*6.1.2 Rusizi District, Rwanda*

*Healthcare Access - Regional Overviews*

of Change [30].

**6. Results**

**6.1 Mobilization of community**

*6.1.1 Mberengwa District, Zimbabwe*

between CHCs and to provide contextual rational for some of the anomalies, or where targets were under or over-reached. These insider observations from the grass roots provides the explanation for various challenges and shortcomings, as well as reasons for success of the CHC Model allowing some recommendations to achieve better Value for Money in future CHC programs based on the CHC Theory

In Mberengwa, an in-depth observation was taken on a small sub-set of six CHCs using an interpretivist approach. This was triangulated with participant observation, key informant interviews and focus group discussions involving Environmental Health staff, local leaders, CHC members and others. Field work was done over 2 weeks in Ward 19, which had 39 CHCs in the 43 villages and a population of 9245, in 1481 households. In addition, two villages without CHCs

We use project monitoring data which, we accept could be open to interviewer bias as the field officers who managed the programme also assisted the facilitators in the collection of the village data. However, an effort has been made to minimize this bias, by using an external researcher in each country to clean data, excluding all incomplete data and verifying all records and findings in Rwanda [32, 45] and Zimbabwe [44] through spot observations. It is also not ideal that all that co-authors of this paper have been associated either with the design of the CHC approach and the implementation of the intervention in both Zimbabwe and Rwanda and may not be strictly impartial. However, in the interests of our genuine concern to improve learning in the sector, we have attempted to provide only such programming evidence which has been verified by external observers conducting research for their

The completion rate of the CHC training was exceptionally high in Mberengwa

with full attendance of all 20 sessions by 6335 (77%) of CHC members. With sufficient time to repeat many of the session for a second time, all members had the opportunity to complete the training if they had missed the original session due to other commitments. The CHC training was well-timed by the NGO to coincide with the dry season (March – December 2012) to coincide with the 8 months of the year when there is little demand from farming to distract members from the training. All CHCs did more than 20 sessions properly, providing only one topic only per session of at least 2 hours of participatory activities. All the mobilization targets were not only achieved but surpassed during the first year, with follow-up by Project Officers, who arranged model home competitions. All CHC held their Graduation ceremonies properly with CHC members receiving certificates with due recognition. Those who did not finish in Year 1 had a second chance to complete their training and graduate in Year 2, while the water and sanitation component of the project was being done. However, as the number of members was limited to 50 per CHC, we could not judge the popularity of a CHC by the number of members

were sampled to serve as control groups to enable comparison [10].

own theses which have subsequently been properly peer reviewed.

**5.3 Limitations and possible sources of bias**

**44**

The completion rate of the training in Rwanda was not as high as had been hoped with only 41% of CHC members attending all 20 sessions in 5 months. However, this appeared to be, not because they did not *want* to attend sessions, but because they did not want to get wet in the torrential rain! In addition, the training was held during the season that farmers were at their busiest in the fields, planting and weeding crops. Not as many members completed as was expected because the training was shortened by a full month and they had no opportunity for repeating any sessions. Crucially there was no time for Graduation Ceremonies and no "Model Home competitions" were held as had been planned. However, monitoring records show that in the post research intervention, all CHCs continued to meet and over 6 sessions were done per CHC after the official end of the cRCT [30]. This demonstrates the demand for CHC activities. As attendance continued without external support, we would take this as an indication of a high level of sustainability. In Rusizi District, despite the constraints encountered by the community, the large size of the CHC in terms of memberships with an average of 80 members per CHC which exceeded the expected target of 70 members per CHC demonstrates popularity of the CHC. At the end of the cRCT intervention (i.e. after the first year), the spread of the intervention had only reached 58%. However, by the end of 3 years, the spread of CHC households had increased to 80% with CHC members ranging from 40 to 100% in 50 villages.

Our monitoring data shows that the uptake of the CHC model in Rusizi, although it was slow initially, did eventually meet all targets. Therefore, we would consider the CHC project to be a popular intervention in Rusizi District, and that what appears to have been community resistance was mainly due to external constraints imposed by the research and implementing team. Once Ministry of Health had clearly endorsed the intervention, the village leaders whole heartedly led the CHC with much interesting anecdotal evidence of community-led initiatives.
