Translating Rwanda's CBEHPP roadmap into practice

Rwanda’s Community Based Environmental Health Promotion Programme (CBEHPP) started in 2009, with the aim to improve community health by reducing the disease burden related to inadequate sanitation, poor hygiene practices, and unsafe drinking water. Rwanda is well-known in the WASH sector for its Community Health Clubs (CHCs) and a sanitation agenda that goes beyond ending open defecation - moving people up the sanitation ladder towards basic (improved) sanitation.

Launched years ahead of the two sister USAID programmes  – Isuku Iwacu and Gikuriro – CBEHPP was not well known by the eight USAID programme districts. In an effort to address this, SNV, through the Gikuriro project, engaged in supporting the roll out of CBEHPP in the districts and in ensuring that pathways to sanitation and hygiene progress across all eight USAID programme districts aligned with national goals. CBEHPP Training of Trainers (ToTs) were organised for 184 district staff (Sanitation and Health Officers and Community Environmental Health Officers at district and sector levels) and WASH officers of the programmes’ sub-partners. Through the Gikuriro programme, 3,272 CHCs were established and 12,241 CHC committee members received CBEHPP training. Mid-way of programme implementation, subsequent refresher trainings were provided to 10,504 CHC committee members. For ongoing self-learning and CBEHPP implementation, CHCs were equipped with 3,579 CHC reporting books; 3,469 CHC register books; 3,579 training manuals; and 3,579 didactic books. To facilitate regular meetings and house visits, 173,950 CHC membership cards were issued to CHC members.

To ensure the sustainability of SNV and its partners’ contributions through the USAID programmes, SNV built on the experience and work of pre-existing government structures and personnel to reach community members, collect, and analyse CHC data. Partnering with Social and Economic Development Officers in the programme also won important gains, in terms of mobilising community members to adopt social behaviour change, provide feedback on WASH facilities construction at household level, and elaborate/validate CHC reports.

Through the CHC and with support from their districts, more than 500,000 (81.45% basic sanitation) households gained access to decent sanitation facilities, and 156,057 households started using handwashing stations with soap.

During the course of the trainings, it became clear that the CBEHPP of 2009 had to be revisited. For example, CBEHPP roll-out exercises entailed conducting dialogue sessions and meetings for large sizes of CHCs (100-150 households) – a size that was not conducive for productive exchanges to take place. Handling of infant faeces, indoor air pollution, menstrual health and hygiene management, WASH needs of people with disabilities, a CHC graduation model to motivate CHC members to improve their capacities, and sustainability elements were not considered in the CBEHPP of 2009. In consultation with the Ministry of Health and WASH stakeholders, these gaps were addressed during a series of exchanges, which led to the revision of the CBEHPP roadmap, training manual, and dialogue tools. These new tools are now being rolled-out.

Of course more effort is still needed. Rwanda may be ahead of many of its neighbours in terms of sanitation and hygiene but the ambition is universal and safely managed access. For this, further financial resources at district and local government levels will be crucial. So far, the CBEHPP roll out relies in part on development partners, but this will not be possible for the entire country. In addition, in some districts, sanitation and hygiene are not prioritised. Overall, these factors had slowed down WASH service delivery investments at community level. Furthermore, competing priorities at national level institutions – during the implementation process (workshops and open days, policy documents approval) – halted progress in programme implementation and the planned schedule. The COVID-19 pandemic also limited programme field activities since mid-March 2020.

Now that parts of the country are showing fast urbanisation, CHC lack of uniformity in performance and capabilities becomes more evident. Apart from the CHC composition being predominantly made up of women (more than 90%); male membership in peri-urban and urban settings was even lower. Low male participation in CHCs likely had an impact on household decision-making on sanitation investments. Also, in peri-urban and urban areas, employed community members did not have the time for or opted out from CHC participation. And for some CHCs, the lack of land tenure discouraged the construction of household latrines, resulting in limited sanitation facilities. More tailoring of CHC activities to different contexts as well as specifically reaching out to men, may strengthen the impact CHCs have.

Looking back on our experience, SNV’s involvement in both USAID-funded WASH programmes validated the need for greater sector investments in roll-out processes. Though the development of a foundational document or policy is one step in the right direction, it is equally important to take concerted steps to make policy terms actionable. Continued partnership and dialogue with government and local partners is also key, as evidenced by revisions that were enacted in the CBEHPP roadmap, training manual and dialogue tools.

Finally, the challenges to improve and sustain progress in sanitation and hygiene demand long-term attention and investments. These could take many forms. For example, beyond organising refresher trainings for CHCs, regular monitoring of CHC’s work may provide useful data to track challenges and responsive actions for replication. Moreover, districts have a role to play in supporting local businesses started by CHCs. Providing certifications for local soap production from authorised institutions such as the Rwanda Standards Board may keep CHC sanitation businesses functional and may encourage growth. Last but not least, further government investment is needed to implement water, sanitation, and hygiene programmes across all the districts of Rwanda to complement investments being made by development partners.

Written by: Getachew Tessema, WASH Sector Leader, SNV in Rwanda

Photos: (Banner) SNV staff engaging in thoughtful discussion with CHC members in Rwamagana, pre-COVID

Notes
1 Between 2016-2020, USAID funded two large, complementary WASH programmes in Rwanda, which includes the Rwanda Rural Sanitation Activity (Isuku Iwacu) and the Integrated Nutrition and WASH Activities (Gikuriro). SNV managed in-country implementation of the Isuku Iwacu project, while in Gikuriro, SNV was a sub to CRS, and responsible for the programme’s WASH component.
2 Kayonza, Kicukiro, Ngoma, Nyabihu, Nyanza, Nyarugenge, Ruhango, Rwamagana