2012 UNC – AA – Waterkeyn, A.


YEAR: 2012

PRESENTER: Anthony Waterkeyn

TITLE: The Dissemination of Community Health Clubs



Preventable diseases such as respiratory infections, diarrheal diseases and malaria account for a large share of mortality in low income economies. For example, diarrheal diseases kill nearly 2.5 million people worldwide and account for a considerable share of under-five mortality and stunting in low income countries. Broad-based economic development that includes improvements in infrastructure and service delivery can address the challenges associated with the infectious disease burden. But for many countries, these improvements are far in the future and are very costly. Behaviour change of individuals can also address these challenges and more importantly can be done right now and relatively cheaply. Understanding how to produce this behaviour change in needy contexts is crucial to the short and medium term response to the high costs imposed by these diseases.

 The MoH in Rwanda clearly appreciates the above and has launched their Community-Based Environmental Health Promotion Programme (CBEHPP). In his Foreword to the CBEHPP Roadmap, Dr Richard Sezibera, previous Minister of Health and now Secretary General for the whole East African Community, stated that 87% of Rwanda’s national disease burden is in fact preventable. He explained that CBEHPP was carefully designed to provide a practical and affordable approach to meet this challenge through the introduction of the Community Health Club (CHC) methodology (in Rwanda CHCs are referred to as Community Hygiene Clubs).

CBEHPP seeks to radically improve the health of the nation through the promotion of an holistic and integrated approach that is being implemented by the MoH’s existing cadre of district-based Environmental Health Officers and Community Health Workers (CHWs). The Roadmap sets out a clear approach for achieving these objectives that includes ‘zero open defecation’ (ZOD) in all villages of Rwanda, at least 80% hygienic latrine coverage and improvements in a range of hygiene related behaviours such as the use of mosquito nets, hand-washing with soap and the storage and use of safe drinking water.

The CHC approach is well placed to address these collective action challenges because CHCs provide a vehicle to inform and incentivize households to change their behaviour in relation to a whole range of preventative health outcomes. The information component arises from the weekly courses, over a period of six-months, which cover a wide range of health, hygiene and sanitary subjects. The incentive for sustainable behaviour change follows from the social sanctions and rewards that club members can impose/bestow on members accordingly. The CHC approach mobilizes local resources and is plausibly cheaper and more sustainable than other top-down interventions. And while it does require external support to jump-start the intervention, there are no subsidies or other transfers required.

The use of CHCs to address health outcomes is not new. The intervention was pioneered in Zimbabwe and replicated in South Africa, Sierra Leone, Guinea Bissau, Northern Uganda and more recently in Vietnam. However, Rwanda is the first country to scale-up for a national roll-out of the CHC approach. The key inputs delivered through this intervention are as follows: a CHW from the village serves as a facilitator and together with instructional materials produced by the MoH, provides information about both undesirable and desirable hygiene and sanitation behavior to club members. The intervention also includes formal imperatives to adopt desirable behavior through “homework” assignments. More informally, compliance to these requirements is supported additionally by peer pressure. No price incentives are provided directly by the intervention, even though in-kind support could be mobilized to help needy club members. As such, the CHC provides a mechanism by which members collectively resolve a wide range of health and other problems. By providing information, an impetus to change behavior and social pressure to remain compliant, the CHC intervention promises a low cost and sustainable response to poor hygiene and sanitation.  The Ministry of Health in Rwanda has committed to rolling out this intervention in all 15,000 villages across the country over the next three years.

This paper will investigate those factors that have influenced the success of the start-up for the programme to-date and will also highlight how such strong Political Will for the CHC approach was won. It will describe how the Roadmap was designed to ensure that CBEHPP becomes fully integrated within existing government structures and institutions while, at the same time, is also capable of gaining maximum support from NGOs and Development Partners.