**7.3 Dedication of Environmental Health staff**

While EHOs in both countries showed complete personal commitment, they were almost always frustrated by the lack of transport in the Ministry of Health, preventing such staff from reaching out and supporting Community Health Club facilitators in distant villages. Those CHCs which were situated near where Environmental Health Officers resided did much better than those in remote villages which were left to their own devices. Although the CHC enables even poorly educated facilitators to run the CHC, they do need strong support from the Ministry of Health with regular back-up of Environmental staff monitoring.

**51**

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

The investment in transport is one of the key inputs required for a health promotion programme which is less about the provision of facilities and more essentially about training with a high level of face-to-face time of project facilitators with the community. However, providing money for transport is one of the least popular budget items considered by donors investing in many African countries. This may be due to the notorious costs of keeping transport functional, yet this is the single most urgent need to build the capacity of Environmental Health side of the Ministry of Health. CHCs in Rusizi were unable to fulfill their role because their motorbikes only arrived after the intervention was complete: their fuel allowance *never* reached the district from the headquarters of MoH. By contrast, in Zimbabwe the NGO programme was properly resourced with each of the 6 full-time project officers stationed in the field with motorbikes who were thus each able to supervise 5 CHCs properly, even though none of the EHOs from MoH were mobile. Therefore, although the supervision of CHCs was more expensive in Zimbabwe, it was cost-

By providing motorbikes, a donor is enabling those field officers who are responsible for ensuring safe water sanitation and hygiene throughout the country to be properly mobile. Our research convinces us that if Environmental Health Department of the Ministry of Health was adequately supported to train and moni-

The main way to assess cost-effectiveness must be the *duration* of the benefits, because if hygiene behaviour back slides and diseases resurge, the intervention has failed to deliver long term sustainability. There are two kinds of sustainability: the behaviour of the individual and the CHC itself. If improving family health, is the main objective, then it is more important that hygiene behaviour changes endure permanently rather than that the CHC, which was purely a conduit of information, survives as a structure. The CHC might not continue as an active group after the initial training, but if hygiene behaviour has changed the individuals within this

We have demonstrated the two main ways that a CHC program can be implemented: either directly by government in a national program supported by NGOs or implemented mainly by NGOs with some government support. Below we show the different advantages and disadvantages to both methods in terms of scaling up.

Monitoring people regularly tends to encourage higher levels of behaviour change—people often improve their behaviour even if they receive nothing material as a reward, simply because they know they are being watched (monitored)—the so-called 'Hawthorn Effect'. The institution that should be undertaking this monitoring role (from village to district, through to Provincial and National levels) is, of course, the Ministry of Health, mandated as it is to ensure the public health standards are maintained. Increasing the capacity to monitor is where funding of resources are most needed. Tempting as it is to achieve higher results by more efficiently using NGO supervision (as they are probably more effective in monitoring and implementing WASH programmes) this can never be a long-term solution.

If a programme is not sustainable after the NGO has left, then it is not costeffective. Although the ACF/Africa AHEAD program in Zimbabwe may have been

tor CHCs in every village, under 5 deaths would be likely to decrease.

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

effective because more beneficiaries could be reached.

group permanently, then this is a public health triumph.

**7.5 Monitoring community**

*7.4.1 Sustainability of hygiene behaviour change*

**7.4 The importance of transport**

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

#### **7.4 The importance of transport**

*Healthcare Access - Regional Overviews*

**7.1 Spread of the intervention**

**7. Discussion**

effectiveness.

**7.2 Quality of the intervention**

had twice as many beneficiaries as Rwanda. The costs included the operational support for 6 field officers and a programme manager, with part time administrative costs for the organization headquarters in Harare, and a shared office in the field. The program is estimated at only US\$4.5 per beneficiary, or US\$22 per household.

The two case studies show that the most successful villages are those where high level of diffusion of innovation has taken place with at least 80% of the households being included within a CHC. Mberengwa District achieved blanket coverage and were able to show over 90% uptake across most indicators. In Rusizi, it was found that villages which had less than 100 households were able to achieve 80% CHC training across all households in the village but only after 3 years. This is a realistic target if sufficient personnel and transport are available to run the program to its best level. The *size of CHCs* seems less relevant than the importance of reaching *all households* in a village, within one or two CHCs. In small villages of under 100 households this can realistically be achieved in the first year, but larger villages need another year to achieve blanket coverage. Perhaps a standard target would be 70 households per year per CHC facilitator. This shows that *village size* should be considered when selecting intervention area so as not to over work each facilitator. A critical mass is likely to be more successful to prevent the spread of diseases such as cholera and diarrhea and malaria, and so this becomes the ultimate test of

The cost-effectiveness of a program depends not only on the Value for Money it can achieve (i.e. how *many* benefits it can deliver, and the *quality* of those benefits), but also on the way the program makes the most of scarce resources and takes advantage of *economies of scale*. The more CHCs that each officer can supervise the less the cost for personnel. We have seen that the size of a CHC can vary from 30 to 100 people. Although Mberengwa demonstrates that a greater number of smaller CHCs (with around 40–50 members) may be more manageable, this may not be the most cost-effective method, as the more people per CHC facilitator, the less the program will cost per beneficiary. Typically, an EHO should be able to monitor one or two CHCs per day, traveling constantly between villages. Therefore, the most cost-effective design is to have at least 100 CHCs in a program monitored by 10–20 EHOs, depending on the transport. Critically, each EHO should have a motorbike

While EHOs in both countries showed complete personal commitment, they were almost always frustrated by the lack of transport in the Ministry of Health, preventing such staff from reaching out and supporting Community Health Club facilitators in distant villages. Those CHCs which were situated near where Environmental Health Officers resided did much better than those in remote villages which were left to their own devices. Although the CHC enables even poorly educated facilitators to run the CHC, they do need strong support from the Ministry of Health with regular back-up of Environmental staff monitoring.

with a dedicated fuel allowance, supplied directly to the district.

**7.3 Dedication of Environmental Health staff**

**50**

The investment in transport is one of the key inputs required for a health promotion programme which is less about the provision of facilities and more essentially about training with a high level of face-to-face time of project facilitators with the community. However, providing money for transport is one of the least popular budget items considered by donors investing in many African countries. This may be due to the notorious costs of keeping transport functional, yet this is the single most urgent need to build the capacity of Environmental Health side of the Ministry of Health.

CHCs in Rusizi were unable to fulfill their role because their motorbikes only arrived after the intervention was complete: their fuel allowance *never* reached the district from the headquarters of MoH. By contrast, in Zimbabwe the NGO programme was properly resourced with each of the 6 full-time project officers stationed in the field with motorbikes who were thus each able to supervise 5 CHCs properly, even though none of the EHOs from MoH were mobile. Therefore, although the supervision of CHCs was more expensive in Zimbabwe, it was costeffective because more beneficiaries could be reached.

By providing motorbikes, a donor is enabling those field officers who are responsible for ensuring safe water sanitation and hygiene throughout the country to be properly mobile. Our research convinces us that if Environmental Health Department of the Ministry of Health was adequately supported to train and monitor CHCs in every village, under 5 deaths would be likely to decrease.

#### *7.4.1 Sustainability of hygiene behaviour change*

The main way to assess cost-effectiveness must be the *duration* of the benefits, because if hygiene behaviour back slides and diseases resurge, the intervention has failed to deliver long term sustainability. There are two kinds of sustainability: the behaviour of the individual and the CHC itself. If improving family health, is the main objective, then it is more important that hygiene behaviour changes endure permanently rather than that the CHC, which was purely a conduit of information, survives as a structure. The CHC might not continue as an active group after the initial training, but if hygiene behaviour has changed the individuals within this group permanently, then this is a public health triumph.

We have demonstrated the two main ways that a CHC program can be implemented: either directly by government in a national program supported by NGOs or implemented mainly by NGOs with some government support. Below we show the different advantages and disadvantages to both methods in terms of scaling up.

#### **7.5 Monitoring community**

Monitoring people regularly tends to encourage higher levels of behaviour change—people often improve their behaviour even if they receive nothing material as a reward, simply because they know they are being watched (monitored)—the so-called 'Hawthorn Effect'. The institution that should be undertaking this monitoring role (from village to district, through to Provincial and National levels) is, of course, the Ministry of Health, mandated as it is to ensure the public health standards are maintained. Increasing the capacity to monitor is where funding of resources are most needed. Tempting as it is to achieve higher results by more efficiently using NGO supervision (as they are probably more effective in monitoring and implementing WASH programmes) this can never be a long-term solution. If a programme is not sustainable after the NGO has left, then it is not costeffective. Although the ACF/Africa AHEAD program in Zimbabwe may have been

more cost-effective per beneficiary, that programme has 'come and gone', whereas the national CBEHPP under MoH continues to slowly transform every village in Rwanda, going from strength to strength on an upward trend.
