Table 1.
The Theory of Change for a Classic Community Health Club Intervention – as used in Rusizi District, Rwanda
| Causes (Determinants) | Effect | Results | Expected inputs (Assumptions) | Outputs | Outcomes |
|---|---|---|---|---|---|
| MACRO LEVEL: National / Provincial and District | |||||
| 1.1.i. Fragile State -breakdown of economy, law, order and security | ii. Government structures are weakened or ineffectual | iii. Emergency humanitarian programmes take over from normal state structures | iv. Political enabling environment. Government (MoH) provides normal services /support | v. Political enabling environment: NGOs / funding agencies support national government CBEHP program | vi. Funding: NGOs and Agencies are able to provide financial and advisory support to districts |
| 1.2.i. Lack of a clear Environmental Health (EH) Strategy within MoH policy / government reshuffle or changes in administration | ii. Environmental Health Department (EHD) is weak and doesn’t manage the WASH sector | iii. Uncoordinated WASH sector /many different strategies and conflicting models of change | iv. EH Policy: Development of a national Road Map for CBEHPP using CHCs in each village with clear methods to achieve behaviour change | v. Higher political visibility - EHD manages the CBEHPP with support for MoH by donor agencies and NGOs | vi. WASH programs can be scaled up and CHC started throughout country |
| 1.3.i. Lack of standardised training materials | ii. Difficult to train trainers effectively | iii. No Core -Trainer of trainers team | iv. Training Material: Develop CBEHPP manual and tools to be readily available | v. National Core Trainers trained in CBEHPP to train all districts at every level | vi. Sustainable human resource in country to implement CBEHPP |
| 1.4.i. Lack of WASH strategy in District | ii. Weak budgetary support & inadequate training for EHOs | iii. District prioritises curative over preventative EHD services | iv. Training Trainers: EHOs and district leadership understand the rationale for starting CHC | v. EHOs monitor CHC and have to account for progress on WASH indicators in CBEHPP | vi. Sustainable district planning and monitoring systems ensuring CHCs continue to function |
| 1.5.i. Lack of transport for EHOs to monitor CHCs | ii. Community monitoring does not take place | iii. Little data on hygiene/ sanitation in villages | iv. Transport: EHOs are provided with reliable motorbikes to reach villages so as to monitor CHCs | v. Mobile EHOs are able to monitor CHCs easily | vi. SDG WASH targets are tracked and therefore more likely to be met at district level |
| 1.6.i. Low profile of EHD in Districts | ii. Not enough EH staff in district | iii. Inability of MoH to properly monitor WASH | iv. Supervision: EHOs supervise CHC facilitators in community | v. CHC facilitators well supported in ensuring active and effective CHC | vi. High Profile of EHD in district |
| 1.7.i. Lack of Meeting venue | ii. Difficult to hold CHC sessions in heavy rainy season | iii. Low CHC attendance due to meeting held outside in rain | iv. Timing / Duration: 24 CHC health sessions have to be timed to be held in the dry season | v. High Completion of training – no excuse for members not to complete training | vi. High coverage of well informed CHC members and active group in all villages |
| MICRO LEVEL: Village and household | |||||
| 2.1.i. Poorly organised community | ii. Low levels of hygiene and sanitation | iii. High diarrhoea rates and resistence to change | iv. Community Mobilisation: A CHC is started in every village | v. Peer support for all households to change with social pressure to meet hygiene standards | vi. a80% housholds are in a CHC sharing same attitudes, beliefs, values. |
| 2.2.i. Lack of informed leadership | ii. Poor decision making | iii. Lack of training and monitoring of hygiene standards | iv. Quality Training: CHC facilitators / leaders are trained in participatory CHC approach & CBEHPP | v. CHC Facilitator within village / village leaders trained to monitor hygiene standards | vi. a50-100 households are active members within a functional CHC |
| 2.3.i. Lack of learning opportunity within village | ii. Inadequate knowledge to prevent disease | iii. Little community action to improve WASH facilities | iv. Exposure: 24 CHC health sessions are offered weekly for at least 6 to 12 months | v. Improved understanding how to prevent disease by safe hygiene and sanitation | vi. a80% of households with knowledge of how to manage family health |
| 2.4.i. Inertia and lack of interest in hygiene & prevention of disease | ii. Not prioritising ways to protect their family | iii. Poor hygiene & little effort/ expenditure on improving WASH facilities | iv. Visibility: Model Home competitions are held to increase interest & attract high level of participation | v. High priority in the investment of time and energy to improve hygiene facilities and change behaviour | vi. a80% uptake of safe hygiene practice and safe sanitation facilities |
| 2.5.i. High risk hygiene practices and sanitation | ii. High levels of preventable disease | iii. High infant and child mortality | iv. Reinforcement: CHC continue to meet after the CHC training is complete | v. Higher social cohesion and increased support for vulnerable individuals | vi. Improved social capital, family healthb and standard of living. |
aThe target of intervention varies depending on the intervention design – This table shows the CBEHPP target in Rwanda. Over 80% compliance of recommended practices (safe drinking source, safe water storage, safe sanitation, zero open defecation, hand washing facility, soap for handwashing, pot racks /clean pots, solid waste managed, individual cups/plates, safe food hygiene, dedicated clean kitchen, grey water drainage
bFor the Stage 1 Training in CHC which focuses on WASH mainly a decrease in diarrhoea, skin disease, bilharzia, intestinal parasites is possible