I came to witness the first of the Graduation Days organised at village level in Rusizi District, in Rwanda in the deep south, a remote area on the border with DRC and Burundi – the dark heart of Africa. A ‘Graduation Day’ is the standard CHC event at the end of six months of weekly sessions, designed to award the Community Health Club members who have completed all 20 sessions.
In Gasharu Village, Girisuku Club (Have Good Hygiene) the training took place every week between March and September 2014. Out of a club of 78 people, there were 55 dedicated members who attended every session and were to receive their certificates Girisuku Health Club is one of the most organised of the 50 CHCs in the district and is under the supervision of the Environmental Health Officer Odette Uwizeyimana, who assists the village level ASOC (Affaire Sociale).
The so called ‘ASOC’ are one of four cadres of health workers per village. They are semi voluntary government field workers working with fellow villagers on primary health in every one of the 15,000 villages in Rwanda. They have been designated to conduct health sessions for the Community Based Environmental Health Promotion Programme, (CBEHPP), which was started in 2010.
Africa AHEAD has been instrumental in getting the CBEHP programme rolled out in Rwanda, providing the advocacy to get it accepted at the highest level with the President himself calling for it to scale up to every village in the country. Four years later there is indeed a registered CHC in 99% of the villages in Rwanda and over 30% have completed the six months of weekly training sessions.
Rusizi District is being put in the spot light as it is the focus of a Randomised Control Trial, funded by Bill and Melinda Gates Foundation to evaluate the efficacy of this hygiene promotion strategy to reduce infant and child morbidity and mortality. Africa AHEAD having sourced the funds, is supporting the Ministry of Health to implement a Classic CHC Programme which can be properly research to see if the Model really does reduce disease through good hygiene
As the co-Founders of Africa AHEAD, my husband, Anthony Waaterkeyn and I, are the original instigators of the CHC Model, so I am always delighted to see how our ideas have translated into reality. I have attended many ‘Graduation Ceremonies’ in Zimbabwe where there are now over 5,000 CHCs, in Sierra Leone, Guinea Bissau, Uganda and South Africa. However, this is the first one I have attended in Rwanda, so I am intrigued to see how it goes.
It never fails to amaze me how throughout Africa the recipe for celebration is so similar in each country and the community always has the same traditional procedure when a formal occasion takes place. We were invited for 10.30 in the morning and arrived in a car full of VIPs: the District Health Team, the Sector Head, the Health Centre Supervisor.
Our team from Africa AHEAD consists of the Monitoring Officer Andrew Ndaririo and Marcie Mbirira, our glamorous Field Officer. We are also with Mr.Joseph Katabarwa, who until recently headed up the Environmental Health Desk in the Ministry of Health and has now left government to join us as Country Director of Africa AHEAD in Rwanda. During his time in government he had the vision to initiate the CBEHPP, working closely with my husband, who was then representing WSP (World Bank) to replicate the CHC approach in a national programme. Rwanda is the first country in Africa to have the courage to scale up the CHCs to every village. It is also one of the few countries in Africa able to meet the Water and Sanitation Millennium Development Goal Targets.
We all take pleasure seeing the happiness of the community, the proud recipients of certification, who now greet us with song and dance weaving towards us in a wave of rhythm and song. We sit down in the row of school chairs laid out for the occasion, and water is brought and placed before us. Introductions are done as the visitors greet the crowd and then the official opening song invites us to relax and enjoy the festivities. More and more people gather to watch the occasion and children hang on the trees wide eyed and entranced by the grown-ups having fun for once.
The entertainment is a drama, and the theme is as predictable in its content, as it is charming in its sincerity. It tells the story of a health worker coming to the village to invite the people to start a health club. Inevitably, there is a cynic who refuses to join and instructs his wife to avoid such a waste of time. ‘I am the head of the house’, he tells her, ‘You come home with me now, and I warn you, I will divorce you if you go to those meetings.’ She tries to explain how the club will benefit him but he says, ‘I am healthy and strong. Why should I worry about disease?’ Then, of course, he gets very ill and has to be taken to the clinic. He is carted off on a bench, carried along with the wailing of siren supplied by a chorus, much to the delight of the audience.
When he gets to the hospital, he is ignored by the doctor because he has no health insurance and no money to pay for the treatment. Rwanda is one of the few countries in Africa offering health insurance at a nominal cost to all citizens. The CHC are helping to ensure that everyone pays this small fee, to avoid just such an eventuality as is happening in this play. The wife is desperate and goes to plead for money from a relation, she tries to sell their only piece of land, but to no avail. She is finally helped out by the CHC, as members club together to raise the fees for the treatment.
The man recovers and returns home. He recognises the error of his ways and apologises to the community for his stubbornness and joins the CHC. He cleans up his house and instructs his wife that now they will build a toilet and practice safe hygiene. The children in the audience all fall about with amusement as they see how the proud man has learnt his lesson. The dramatic tension eases as the group comes back to reality, having been completely transfixed by the story. Drama is the way to transfer messages such as this in Africa and song is the way to unite people. They break into dance again, and the drum throbs to the memorising rhythm of the chanting.
The ASOC comes forward and gives a short catalogue of all the changes that have taken place in the village since the CHC began six months ago. She tells us that toilets are being built and the old ones are being cleaned up and covered, that hand wash facilities are being constructed next to the toilets to ensure people wash their hands, and that they are building pot racks to keep their plates of the ground, as well as wash shelters so they can wash in private every day. She claims that many diseases are decreasing in the villages, less diarrhoea and vomiting, less malaria, and the children are growing strong. It is everything that we want to hear, but can it really be true? The Head off the Cell, congratulates the CHC members and says that she has never seen such community participation and that she is going to tell all her other district leaders about the CHC.
When my turn comes to speak, I congratulate them but tell them to beware as a certificate hanging in their home is a dangerous thing. I ask them why. Immediately the Chairperson of the Club cottons on. He explains the CHC member will have to continue to meet the standards of hygiene that the certificate represents or he will be castigated by his neighbours for being a fraud. The all agree solemnly that they will be true to their CHC standards. Like the Boy Scouts, people in Community Health Cubs change their core values, and CHC Members have a ‘culture of health’ whereby they must always be hygienic in all their ways.
I challenge the members to let the VIPs at the ceremony to come and see their clean homes. They agree without hesitation, so I ask for all the membership cards as a means of random selection. They all hand in their green cards and each of the VIPs select one at random. The person who owns the card has to take that visitor to their home to verify the standard of hygiene.
The card that I select belongs to the oldest woman in the group, who totters forward delighted to have nabbed the only white person in the group. She leads me off chuckling to herself. She calls to her friends, ‘You see? This is the same white woman that I greeted in the path, when she came last time, and I told her ‘Be blessed in the name of Jesus Christ’and now He has sent her back to see my home.’ The ancient woman’s name is Valaria, skinny as a rake, rheumy beady little eyes, but as sharp as a button. She powers her way up a slippery path to her home, stabbing the treacherous path with her stick, and then asks me if I can manage the hill!
She turns off the slimy path to a little muddy shack, and with great pride beavers off to show me her clean water container, her cup, her plate, all clean and well stored. Outside the hut her son sits in a drunken stupor. She says it is surprising that he is here, as normally she lives alone, but he did build her latrine a few years before. We go to see the ‘long drop’ which even has a hand washing facility next to it, a plastic jerry can, hanging from a tree, but with no water.
One wonders how she collects water, and she tells us she has to ask others to help her. She has been given a DelAgua water filter through a goverrnment programme, which is providing filters throughout the District. She now is able to purify her drinking water and demonstrates how clear it is.
She shows us where she will put her certificate and says, ‘This is the first one I have ever got. I was born in 1935, and I didn’t go to school, but I attended every one of the sessions at the club. I know what to do.’ Despite her absolute poverty she is an example of great resilience.
My own mother is nine years older than Valarie, goes to church once a week just to socialise and have some interaction with others. Valaria goes to the health club meeting for the same reason every week, to get out of her little hovel and she says she never missed one session . Hygiene training in the CHC is not just about learning and improving physical well being, but also the alleviation of mental stress of isolation. CHCs build community and trust between neighbours. My visit has focused the spotlight on her latrine which needs a better cover. The neighbour says he will be sure they get one for her. They have built latrines for other old women in the village already. We part reluctantly. I was enjoying her ancient vivacity and inspired by her survival in such a dire existence.