At a Conference convened in Seattle, at the Bill & Melinda Gates Foundation, in November 2011, top experts discussed how to achieve ‘Impact at Scale’, in order to more effectively reduce infant and child mortality. One of the key recommendations of the convening was the use of Community Health Workers in every village as a strategy to control preventable diseases. This resonates very strongly with the Community Health Club (CHC) Model of development which depends entirely on the Community based field workers to train and monitor community.
This insight also is reflected in Rwanda, one of the few countries in Africa likely to meet the MDG targets. President Paul Kagame, in his Presidential Initiative (2010) directed each of the 15,000 villages in the country to start Community Hygiene Clubs, using existing Community Health Workers to conduct weekly hygiene sessions, through the Community Based Environmental Health Promotion Programme (CBEHPP) which was launched at that time. The latest figures (August, 2012) show that already 95% (over 12,000 CHCs) have been registered, but that only 8% of the hygiene clubs have started the training of the community, although this should increase significantly this year with many NGOs starting to implement the CBEHP programme.
The CHC Model which is incorporated in the CBEHPP of Rwanda were highlighted at a presentation given by the Directors of Africa AHEAD in Seattle at the Gates Foundation (October, 2011) to the Water, Sanitation, and Hygiene program. A follow-up convening hosted in Kigali, (December, 2011) by the Environmental Health Department of the Ministry of Health, brought together representatives from the WSH program of the Gates Foundation, NGOs in the WASH, and a group of public health researchers. A field visit to Rulindo District, enabled the participants to see that CHCs were indeed a reality, and that MoH officials and Mayors of each of the 30 districts, are responding to the challenge. It was an obvious opportunity to measure the ability of village level training by CHWs to impact on the health of the population.
Although the CHC approach has been in operation for more than 15 years with strong evidence of hygiene behaviour change taking place (Waterkeyn and Cairncross, 2005), the health impact has never been objectively evaluated. Innovations for Poverty Action (IPA), funded by Gates Foundation, will evaluate the CBEHPP program over the next four years, providing for the first time, rigorous evidence into the health impact, and the cost-effectiveness of the CHC approach. 150 randomly selected communities will serve as the study sample. One third of these communities will be randomly selected to receive training and monitoring by MoH.
Africa AHEAD, having been involved from the inception of CBEHPP, with the introduction of the CHC Approach into Rwanda, will be a sub-grantee of the Gates Foundation through the Ministry of Health, building capacity for the monitoring and quality control for the program. The randomized control trial will take place in just one district, in the far south-west of the country, Rusizi District, on the borders with Burundi and DRC. Africa AHEAD will be registering in Rwanda to provide support to optimize the methodology and ensure through MoH that a classic demonstration is available for Innovations for Poverty Action to evaluate the CHC Model properly. In July 2012, the Gates Foundation, IPA and Africa AHEAD met with the Director of Maternal and Child Health, Ministry of Health, and an agreement was signed for the monitoring and evaluation of the CHC Approach in Rwanda.
With many NGOs conducting the CBEHPP throughout Rwanda there is still much work to be done to coordinate this programme and ensure the CHC approach loses nothing by replication at such a scale. Africa AHEAD will be working closely within Ministry of Health Environmental Health Desk to monitor the programme effectively through the use of cell phone surveys, and coordination through a CBEHPP website. It is a great bonus internationally, that this program will be properly monitored and documented. The expectation is that when the MDG tally is made in 2015, Rwanda, is likely to be a shining example of the effectiveness of using CHWs to reduce infant and child mortality. By this time objective findings on the CHC approach, should be available, which will inform decisions on how best to enable the rest of Africa to improve hygiene behaviour in a post MDG world.