**2. The development of the Community Health Club Model**

## **2.1 Community health clubs in Zimbabwe**

In Zimbabwe, the Community Health Club (CHC) Model of development has succeeded in mobilizing communities in over 2340 CHCs in an integrated way (mainly Stages 1 and 2) over the past 25 years, through Africa AHEAD, the pioneer of this approach, thereby benefitting over 1.7 million people, across over half the districts in the country [3]. Although the full four-stage AHEAD Model has been used less often due to sector-specific donor funding in past years, the full AHEAD model was successfully conducted in 285 CHCs in Makoni District between 1999 and 2003 [4] and was found to be a cost-effective method of integrated development at <US\$5 per beneficiary per year for Stage 1. Since 2003, over 30 NGOs have

**33**

*Comparative Assessment of Hygiene Behaviour Change and Cost-Effectiveness of Community…*

been trained by Africa AHEAD and CHCs are now routinely used throughout Zimbabwe by most NGOs. CHCs have enabled many communities to be better organized to mitigate against cholera [5] as well minimize common diseases such the diarrhea, pneumonia and malaria, skin and eye diseases as well as neglected tropical diseases such as intestinal helminths (worms) and schistosomiasis (bilharzia) which were virtually eliminated in reported clinical cases in an area in Makoni District where CHCs had been active for 4 years [6]. An assessment of hygiene behavior change in CHC programs in Chipinge, Chimanimani and Buhera Districts also showed a strong pattern of hygiene improvement based on monitoring records of the program, where 12,311 CHC members enrolled in 127 FAN Clubs [7]. This resulted in improved livelihoods and social capital through communal nutrition gardens with a community member reporting: *'There was a new spirit of cooperation, empathy and love within the participating communities as a result of the FAN intervention as the training provided a mechanism for visiting each other and showing empathy for each other in times of need.'* Although there is much anecdotal evidence through qualitative research [8–10] in Zimbabwe, there is an absence of any comparative research on CHC impact and 'Value for Money' between different countries in the

Africa AHEAD was instrumental in starting CHCs in around 20 countries through the training of other NGOs. Project monitoring records of these initiatives have shown positive hygiene behavior changes in a diverse range of cultures. In East Africa, an outstanding response was recorded in Uganda in 2004, where 116 CHCs were started in 15 camps for internally displaced people enabling the construction of 8504 latrines, as well as 6060 bath shelters and 1552 hand washing facilities within 4 months [11]. In peri-urban areas in both Namibia [12] and South Africa [13], CHCs have been successfully used to enable community maintenance for ablution facilities in informal settlements. In one South African slum, open defecation was reduced by 76%, and dumping of solid waste reduced by 50%. In the rural areas of Kwa Zulu Natal, communities improved their hygiene, sanitation and water

In West Africa, the Community Health Club Model was introduced into Sierra Leone in 2002 for post conflict rehabilitation, which then morphed into the 'For Di Pikin Dem Wel Bodi' program which is successfully improving child and maternal survival rates in Koinadugu District [15]. CHCs were also used to mobilize Muslim communities in a trial in Guinea Bissau to reduce infant and maternal mortality by

The CHC concept was transplanted from Africa to the urban slums in the Caribbean, firstly being replicated into the Dominican Republic [17], and then, more successfully, across the island to Haiti by voluntary community leaders who report that CHCs *'foster positive social relations that can positively improve healthrelated behaviors* [18].*'* In Guatemala they are being used to build trust to enable a strong community response for a water supply project [19]. In 2009, Vietnam, the Ministry of Health started CHCs in three provinces which they considered a *'low cost, high impact'* method demonstrating a significant reduction in diarrhea cases as measured by reported clinical cases at a cost of under one dollar per CHC benefi-

However, none of these programs have been revisited to assess their progress nor have different programmes been compared in published literature and much useful

*DOI: http://dx.doi.org/10.5772/intechopen.89995*

published literature.

supply through CHCs [14].

increased treatment seeking behavior [16].

ciary using government environmental health workers [20].

learning is being lost for lack of such research.

**2.2 Replication of the CHC model to other countries**

*Comparative Assessment of Hygiene Behaviour Change and Cost-Effectiveness of Community… DOI: http://dx.doi.org/10.5772/intechopen.89995*

been trained by Africa AHEAD and CHCs are now routinely used throughout Zimbabwe by most NGOs. CHCs have enabled many communities to be better organized to mitigate against cholera [5] as well minimize common diseases such the diarrhea, pneumonia and malaria, skin and eye diseases as well as neglected tropical diseases such as intestinal helminths (worms) and schistosomiasis (bilharzia) which were virtually eliminated in reported clinical cases in an area in Makoni District where CHCs had been active for 4 years [6]. An assessment of hygiene behavior change in CHC programs in Chipinge, Chimanimani and Buhera Districts also showed a strong pattern of hygiene improvement based on monitoring records of the program, where 12,311 CHC members enrolled in 127 FAN Clubs [7]. This resulted in improved livelihoods and social capital through communal nutrition gardens with a community member reporting: *'There was a new spirit of cooperation, empathy and love within the participating communities as a result of the FAN intervention as the training provided a mechanism for visiting each other and showing empathy for each other in times of need.'* Although there is much anecdotal evidence through qualitative research [8–10] in Zimbabwe, there is an absence of any comparative research on CHC impact and 'Value for Money' between different countries in the published literature.

#### **2.2 Replication of the CHC model to other countries**

Africa AHEAD was instrumental in starting CHCs in around 20 countries through the training of other NGOs. Project monitoring records of these initiatives have shown positive hygiene behavior changes in a diverse range of cultures. In East Africa, an outstanding response was recorded in Uganda in 2004, where 116 CHCs were started in 15 camps for internally displaced people enabling the construction of 8504 latrines, as well as 6060 bath shelters and 1552 hand washing facilities within 4 months [11]. In peri-urban areas in both Namibia [12] and South Africa [13], CHCs have been successfully used to enable community maintenance for ablution facilities in informal settlements. In one South African slum, open defecation was reduced by 76%, and dumping of solid waste reduced by 50%. In the rural areas of Kwa Zulu Natal, communities improved their hygiene, sanitation and water supply through CHCs [14].

In West Africa, the Community Health Club Model was introduced into Sierra Leone in 2002 for post conflict rehabilitation, which then morphed into the 'For Di Pikin Dem Wel Bodi' program which is successfully improving child and maternal survival rates in Koinadugu District [15]. CHCs were also used to mobilize Muslim communities in a trial in Guinea Bissau to reduce infant and maternal mortality by increased treatment seeking behavior [16].

The CHC concept was transplanted from Africa to the urban slums in the Caribbean, firstly being replicated into the Dominican Republic [17], and then, more successfully, across the island to Haiti by voluntary community leaders who report that CHCs *'foster positive social relations that can positively improve healthrelated behaviors* [18].*'* In Guatemala they are being used to build trust to enable a strong community response for a water supply project [19]. In 2009, Vietnam, the Ministry of Health started CHCs in three provinces which they considered a *'low cost, high impact'* method demonstrating a significant reduction in diarrhea cases as measured by reported clinical cases at a cost of under one dollar per CHC beneficiary using government environmental health workers [20].

However, none of these programs have been revisited to assess their progress nor have different programmes been compared in published literature and much useful learning is being lost for lack of such research.

*Healthcare Access - Regional Overviews*

existing resources.

main stages, preferably over a 4-year period:

to improve hygiene (Goal 3)

through self-supply (Goal 6)

ensuring a balanced diet (Goal 2)

**2.1 Community health clubs in Zimbabwe**

income generating projects (Goal 5 and 6)

**2. The development of the Community Health Club Model**

community development initiatives from the 'silo vision' which characterized much community development from 2000 to 2015, when the Millennium Development Goals (MDGs) [2] encouraged a more narrow focus, to a more integrated approach with the current SDGs. As no single SDG goal on its own will be sufficient to completely eliminate poverty, implementing organizations are looking for ways to combine programs across sectors: for example, the Goal 6 (Safe Water and Sanitation) if combined with Goal 2 (Food Security and Good Nutrition), is likely to be more successful in improving Goal 3 (Improved Family Health). If, in the same program, Goal 5 (Women's Empowerment) results in Goal 8 (increased Employment), then a substantial reduction of the primary Goal 1, (the elimination of *Absolute* Poverty) would be expected. Integrated programs are not only more aligned with this holistic

people-centered approach but will also be more likely to be cost-effective.

The Community Health Club (CHC) model of community development is an integrated and holistic strategy to start up CHCs—voluntary Community-Based organizations (CBOs) in rural or peri-urban area—which include all residents in active membership of a group. Membership of a CHC is freely available to all ages, education levels and social status. The club meets weekly for at least 6 months to find ways to improve family health by preventing common diseases through safe hygiene, with the purpose of increasing social capital, through shared understanding and coordinated action with the objective to improve living standards with

The CHC is the vehicle for community development which, if extended into a full A.H.E.A.D Model (Applied Health Education and Development), can easily coordinate many activities into a single program in a process of development in four

• Stage 1: Health Promotion (HP): Health education and participatory activities

• Stage 3: Food, Agriculture and Nutrition (FAN) Clubs: nutrition gardens and

• Stage 4: Gender Equity & Women's Empowerment (GEWE): management of

In Zimbabwe, the Community Health Club (CHC) Model of development has succeeded in mobilizing communities in over 2340 CHCs in an integrated way (mainly Stages 1 and 2) over the past 25 years, through Africa AHEAD, the pioneer of this approach, thereby benefitting over 1.7 million people, across over half the districts in the country [3]. Although the full four-stage AHEAD Model has been used less often due to sector-specific donor funding in past years, the full AHEAD model was successfully conducted in 285 CHCs in Makoni District between 1999 and 2003 [4] and was found to be a cost-effective method of integrated development at <US\$5 per beneficiary per year for Stage 1. Since 2003, over 30 NGOs have

• Stage 2: Water, Sanitation & Hygiene (WASH): construction of facilities

**32**

#### **2.3 Scaling up the Community Health Club Model in Rwanda**

Rwanda is the only country in Africa to have embedded the CHC model into a national program known as the Community Based Environmental Health Promotion Programme (CBEHPP) [21]. In 2010 the Economic Development and Poverty Reduction Strategy II laid out the target of *'CHCs with enhanced health promotion and behaviour change capacity'* to reach 70% of all villages in Rwanda by 2018 [22]. By 2015, CBEHPP had succeeded in establishing CHCs in virtually all the 15,000 villages throughout this small, but highly organized country of 12 million people. CBEHPP contributed to Rwanda becoming one of only five countries in Africa to meet sanitation targets of the MDGs and to halve the number without sanitation in the country. The *Imihigo* assessment is a regular evaluation by government in Rwanda whereby each Mayor is held accountable for various achievements (including a CHC in every village). The *Imihigo* assessment in 2015 recognized that CBEHPP had successfully galvanized communities in Rusizi District to achieve hygiene and sanitation change [23].

Based on the Rwandan success story using CBEHPP, the African Union (AU), with backing from the African Development Bank (AfDB) and the African Ministers' Council for Water (AMCOW) recommended in 2016 that the CHC Model should be used in the 10 most fragile states in Africa to achieve the SDGs. The AU's Kigali Action plan states:

'… Rwanda has gained substantial experience with social approaches such as the Community Based Environmental Health Promotion Programme (CBEHPP) and Community Health Clubs (CHCs) the implementation of which has enabled the country to significantly reduce the debilitating national hygiene and sanitationrelated disease burden and, in so doing, attain key outcomes in efforts to achieve the MDG targets not only for water supply and sanitation, but also poverty reduction outcomes.' [24].

CBEHPP in Rwanda, having reached most villages across the country, has now been extended into a well-resourced USAID-funded Integrated Nutrition–WASH program which aims to reduce the prevalence of stunting in eight districts using existing CHCs to roll out a Food Security and Nutrition program in line with the 'full' four-stage AHEAD Model, thus providing a valuable example of CHCs being taken to scale.

### **3. Cost effectiveness**

The rationale for providing water and sanitation initiatives has been based on the need to control diarrheal diseases, which still claim the life of one in every nine children before their fifth birthday [25]. Whilst many diseases can be fairly easily controlled by a single action (e.g. the use of insecticide treated bed-nets to prevent malaria), the control of diarrhea is more challenging because there are at least five main transmission routes through which feces reach the mouth. These are known as the '5 "F's"– Flies, Fluids, Fingers, Food, and Fields [26] - all of which have to be safely controlled if the prevalence of diarrhea is to decease. It has long been understood that if only one "F" component is addressed alone, without the other 4 "F's" then diarrhea is unlikely to be successfully reduced. Research has shown that safe drinking water is estimated to reduce diarrhea by only 15%, safe sanitation by 35%, hygiene promotion by 33% [27] and regular handwashing with soap by 47% [28]. The training in the CHC tackles all 5 "Fs" over a 6 month period and therefore theoretically (if over 80% of CHC members respond and improve their hygiene) diarrhea should be decreased.

However, diarrhea accounts for only 11% of death globally among children under five in developing countries: pneumonia accounts for 18%; complications

**35**

*Comparative Assessment of Hygiene Behaviour Change and Cost-Effectiveness of Community…*

during pregnancy for 14%; death in childbirth 9% and malaria for 7% of child deaths [25]. The most effective intervention to prevent infant deaths would be to improve nutrition because malnutrition (miasma) accounts for 33% of all the deaths mentioned above i.e. Children who have pneumonia, diarrhea, and malaria have less chance of survival if they are malnourished and stunted. Many of these child deaths could be prevented with little cost, if mothers were properly trained in CHCs, enabling them to improve their understanding of disease prevention, to protect their children by safer hygiene in the home and ensure early treatment to

However, there is a caveat – as public health relies on reaching the critical mass in a population, we maintain that at least 80% of the CHC members should conform to the recommended practices if any impact is to be found on prevention of diarrhea. This critical assumption is highlighted in the recent debate [29, 30] as to whether CHCs in Rusizi District in Rwanda, achieved sufficient quality and quantity of training to bring about the prevention of diarrhea let alone control stunting. Although much research has been done in WASH literature on a *single* aspect of 'effectiveness' (i.e. water *or* sanitation *or* hygiene) there are few peer reviewed papers that address *all three* of these essential aspects of WASH. This may be because few programs are sufficiently integrated to *provide* all three inputs. A review of a Cost-Effectiveness Analysis [31] found only six studies, of which, only three, met the minimum level of methodological soundness. Two of these referred to our own work in Zimbabwe [4, 32] and the other to a study in Bangladesh [33]. In this review, 'Effectiveness' was defined as '*the adoption of specific recommended hygiene practices by those exposed to a health promotion programme*', whilst '*Cost*' was calculated roughly by taking the monetary expense of only the *field* inputs divided by the number of people benefitting, giving a '*cost per person per year*'. In this paper we use the same definition of *'*cost-effectiveness*'* as it is measured in monetary terms (US\$) – i.e. the production of *'a unit of effect through an intervention'*. The term

'Value for Money' is similar but emphasizes the *quality* of services.

within the household (defined as 'those eating from the same pot').

**4. Description of the interventions**

**4.1 Mberengwa District, Zimbabwe**

This paper looks at the cost-effectiveness of two interventions which use the CHC Model: an intervention in Rusizi district in Rwanda implemented between 2014 and 2017 which was part of the National CBEHP Programme, and a project in Mberengwa District in Zimbabwe implemented in partnership with an NGO between 2012 and 2014. We access the different inputs and analyze the cost-effectiveness of the two different strategies against intermediate outcomes of hygiene

The field cost includes all training expenses of personnel but does not include costs of directs inputs in the form of subsidy for cement for sanitation nor water hardware, i.e. filters or handpumps. Neither were the indirect costs for the NGO management nor research costs included in this calculation of cost-effectiveness. Indirect beneficiaries, (i.e. those outside the program that might benefit incidentally by diffusion of innovation or emulation) were not counted, as we only monitor the households who are registered CHC members and their immediate family living

The CHC approach in Zimbabwe has been adopted into both the National Water

Policy [34] and the National Sanitation and Hygiene Policy [35], although the Government of Zimbabwe has not yet been able to launch a national CHC program

*DOI: http://dx.doi.org/10.5772/intechopen.89995*

reduce child mortality.

behavior change.

#### *Comparative Assessment of Hygiene Behaviour Change and Cost-Effectiveness of Community… DOI: http://dx.doi.org/10.5772/intechopen.89995*

during pregnancy for 14%; death in childbirth 9% and malaria for 7% of child deaths [25]. The most effective intervention to prevent infant deaths would be to improve nutrition because malnutrition (miasma) accounts for 33% of all the deaths mentioned above i.e. Children who have pneumonia, diarrhea, and malaria have less chance of survival if they are malnourished and stunted. Many of these child deaths could be prevented with little cost, if mothers were properly trained in CHCs, enabling them to improve their understanding of disease prevention, to protect their children by safer hygiene in the home and ensure early treatment to reduce child mortality.

However, there is a caveat – as public health relies on reaching the critical mass in a population, we maintain that at least 80% of the CHC members should conform to the recommended practices if any impact is to be found on prevention of diarrhea. This critical assumption is highlighted in the recent debate [29, 30] as to whether CHCs in Rusizi District in Rwanda, achieved sufficient quality and quantity of training to bring about the prevention of diarrhea let alone control stunting.

Although much research has been done in WASH literature on a *single* aspect of 'effectiveness' (i.e. water *or* sanitation *or* hygiene) there are few peer reviewed papers that address *all three* of these essential aspects of WASH. This may be because few programs are sufficiently integrated to *provide* all three inputs. A review of a Cost-Effectiveness Analysis [31] found only six studies, of which, only three, met the minimum level of methodological soundness. Two of these referred to our own work in Zimbabwe [4, 32] and the other to a study in Bangladesh [33]. In this review, 'Effectiveness' was defined as '*the adoption of specific recommended hygiene practices by those exposed to a health promotion programme*', whilst '*Cost*' was calculated roughly by taking the monetary expense of only the *field* inputs divided by the number of people benefitting, giving a '*cost per person per year*'. In this paper we use the same definition of *'*cost-effectiveness*'* as it is measured in monetary terms (US\$) – i.e. the production of *'a unit of effect through an intervention'*. The term 'Value for Money' is similar but emphasizes the *quality* of services.

This paper looks at the cost-effectiveness of two interventions which use the CHC Model: an intervention in Rusizi district in Rwanda implemented between 2014 and 2017 which was part of the National CBEHP Programme, and a project in Mberengwa District in Zimbabwe implemented in partnership with an NGO between 2012 and 2014. We access the different inputs and analyze the cost-effectiveness of the two different strategies against intermediate outcomes of hygiene behavior change.

The field cost includes all training expenses of personnel but does not include costs of directs inputs in the form of subsidy for cement for sanitation nor water hardware, i.e. filters or handpumps. Neither were the indirect costs for the NGO management nor research costs included in this calculation of cost-effectiveness. Indirect beneficiaries, (i.e. those outside the program that might benefit incidentally by diffusion of innovation or emulation) were not counted, as we only monitor the households who are registered CHC members and their immediate family living within the household (defined as 'those eating from the same pot').

## **4. Description of the interventions**

#### **4.1 Mberengwa District, Zimbabwe**

The CHC approach in Zimbabwe has been adopted into both the National Water Policy [34] and the National Sanitation and Hygiene Policy [35], although the Government of Zimbabwe has not yet been able to launch a national CHC program

*Healthcare Access - Regional Overviews*

The AU's Kigali Action plan states:

outcomes.' [24].

**3. Cost effectiveness**

diarrhea should be decreased.

**2.3 Scaling up the Community Health Club Model in Rwanda**

Rwanda is the only country in Africa to have embedded the CHC model into a national program known as the Community Based Environmental Health Promotion Programme (CBEHPP) [21]. In 2010 the Economic Development and Poverty Reduction Strategy II laid out the target of *'CHCs with enhanced health promotion and behaviour change capacity'* to reach 70% of all villages in Rwanda by 2018 [22]. By 2015, CBEHPP had succeeded in establishing CHCs in virtually all the 15,000 villages throughout this small, but highly organized country of 12 million people. CBEHPP contributed to Rwanda becoming one of only five countries in Africa to meet sanitation targets of the MDGs and to halve the number without sanitation in the country. The *Imihigo* assessment is a regular evaluation by government in Rwanda whereby each Mayor is held accountable for various achievements (including a CHC in every village). The *Imihigo* assessment in 2015 recognized that CBEHPP had successfully galvanized

communities in Rusizi District to achieve hygiene and sanitation change [23].

with backing from the African Development Bank (AfDB) and the African Ministers' Council for Water (AMCOW) recommended in 2016 that the CHC Model should be used in the 10 most fragile states in Africa to achieve the SDGs.

Based on the Rwandan success story using CBEHPP, the African Union (AU),

'… Rwanda has gained substantial experience with social approaches such as the Community Based Environmental Health Promotion Programme (CBEHPP) and Community Health Clubs (CHCs) the implementation of which has enabled the country to significantly reduce the debilitating national hygiene and sanitationrelated disease burden and, in so doing, attain key outcomes in efforts to achieve the MDG targets not only for water supply and sanitation, but also poverty reduction

CBEHPP in Rwanda, having reached most villages across the country, has now been extended into a well-resourced USAID-funded Integrated Nutrition–WASH program which aims to reduce the prevalence of stunting in eight districts using existing CHCs to roll out a Food Security and Nutrition program in line with the 'full' four-stage AHEAD Model, thus providing a valuable example of CHCs being taken to scale.

The rationale for providing water and sanitation initiatives has been based on the need to control diarrheal diseases, which still claim the life of one in every nine children before their fifth birthday [25]. Whilst many diseases can be fairly easily controlled by a single action (e.g. the use of insecticide treated bed-nets to prevent malaria), the control of diarrhea is more challenging because there are at least five main transmission routes through which feces reach the mouth. These are known as the '5 "F's"– Flies, Fluids, Fingers, Food, and Fields [26] - all of which have to be safely controlled if the prevalence of diarrhea is to decease. It has long been understood that if only one "F" component is addressed alone, without the other 4 "F's" then diarrhea is unlikely to be successfully reduced. Research has shown that safe drinking water is estimated to reduce diarrhea by only 15%, safe sanitation by 35%, hygiene promotion by 33% [27] and regular handwashing with soap by 47% [28]. The training in the CHC tackles all 5 "Fs" over a 6 month period and therefore theoretically (if over 80% of CHC members respond and improve their hygiene)

However, diarrhea accounts for only 11% of death globally among children under five in developing countries: pneumonia accounts for 18%; complications

**34**

to coordinate the sector as has been so effectively done in Rwanda. In Zimbabwe, NGOs are largely coordinated through UNICEF which heads the WASH Cluster. Zimbabwe AHEAD (ZA) partnered with Action Contre la Faim (ACF) to implement the Public Health Promotion and Community Livelihoods Improvement Program in Gutu and Mberengwa Districts [9]. Midlands Province is one of the most arid areas of Zimbabwe with a low rainfall of 150–250 mm. Literacy is over 80% for both men and women. ZA was responsible for the 'software' (meaning mobilization and training of people) in Stage 1 (Health Promotion), whilst ACF managed the implementation of the 'hardware' component (i.e. infrastructure) for the Stage 2 (Water and Sanitation) and Stage 3 (Food, Agriculture & Nutrition) (FAN) in the two subsequent years.

The main task for ZA was to mobilize the community and to start up and train CHCs, in order to promote full community participation and inculcate increased responsibility to ensure strong community ownership for the water provision programme. Most people in the area are subsistence farmers, but as many men are away from home all year working in South Africa, their wives remain to run their farms. The year 2012 was not an enabling period in which to run a program in a remote rural area, as the economy had collapsed with hyperinflation, political tensions were high, and Zimbabwe had dropped to the 14th lowest in Human Development Index in the world [36] with a critical scarcity of fuel, banknotes and electricity.

Stage 1 of the program ran for 24 months, from February 2012 to January 2014. This was a well-staffed programme with 6 field officers stationed across 8 wards, supervised by a programme manager based in the District Office (**Table 1**)*.* The aim was to achieve blanket coverage of households in these wards, so that all available households were within in a CHC.

Unlike other CHC programmes where CHCs have around 100 members, ACF was adamant that to ensure better quality of training, the size of the CHC membership should be restricted to between 40 and 50 members in each CHC. Therefore, to enable the whole village to join, a second CHC would be formed if there was enough demand from the community. In fact, such was the popularity of the CHCs that the target of 8208 possible members was exceeded with a total of 9615 members registered resulting in universal coverage within 2 years (**Table 1**)*.* To achieve more gender balance, it was strongly advocated by the project officers in mobilizing the community, that the CHC was not only a woman's concern, but that husbands as well as wives should be members. As a result, there were 1196 male CHC members (18% of the total membership), resulting in 1407 households where both husband and wife attended the CHC together. Blanket coverage was achieved with the total number of members being 17% more than number of households. As for compliance with training, with sufficient time and personnel, all of the CHCs managed to complete the required number of 20 training sessions, with 4864 sessions being held in total. Mberengwa had an exceptional completion rate, with 77% of CHC members graduating with full attendance, which is higher than many other CHCs project in Zimbabwe.

Ministry of Health had three Environmental Health Technicians (EHTs) stationed in the project area who were meant to be involved in the programme but had no transport: they relied on the NGO which effectively managed the program, with all field officers having their own motorbike. To understand the scale of the project, mobilization details can be compared between Mberengwa in Zimbabwe and Rusizi in Rwanda (**Table 1**)*.*

#### **4.2 Rwanda: Rusizi District**

In 2012, a cluster Randomized Controlled Trial (cRCT) was proposed to establish the cost-effective of the CHC model within CBEHPP. Rusizi District was

**37**

*Comparative Assessment of Hygiene Behaviour Change and Cost-Effectiveness of Community…*

**achieved**
