Randomised Control Trial in Rwanda takes off

Amans Ntakarutimana, Programme Manager, Africa AHEAD-Rwanda
Amans Ntakarutimana, Programme Manager, Africa AHEAD-Rwanda

In 2010 the Community Based Environmental Health Promotion Programme (CBEHPP) was started by the Rwandan Ministry of Health Environmental Health Department which involved the scale up of Community Health Clubs (CHCs) throughout the country.  It was important for MoH to have accurate data to assess the impact of the CHC Model. Being the prime instigator of the CHC Model, Africa AHEAD was asked to assist and requested Gates Foundation to support this research. They engaged IPA (Innovation for Poverty Action) as the evaluation team to conduct a Randomised Control Trial to measure cost effectiveness of the inputs as against the impact both on health and social capital.

There was some doubt if the CHC model could be reliably tested with existing programmes because  implementing partners could not be adequately controlled. Therefore it was decided that MoH with assistance from AA should provide the ‘classic’ demonstration of the CHC Model in 50 villages as it is meant to be done in the manual.  It was decided to construct an imitation of the type of implementation which is sometimes done to mirror what is considered by the MoH (and AA) as a half done job, and this was to be called the Lite arm, undertaken in another 50villages. A third arm of Control villages were to be used for comparison and then given the classic training in two years time after the research.Rusizi District was selected for  the RCT as it boarded on Burundi and DRC and was the least developed area in Rwanda and closest to neighboring country living standards.

The Ministry of Finance supported CBEHPP because it is assumed that there are national savings with a more holistic approach that it is addresses not only diarrhoea but also nutrition, stunting through environmental enteropathy, bilharzia, skin disease and worms and may also minimise ARIs, Malaria, and HIV/AIDS deaths due to early treatment seeking behavior. We are therefore  testing out the hypothesis: the CHC model implemented in its classic form will give greater impact. The classic CHC  will be more cost effective because, although there are more costs to doing it properly there is also more impact, as saving is made on treating diseases which can be prevented.   This research may also inform other countries and contribute to the ongoing debate in the WASH Sector, as to the best practice for achieving hygiene and sanitation behavior change.


EHT demonstrating how to use Visual Aids in a participatory Training session
EHT demonstrating how to use Visual Aids in a participatory Training session


Training of Trainers

After the training of 50 CHC Facilitators in February 2014, weekly health promotion sessions started in the 50 selected villages of the implementation arm of the trail. This began with the registration of CHC member’s, election of CHC committees, village mapping, agreement on meeting days, venue and time in partnership with local leaders before health sessions began.

EHTs Rusizi
Environmental Health Technicians in Rusizi trained by Africa AHEAD in Nov. 2013


Dialogue sessions and progress

At community level, the CHC methodology really  involves the villagers. The CHC facilitators, assisted by heads of villages and CHC committees are running sessions on the planned topics in agreement with CHC members and the progress in community organisation is very noticeable. The 24 sessions follow the manual which was designed by Africa AHEAD in conjunction with MoH and Unicef. These 24 health promotion sessions are expected to be completed by August 2014.


CHC activities and progress in hygiene and sanitation behavior and practice

After 3 months of CHC activities, most CHCs have covered at least 10 topics. When you visit villages, you are likely to be welcomed by joyful men and women, who are empowered and self confident from the achievements of their homes: clean homes, hygienic drinking water storage, pot racks (see below), step and wash facilities, clean bedding, kitchen garden, bath shelter in construction with good progress in getting and use of hygienic latrines. We have found that it possible to easy to start off CHCs but the CHC evolves beyond the planned activities  and has a life of its own. When CHC members are together they inspire each other, which pushes all  the CHC members to plan and decide on other beneficial activities and projects.


Hope for the behavior change

Already, private behaviour is becoming a public concern, with the general consensus from the critical mass ensuring that all individuals are discouraged from poor hygiene behaviour in favour of agreed and accepted standards and norms.