REPUBLIC OF RWANDA MINISTRY OF HEALTH

1. REPUBLIC OF RWANDA MINISTRY OF HEALTH COMMUNITY HYGIENE CLUBS

2. CURRENT STRATEGY FOR PREVENTION OF DIARRHEAL DISEASES THROUGH COMMUNITY HYGIENE CLUBS Community Based Environmental Health Promotion Programme (CBEHPP) Ministry of Health Joseph Katabarwa Katabarwa.theodomily@gmail.com Cell number: +250 788 461 076

3. WHY CBEHPP ? • Repeated episodes of diarrhoea and intestinal parasites infection increases < 5 morbidity and mortality, malnutrition and poverty outcomes • Some of the main causes of morbidity and mortality in Rwanda are infectious diseases including diarrhoea, intestinal parasites, skin and eye infections: • The prevalence of diarrhoea has hardly decreased between 2005 and 2010, 14 % and 13 % respectively (DHS 2010)

4. WHY CBEHPP ? • 25% of school children in Rwanda are infected with intestinal worms (source: CFSVA & Nutrition, 2009) • 44% of primary school children are infected with amoebiasis (source: SPH, 2007) • Those diseases can be prevented through improved hygiene practices which are currently insufficient (eg. Households having water and soap at handwashing places is 10% (DHS 2010)

5. PREVENTING DIARRHOEAL DISEASES THROUGH COMMUNITY HYGIENE CLUBS • Annually, more than 80% of the cases of diarrhoea worldwide are the result of fecal-oral contamination • They can be avoided through cost-effective environmental health improvement interventions (EHP etal., 2004) • The key interventions for prevention of diarrhoeal diseases (Val Curtis etal., 2003). : • Handwashing (reduced risk of 47%) • Hygiene promotion (reduced risk of 35%) • Drinking safe water (reduced risk of 15%)

6. CBEHPP Expectations of success through the Community Hygiene Clubs The CHC Approach has been tried and tested in Zimbabwe, Sierra Leone, Guines Bissau, Uganda, South Africa and in Vietnam. Every time it has delivered reliable results, varying according to the level of development in each context. We expect the same in Rwanda that has been achieved in the example opposite (Zimbabwe, 2002) Difference of Prevalence of Observed Hygiene Indicators between Community Health Club Members and non Members in Tsholotsho District, Zimbabwe. 2001 Source: Waterkeyn,J. 2005 (Africa AHEAD)

7. NATIONAL VISION AND POLICIES FOR IMPROVING HEALTH OF THE POPULATION • Vision 2020: all households will have mastered and be practicing ‘good hygiene and waste disposal.’ • Economic development and poverty Reduction Strategy (EDPRS): Streamline interventions required to implement the vision • Health Sector Policy: Promoting good hygiene contributes to healthier lifestyles and prevention of diseases • Environmental Health Policy and National policy for Water and Sanitation Services: Determines the modalities of implementation of the CBEHPP strategy for improved health of the population.

8. Community-Based Environmental Health Promotion Programme Cross-cutting Sectors & Ministries CBEHPP MOH: Sustainable Hygiene behavioral change CHWs MINEDUC: Enhancing human resources CBEHPP (CHCs) MINALOC & MINECOFIN: National development & poverty alleviation MININFRA: Increasing access to rural /urban WSS

9. Community based Environmental Health Promotion Program The purpose by 2015: Reduce by 2015, the national disease burden due to hygiene preventable diseases through Community Hygiene Clubs to contribute to the improved health and poverty reduction outcomes

10. SOME OF CBEHPP OBJECTIVES The CBEHPP strategy was launched in Rwanda on December 2009 to harmonize hygiene promotion efforts and instillation of deep rooted sustainable hygiene behaviour change through the following strategic interventions. • Establishment of Community Hygiene Clubs (CHCs) in all villages • Increase use of hygienic latrines in homes, schools and health facilities

11. SOME OF CBEHPP OBJECTIVES • Increase hand washing with soap at critical times in homes, schools and health facilities • Increase drinking of safe water in homes, schools and health facilities • Achieve Zero Open Defecation in all villages through construction and use of improved toilets • Improve safe disposal of children’s faeces in all households 7. Increase households with bath shelters, rubbish pits, pot-drying racks and clean yards

12. CBEHPP • CBEHPP: • Aims to reach all 15,000 villages in Rwanda • Establish a Community Hygiene Club (CHC) in every • village • All households in each village will be CHC members • One member represents the household in a Club session Community-Based Environmental Health Promotion Programme • CHC Members required to meet every week for 2 hours • Informed decision making through good information • Creating a common unity/goal through activities • Action oriented with weekly hygiene improvements • (e.g. making existing toilets hygienic).

13. APPROACHES FOR HYGIENE BEHAVIOR CHANGE CHC Approach: Implementation strategy Other Approaches as Implementation strategies • 6 months, 20 sessions ( two hours each week) • One ‘Triggering’ day + a few follow-up visits • Learning through fun participatory activities reinforce good practice (song, drama) • Village walk to shock community that they are eating their own faeces • Informed group decision making and weekly homework • Community shamed into action • Enforcement of change with fines • Voluntary household improvements • Zero Open Defecation (ZOD) & 20+ other hygiene improvements

14. CBEHPP Training Manuals for CBEHPP developed Community Health Workers 5 day workshop, to enable Environment Health Officers and Community Health Workers to effectively facilitate the 20 topics. District Environmental Health Officers 3 day training in all aspects of the CHC Approach to be used in CBEHPP to enable planners to have an understanding of the CHC approach.

15. Tool kit of Visual Aids developed for participatory activities (PHAST) CBEHPP • Design & development of more than 300 illustrations for 20 topics. • These were all individually pretested and altered to ensure they are 80% comprehensible for illiterate/semi literate and to fully represent the Rwandan context. Pretesting visual aids. Photo credit: Waterkeyn J.

16. Training of National Core Trainers CBEHPP Training session held for core trainers. Photo credit: Waterkeyn J. In November 2010 the core team were trained in order to scale up training. Roll out of EHO Training in 5 Districts in December 2010, and 4 other districts in 2011. 1. Starting up a CHC 2. Cause and cure of disease 3. Personal Hygiene 4. Skin Diseases 5 Hand washing Times & Method 6.a. Infant Care 6.b. Immunisation 7. Worms 8.a. Diarrhoea: Transmission 8.b. Diarrhoea: Dehydration 9.a. Malnutrition 9.b. Balanced diet 10. Child Care 11. Kitchen hygiene 12.a. Rat control 12.b. Solid waste 13. Food Security 14. Water Sources 15.a. Water Storage 15.b. Water Usage 16.a. Zero Open Defecation 16.b. Improved Sanitation 17. Respiratory Disease 18. Malaria 19. Bilharzia 20. HIV/ AIDS 1. Starting up a CHC 2. Cause and cure of disease 3. Personal Hygiene 4. Skin Diseases 5 Hand washing Times & Method 6.a. Infant Care 6.b. Immunisation 7. Worms 8.a. Diarrhoea: Transmission 8.b. Diarrhoea: Dehydration 9.a. Malnutrition 9.b. Balanced diet 10. Child Care 11. Kitchen hygiene 12.a. Rat control 12.b. Solid waste 13. Food Security 14. Water Sources 15.a. Water Storage 15.b. Water Usage 16.a. Zero Open Defecation 16.b. Improved Sanitation 17. Respiratory Disease 18. Malaria 19. Bilharzia 20. HIV/ AIDS No. Topic Date Signature of Facilitator Weekly Homework Signature of Facilitator 1. Introduction Bring friends and family 2. Common Diseases Know common diseases 3. Personal Hygiene Family Wash Shelter 4. Hand washing Hand Wash Facility / soap 5. Skin Diseases Children no Skin Disease 6. Diarrhoea Knowledge of SSS / ORS 7. Infant Care Correct Child Immunisation 8. Worms Children no worms 9. Food Hygiene Clean drying rack 10 Nutrition Good Road to Health 11. Food Security Kitchen Gardens 12. Water Sources Clean Water Source 13. Safe Drinking Water Safe storage and usage 14. Adequate Sanitation ZOD / Clean safe latrine 15. Green & clean home Waste management and greening 16. Good Parenting Clean children 17. Respiratory Disease Good Ventilation 18. Malaria Use of treated bed nets 19. Bilharzia Treatment for Bilharzia 20. HIV/ AIDS VCT No. Topic Date Signature of Facilitator Weekly Homework Signature of Facilitator 1. Introduction Bring friends and family 2. Common Diseases Know common diseases 3. Personal Hygiene Family Wash Shelter 4. Hand washing Hand Wash Facility / soap 5. Skin Diseases Children no Skin Disease 6. Diarrhoea Knowledge of SSS / ORS 7. Infant Care Correct Child Immunisation 8. Worms Children no worms 9. Food Hygiene Clean drying rack 10 Nutrition Good Road to Health 11. Food Security Kitchen Gardens 12. Water Sources Clean Water Source 13. Safe Drinking Water Safe storage and usage 14. Adequate Sanitation ZOD / Clean safe latrine 15. Green & clean home Waste management and greening 16. Good Parenting Clean children 17. Respiratory Disease Good Ventilation 18. Malaria Use of treated bed nets 19. Bilharzia Treatment for Bilharzia 20. HIV/ AIDS VCT Family Cases in 6 Months 1 2 3 4 5 6 Diarrhoea Dysentery Miasmas Kwashiorkor Scabies Ringworm Worms Lice Colds Flu Measles Malaria Bilharzia Bronchitis Pneumonia TB HIV AIDs Typhus Cholera Meningitis STIs Depression • Ministry of Health, Rwanda • COMMUNITY BASED ENVIRONMENTAL • HEALTH PROMOTION PROGRAMME • Ministry of Health, Rwanda • CHC NAME • MAIN MEMBER: • 2ND MEMBER • EHO NAME: • CHC NAME: • PROVINCE: • DISTRICT: • SECTOR: • UMUDUGU: • START DATE • COMPLETION DATE Family Cases in 6 Months 1 2 3 4 5 6 Diarrhoea Dysentery Miasmas Kwashiorkor Scabies Ringworm Worms Lice Colds Flu Measles Malaria Bilharzia Bronchitis Pneumonia TB HIV AIDs Typhus Cholera Meningitis STIs Depression • Ministry of Health, Rwanda • COMMUNITY BASED ENVIRONMENTAL • HEALTH PROMOTION PROGRAMME • Ministry of Health, Rwanda • CHC NAME • MAIN MEMBER: • 2ND MEMBER • EHO NAME: • CHC NAME: • PROVINCE: • DISTRICT: • SECTOR: • UMUDUGU: • START DATE • COMPLETION DATE P D S C U CHC H/h P D S C U CHC H/h COMMUNITY BASED ENVIRONMENTAL HEALTH PROMOTION PROGRAMME

17. 1 Introduction Bring friends and family 2 Common Diseases Know common diseases 3 Personal Hygiene Family wash shelter 4 Hand washing Handwash facility/ soap 5 Skin diseases Children no skin diseases 6 Diarrhoea Knowledge of SSS/ORS 7 Infant Care Correct Immunization 8 Intestinal Parasites/Worms Children no Worms 9 Food Hygiene Clean Drying Rack 10 Nutrition Good Road to Health 11 Food Security/Safety Kitchen Garden 12 Water Sources Clean Water Source 13 Safe Drinking Water Safe Storage and Usage 14 Adequate Sanitation ZOD/Clean Safe Toilets 15 The Model Home Waste Management and Greening 16 Good Parenting Clean Children 17 Respiratory Diseases Good Ventilation 18 Malaria Use of Treated Bed Nets 19 Bilharzia Treatment for Bilharzia 20 HIV/AIDS VCT and PMTCT CHC Approach Facilitating Live Discussions?

18. CHC Approach Facilitating Live Discussions? Reinforcement: Peer pressure / home visits Homework: Recommended Practices Measurable: Specific Targets Each Week

19. Concept of community participatory programming Community diagnosis Monitoring& Evaluation Participatory planning Implementation of activities

20. No Material Handouts: The Only Reward is a Certificate

21. Progress Measurement of CBEHPP Program data: • % of established CHCs (91% - District reports May, 2012) • % of functioning CHCs (38% - District reports May, 2012) • NGOs and Organizations fully involved in CBEHPP implementation: WSP, UNICEF, USAID through World Vision, WaterAid through KHI, EU through Health Poverty Action/SALTWASH, Luxemburg and Medicus Mundi. Progress measurement • Baseline assessment of key indicators (survey) • Monitoring: • Quarterly households’ hygiene and sanitation data collection by CHWs and CHCs executive committee members • Yearly households hygiene and sanitation survey by CHWs and executive committee of CHCs • Qualitative and quantitative evaluation of health and hygiene impact after three and five years

22. Integrated Community Development Primary Health Water & Sanitation Environment Home-based care POVERTY ALLEVIATION THROUGH CHCs Education Food Security Skills Training Income Generation

23. Conclusion CBEHPP Given that CBEHPP will be implemented in all 15,000 villages in the next few years, it is expected to induce significant levels of behavior change with the resultant decrease in prevalence of hygiene preventable disease (diarrhea, intestinal infections etc.) throughout Rwanda

24. With technical and financial support of: