members indicated that the popularity of Health Clubs was largely due to a strong interest in acquiring knowledge. Consistently high attendance rates suggested that women were prepared to invest considerable effort to learn. A post intervention survey found that good knowledge of Malaria amongst health club members was 34% higher than non-members, and for Tuberculosis it was 58% higher (Waterkeyn, 2006). Taking an average of nine different topics, there was 47% difference between intervention and control areas (0>0.0001).

Maslow’s Hierarchy of Needs (1954) was used to categorise suggestions from the community as to their main needs, using a method of pair-wise ranking on a matrix. In a random sample of ten community health clubs, 20% voted their highest priority as Knowledge, whilst the remaining 80% ranked Knowledge in second place, only slightly less important than their Need for Safety. These findings indicate that semi-literate communities have the capacity to assimilate multiple messages and through group decision-making can significantly change their hygiene behaviour, acting on a broad range of health issues. By addressing all preventable diseases in a more holistic approach to health, programmes would be more cost-effective and appropriate to the needs of rural communities.

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.