Sierra Leone

2002-2003:  Sierra Leone:

A consultancy for CARE International for the Directors Juliet and Anthony Waterkeyn  in 2002-3 provided an opportunity to introduce the CHC methodology into Sierra Leone. The pilot project in Bo and Moyamba Districts in 2002,  comprised of 52 CHCs in 25 villages. CHCs are now a common strategy in Sierra Leone and a training manual for the country has been produced, enabling the scaling up of this approach to take place.

• Country: Sierra Leone
• Period: 2002 -3
• Donor: Big Lottery Fund
• Partner: Care International
• Provinces: 
• Districts: Bo & Moyamba
• Number of Villages: 29
• Number of households:

• Number of CHCs: 52
• Number of Members: 1,853
• Number of Project Officers: 15
• Coverage of CHC Households: 92%-100%
• Number of CHC facilitators: 25
• Number of beneficiaries:  12,971

One of 52 CHCs which were started by CARE in 2002.

With 1,853 regular members, there is a completion rate of 72%, (1,335 members). This is an impressive achievement as health sessions were held at the most difficult time of the year when demands from farming were high and in many villages, members were also constructing their new homes and trying to re-settle. This high adherence to regular attendance does reflect the appeal of these meetings and the fact that they are useful to the members.

A base line was conducted but the end line was not done, therefore no data for behaviour change is available. After one year a rapid rural assessment done by AA Directors showed anecdotal evidence that there was a marked visual difference between CHC and non CHC villages.

‘There is also empirical evidence on the ground that there have been many fundamental changes in hygiene behaviour. It is now obvious, even to the casual observer, driving on the main Freetown-Moyamba-Bo road, which villages have CHCs.

Each house has its own plate rack, numerous bamboo washing poles have been erected and clothes are hung to dry, whereas in other villages both utensils and clothes are left on the ground. The CHC villages tend to be very well swept, and have designated refuse disposal sites at the edge of the village. They are also identified by the new Community Health Wells, which use a windlass rather than a hand-pump. Most houses are in the process of constructing their own latrines, although with the superstructure being made of local materials, resembling the huts themselves, they are difficult to identify from afar. The level of demand for improved sanitation is outstanding by general development standards in Africa. 

A walk through any CHC village will confirm that, whereas before this intervention there was widespread open defecation practiced,  there is now minimal fouling around the nearby bush. According to all the CHC villages visited in this evaluation, cat sanitation is now mandatory, as are all other recommended CHC practices.

If this is so, there may well be disease reduction. It is evident that in some of the more successful CHC villages the levels of child malnutrition is decreasing. In one instance, the steep reduction of outpatients from a CHC village has been noted by the local clinic. Most importantly, the villagers themselves are confident in their ability to prevent and cure diarrhoea in particular, and have taken responsibility for their own health.’

Without a champion in the country to advocate for more sustainable development, the CHC programme was forgotten by the WASH sector except in the few districts where CARE was working. When Juliet And Anthony Waterkeyn conducted the evaluation of the health promotion sector in 2014 for DFID/Adam Smith, the CHC programme was still flourishing whilst CLTS programmes were already being shown as unsustainable. However the criticism of CLTS was quickly suppressed by those with interests to shown its sucess. Despite a high interest by senior MoH to once again pilot the CHC approach, nothing has moved forward. With the advent of the crisis to fight Ebola, once again the CHC approach was marginalised. Whilst Africa AHEAD offered to provide emergency CHC programme this was ignored by Dfid and Unicef.

Care Staff trained in the CHC approach: the first training outside Zimbabwe in 2002.

Extract from Rapid Rural Assessment

‘The perception of the communities consulted in a survey of 19 out of the 29 villages in this project, is that the health education sessions have already reduced many diseases, particularly diarrhoea and skin diseases, purely through improved health knowledge and change of attitudes and beliefs. Although it is hard to believe, the communities repeatedly mentioned that levels of fly and mosquito infestation have indeed dropped and they believe this is as a result of their improved hygiene practices and safe drinking water. If this is so, the project will be unique, as it is notoriously difficult to achieve a decrease in these diseases due to the raft of improvements that need to be consistently made by all members of the village. 

One of the most outstanding aspects of the community health clubs established in this project is that they do genuinely represent all of the households in each village. This was confirmed by every one of the 19 villages visited. The community were adamant that one or more of the family from each house were regular members. I was referred repeatedly to examples where the husband had joined with his wife, mother, sister and elder daughter. This is also evident in the consensus within the villages, as there is no apparent obstruction by husbands to practices that their wives have learnt in the health sessions. 

To appreciate fully the achievement of this high response rate, it much be understood that wherever CHCs have been established before now in other countries, there is usually not more than 60% coverage, and only after four years of fresh intakes annually does the figure reach near 100% representation.’

Whilst the consultants from what was still to become Africa AHEAD did not go back to Sierra Leone for a decade, the CHC model had a life of its own within CARE International. Moving to the district of Koinadugu, an adaptation of the CHC model was rolled out with impressive results. An evaluation of this programme in 2007 showed the popularity of CHCs and high levels of hygiene behaviour change. These finding should have been the cue for scaling up but at this stage the WASH wing of Unicef was championing CLTS which as  the latest magic bullet  in Sierra Leone, displacing much the  CHC approach.

Meanwhile the Maternal Health wing was still using CHCs for Reproductive health programme in Koinadugu and Kono, where we found CHCs fully functional in 2013. (See below)