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This project took place in three districts of Zimbabwe, Chimanimani, Chipinge and Mutare in 2013. It was a one year emergency project funded directly to Zimbabwe AHEAD by USAID. It was an exceptionally successful project given the short implementation time of 8 months and resulted in 380 CHCs with over 23,000 members of which 63% completed all of the 20 hygiene sessions. The results below were impressive by any standards and have encouraged the Minister of Health, who visited the CHCs in Chipinge recently, to call for CHCs to start up in all villages in Zimbabwe.
Baseline and End line Household Inventory
To accurately measure the outcomes of the project quantitatively, a baseline and end line household inventory was done at 10,321 households (44% of total membership) in the 3 project areas, by the CHC committee, supervised by EHTs. Although this is not an objective verification, we have found that community members themselves usually deliver the true picture, as it is part of their job to monitor their village properly. The household inventory covered 19 observable indicators at each household before and after the intervention. Results of the two inventories are presented in Table 5. and Table 6. below.
Table 5. Baseline information compared to Post Intervention change of 19 proxy indicators of hygiene behavior change in three Districts of Zimbabwe, after 8 months. 2013. Zim AHEAD
6.2 Discussion on findings
All 19 nineteen indicators changed across the project with average improvement of 20% from 59% to 80% with the range of between 54% and 4% of change over eight months.
6.2.1. Handwashing and Personal Hygiene
Hand washing practices recorded the highest change at 54% increase as the tippy taps were easy to make with readily available materials. Not only did every house have at least one hand washing facility, 28% had more than one, indicating a complete conversion to the importance of washing hands after using the toilet and keeping hands clean generally.
Unique to this project was the recommendation to build bathing shelters to encourage frequent washing in privacy, and avoid washing in rivers where bilharzia is contracted. This increased by 21% from 46% to 71% (7,328 households)All variables are highly significant at p>0.001
Our objective is to develop such a strong culture of hygiene that it extends to all areas of the home. Skin disease such as scabies and ringworm is spread by lack of washing, and sharing of unwashed bedding and clothes. Therefore a good indicator of personal hygiene is the number of children without skin diseases, as rashes of scabies and the clear ring shaped lesions of ringworm are easily observed. Bedding was assessed for cleanliness and in 89% of homes was found up to standard with a 10% improvement (1,073 households). This is also triangulated with the improvement of homes where children did not have skin disease which had improved by 7% (i.e. 392 more households where children had no scabies or ringworm).
6.2.2. Kitchen Hygiene
Kitchen hygiene is aimed at preventing germs spreading during the handling of food. To break the fecal-oral route transmitted by flies, we recommend kitchens should be well swept and surfaces kept clean, so flies are not attracted. Pots and plates should be washed properly and dried in the sun, above ground on a pot rack out of reach from dogs, goats and chicken contamination. It is also recommended that each person have their own plate as sharing one plate spreads germs from dirty hands (as well as children eating less as they have to compete with adults for their share). A refuse pit is recommended to attract flies away from the kitchen and refuse should be burnt regularly so preventing breeding. A VIP latrine is also part of the general effort to prevent flies from accessing food as they may go down the latrine but cannot escape if the vent pipe is properly sealed with fly gauze. A wash hand facility (tippy tap) with access to soap is also critical to prevent food contamination from dirty hands. As shown in Table 6. above in indicators 5-8, kitchen hygiene improved significantly with over 86% practicing safe food hygiene with 3 different indicators: 87% members had refuse pits (43% improvement), 86% were using individual family utensils for eating (33% improvement), and 92% had pot racks (21% improvement). In addition 58% had decorated kitchens indicating a high level of effort (22% improvement) was being made in this project to upgrade kitchens.
6.2.3. Self Supply Sanitation
There was a very high demand for sanitation, after going through the PHHE sessions in the CHCs. Club members worked in small groups to construct permanent BVIPs with the support of the EHTs who trained the CBFs in siting and pegging the toilet pits. There were 55 builders trained and they got overwhelmed with the demand from the communities. Chimanimani District was outstanding with 91 toilets completed in six months and close to 650 pits were dug and lined for VIP Latrines by the project end all with 100% self supply. The community’s biggest challenge was that of the shortage of river sand needed for lining the pits and constructing the slab and infrastructure as it was only available 80 km away from the project area. Pit lining was done with rocks to reduce the costs. Across the two rural districts, sanitation coverage increased by 14%. This is an impressive achievement in a very short time given that no material inputs were supplied by the project for this sanitation.
7.1. CHCs turn into Savings Clubs
Savings clubs were started within the 86 CHCs (23%) in the 3 districts as the club members realized the need for self financing of activities to compliment health and hygiene education so as to be able to buy such items as soap, kitchen utensils, cement for latrine construction, borehole spares etc. Each club member contribute US$1 weekly at the club venue each time the club met. The contributions were then directed to a specific activity with the Club Executive Committee monitoring the progress.
11. Sustainability, Replication and Scale up
This project was an exceptional project by any standards but it was too short. It is sad to note that we are exiting the project (October 2013) when self supply sanitation was starting to pick up in Chimanimani, and so much more could have been achieved with a little more support for Zim AHEAD to keep up the pace in the communities. Because this was an OFDA funded emergency project it could not be extended despite the extraordinary chance to make even more impact at scale. This underlines the dilemma of much of community development. When solutions such as the CHC Model are able to demonstrate that they are able to mitigate against future disasters, they should be taken to their full capacity.
ZimAHEAD continues to look for a committed donor for long term funding to continue to scale up the CHCs in Zimbabwe to other households. For sustainability, the 380 CHCs which have finished Stage 1 (Hygiene Promotion) in this project, should now move onto activities to sustain family health such as nutrition gardening which will ensure the continued livelihoods of households are maintained now that they have reached a high level of hygiene. At present Zimbabwe AHEAD, so adept at achieving targets at minimal cost, is all but idle. In the near future USAID is funding a project through DAPP to start CHCs in Goromonzi and Chipinge. Meanwhile we leave 380 communities ripe for sustainable development stranded, having been with them for less than a year. We appeal to USAID to do an external evaluation to verify our claims with a view to extending this project in existing areas of Mutare and Chimanimani to achieve sustainable outcomes.
The community response was exceptionally high and warrants an expansion of this programme which only cost US$2.34 per beneficiary and has achieved so much already in less than a year. The target is to reach at least 1 million beneficiaries in Zimbabwe in the next five years. The National Sanitation and Hygiene Strategy of 2011 states the Community Health Club approach is the methodology through which Participatory Health and Hygiene Education should be channeled. In 2013 the Government of Zimbabwe in the Water Policy directed that every village should have a functional Community Health Club (CHC) that seeks to empower communities to take full responsibility in preventive health. Hearing about the success of the CHCs in this project, the Minister of Health himself visited the project in Chipinge in April 2014, to verify the impact on the community. The Minister commended the efforts that had been made by Zim AHEAD thanks to USAID funding, and said that there was need to scale CHCs up nationally, incorporating new research findings on environmental enteropathy. He noted that in Rwanda CHC had been adopted at a national level so that each and every village has a CHC as the main tool for disseminating primary health care information. He wants the same in Zimbabwe and the MoH has proposed that Zim AHEAD should train MoH staff throughout the country. Although the CHC methodology is being used sporadically by different NGOs in different parts of the country, there is little coordination and short projects such as this one, are not linked into a national programme. This successful project needs to be scaled up to a national programme managed by Ministry of Health so that in future Government of Zimbabwe can prevent cholera with less dependence on donors such as USAID/OFDA to assist in such emergencies.