The Lancet recently published results from a randomized controlled trial of community health clubs (CHCs) in Rwanda – results that show that the clubs had virtually no effect on neither hygiene and sanitation behaviors nor health outcomes. In 2016, The Water Trust began piloting a hygiene and sanitation program in western Uganda that addresses several perceived weaknesses in the CHC model.
After nine months, early results are promising enough to warrant a more rigorous evaluation and piloting in additional contexts. If successful, the program could be scaled in Uganda and beyond through government and NGO implementers.
By Chris Prottas
In 2016, The Water Trust reviewed the performance of our own hygiene and sanitation promotion efforts. We found that, while open defecation was typically eliminated, critical hygiene habits such as handwashing with soap failed to significantly improve.
Through focus group discussions, we identified several weaknesses in our approach, many of which are shared with the CHC approach evaluated in Rwanda:
- No programming to build household and group confidence in their respective abilities to improve their lives.
- Hygiene and sanitation trainings carried out by NGO staff tend to be brief and infrequent, and overly focused on conceptual knowledge.
- Limited participation in group meetings due to a lack of personal material incentive and the exclusion of other community priorities from the mandate of the group.
- No robust constitution and meeting rules to support group decision-making and good governance.
- Inadequate access to loans for investments in sanitation products and inadequate supply of local artisans trained to build sanitation products.
In light of these weaknesses, last fall we revamped our hygiene and sanitation programming, investing in regular coaching visits by trained NGO staff for a period of 12-18 months. The most successful program complemented the recurring coaching visits with the formation of community savings groups charged with water point maintenance and hygiene and sanitation promotion. The group management rules are based on the Village Savings and Loan Associations (VSLA) methodology. Due to the social mission of the groups, we refer to the groups as “Self-Help Groups” (SHGs).
At a cost of $10-15 per person reached, The Water Trust’s village program aims to address several weaknesses identified in traditional volunteer-led approaches to hygiene and sanitation promotion:
- Build self-confidence: Initial participatory activities focus on building communities’ awareness of risks and developing community-led action plans to mitigate risks. Ongoing coaching by trained NGO staff builds self-efficacy as community members upgrade their homes. Collective decision-making in SHG meetings builds confidence in their capacity for collective action.
- Engage community priorities: SHGs garner high rates of community participation due to the savings and lending services they provide, and the social capital they engender. The SHG’s broad mandate includes hygiene and sanitation promotion, but not to the exclusion of other challenges and concerns confronting households, such as the need to pay for school fees and invest in their livelihoods.
- Build a robust local institution: SHGs operate with robust constitutions and meeting rules to support group decision-making and good governance, even after support from the NGO ends. Follow-up studies show that more than 94% of savings groups founded with the VSLA methodology survive more than five years.
- Strengthen the system: The SHGs are legally-registered entities and NGO staff link the groups with government health workers and local artisans. The latter are trained to create high-quality sanitation products.
Disrupt current behaviors
|Encourage and reinforce new habits ||
|Build durable, enabling institutions||
After nine months, the initial results of this SHG-centered program across 20 villages suggest it can significantly improve hygiene and sanitation behaviors. The results below were achieved with a more modest intervention than that described above, as only one SHG was formed per every village, rather than the two to four per village anticipated in future projects.
- The SHG approach could be replicated by NGOs and governments as an alternative to the community health club approach. In Uganda, local governments maintain staff that could implement the SHG program, provided they were appropriately trained and managed.
- The Village Savings and Loan Association methodology is a popular model for expanding access to financial services to low-density areas. CARE alone has launched more than 200,000 VSLAs to support more than 5 million people worldwide. The incremental cost of WASH promotion is relatively low, and both existing and new groups provide a large platform to improve global hygiene and sanitation behaviors.
- Before scaling this approach, it is critical to rigorously evaluate the impact of the program on both intermediate outcomes (e.g., handwashing facility coverage) and health outcomes over a longer timeframe. In 2018, we hope to conduct a randomized controlled trial of the program.
- We believe this approach should likewise be adapted and tested in multiple programmatic contexts in order to understand both the depth of its impact and the breadth of its suitability.
Read last week’s article to learn more about the impact of the program on water point sustainability.
 Habits include: (1) inspect and clean containers before collecting water; (2) appropriately wash hands after latrine and before eating/breastfeeding (3) dispose adult and child feces in latrines; (4) clean and store utensils and cover food; and (5) contribute maintenance fees for water point in weekly meetings.