Leadership matters: The case of community led total sanitation and hygiene

By Araya Mengistu


Ethiopia is a country showing strong progress in achieving global and national goals for WASH services. It has achieved the MDG target 7c for water supply. Although still behind for sanitation targets, considerable progress is made. As of 2012, 37 per cent of communities practiced open defecation, as compared to 92 per cent in 1990[1]

The progress on sanitation is mainly achieved through the national Health Extension Programme (HEP) and the community led total sanitation and hygiene (CLTSH) approach. CLTSH is an approach that helps to mainly rural communities to understand undesirable effects of poor sanitation, and through a process of “triggering” – igniting a change in behaviour – achieve sustained behaviour change leading to spontaneous and long term abandonment of Open Defecation (OD) practices. Since its introduction in 2006/7, CLTSH has remained the only instrument in Ethiopia to induce behaviour change of communities to consider construction of latrines and use them – discouraging the practice of open defecation. Although the achievements in the past decade are significant, the success of the approach varied significantly from place to place.

For example, the Oromia regional state, the largest in the country, consists 265 rural and 39 urban districts or woredas. Out of 6,531 kebeles (sub-districts each with an average population of 5,000) in rural areas, about 16 per cent are open-defecation free (ODF) – meaning no-one, including visitors and passing pedestrians, are openly defecating and all have access to basic latrines with handwashing facilities.

UNICEF supports 24 woredas in Oromia state between 2011 and 2015. Of the supported woredas, 24 per cent (116 of 477 kebeles) have achieved ODF status. Compared to regional average of 16 per cent, this is a huge achievement. Sire, one of the supported woredas, has recently been graduated in 2015 with 100 per cent performance, declaring all 18 rural kebeles ODF. Other woredas are at various stages. 11 woredas are between 20-50 per cent progresses, while the rest 12 woredas are of 0-10 per cent progress. Compared to these, Sire Woreda shows an outstanding performance.

Such exceptional achievement requires successfully overcoming a number of challenges. A key challenge is lack of thorough understanding of the steps involved in CLTSH and their importance. Usually CLTSH is about training facilitators and triggering communities. However, many practitioners agree that this is the easiest part. Rendering adequate supervision after the triggering stage and providing support that is necessary to sustain the momentum is the difficult part. Other challenges include diffusion of information to neighbouring communities that make the approach ineffective, lack of trainers with actual field experience, high staff turnover, poor coordination among stakeholders, weak commitment of staff and trained people and application of CLTSH without adequate or proper organisation and preparation.

Growing over all these challenges and as a result of four years of effort, Sire Woreda celebrated 100 per cent ODF achievement in April 2015, with all rural villages and kebeles free from open defecation.

Even though, some of these kebeles were declared ODF two or more years ago, , they continued to sustain their status despite the usual trend of falling-back to OD practice noticed as time elapses. This demonstrates an effective post-triggering activity by the Woreda that effectively complimented the planning and triggering activity.

How was this achieved? The Woreda administration leveraged existing structures to sensitize the leadership ladder down to village level on CLTSH and built it in to the regular reporting and evaluation process. This has helped to mobilize the largest possible support to the effort of Health Extension Workers (HEWs) and CLTSH facilitators, including teachers and students under the guidance and support of the Woreda Health Office. It has also avoided diversions of focus (including manpower, logistics, and resources) as CLTSH has become an official woreda priority.

Two notable practices can be praised in the woreda for this success.  (a) the technique of triggering one full kebele at a time in contrast to the usual practice of village by village, and (b) use of different post-triggering follow-up technique suited to context. The advantage of the first technique was twofold. It helped to avoid diffusion of information in to neighbouring communities. Since, focusing in one kebele at a time required more trained people, the coordinators called upon trained and experienced facilitators from adjacent woredas to support, which worked really well. On the other hand, the woreda experts consciously applied different post-triggering follow-up methods. In highland areas, they applied the ‘flag system’, where by communities themselves awarded white flags to households who have constructed basic latrines, and red flags to those who did not. In low land areas, students were organized to alert the community when they see any one defecating in the open, who will then ensure the person buries the excreta.

Currently, the Woreda continues to strengthen the community platforms for monitoring progress and pro-actively works with local leaders to provide the necessary guidance and technical support to sustain the achievement. As a result of this, they are expecting at least two kebeles to achieve secondary ODF, which includes upgrading of basic latrines to improved latrines (with washable slab, vent pipe, hole-cover) with hand washing facility by the whole community. The commitment of leaders, and subsequent effective coordination in the Woreda has benefited the wider community to keep children, women and the society at large healthy.

[1] Joint Monitoring Programme 2014.

Since 2014, ART clients in Ethiopia have been getting their CD4 status in 20 minutes

By Tesfaye Simerta

Ayele Feyisa Laboratory technical take sample of blood
Ayele Feyisa Laboratory technician takes sample blood at Chancho health centre, Oromia special zone surrounding Finfinne Sululta woreda, Ethiopia ©UNICEF Ethiopia/2014/Ayene

CHANCHO TOWN, OROMIA REGION, ETHIOPIA, 23 October 2014 – The Chancho Health Centre, 45kms north of Addis Ababa, is where Rediet* goes for her follow-ups, having discovered she was HIV positive back in 2013. Today, there are lots of people waiting alongside Rediet to utilise the laboratory services. Chancho is one of the health centres that the Ethiopian Government – supported by the Clinton Health Access Initiative (CHAI), UNITAID and UNICEF – is using to advance access to Point of Care Technologies (POCT). These provide results on the same day, in order to make HIV testing and treatment more effective, efficient and easier for both health care workers and patients.

Now, Rediet is a mother of a one-year-old baby girl and is still following up on her status regularly.

“Now I have stopped having to wait to hear my CD4 count status at the Fiche Hospital, far from here,” said Rediet, who used to have to travel to Fiche Town to get the test done. “When I went to Fiche, I was paying transport expenses for a round trip, but here it is accessible – about an hour and half walking distance from my home. Previously, when my blood sample was sent to Fiche Hospital, I was not able to know my CD4 count status for a month or more and could not receive treatment. Now that the machine has arrived in the Health Centre, I get my results just after 20 minutes of testing, receive my treatment here and then go home.”

According to Mr Asfaw Referra, Anti-Retroviral Treatment (ART) Focal Person at the Chancho Health Centre, there are now around 500 clients using the CD4 count of POCT, of which one in ten are children. “Clients are very happy about this machine, since they can discover their CD4 count status just after 20 minutes,” he told us. “There were clients whose CD4 counts had dropped as low as 93. As they start their ART treatment immediately after we know their CD4 count, however, we are very excited when these people show signs of improvement.”

In addition, before the POCT machine was introduced to the Chancho Health Centre, the number of clients allowed to give blood samples was restricted.

Aduna Lema is one of the many client in Chancho health center“The sample we used to take to Fiche hospital was restricted to between 10 and 15,” Abebe Gelme, Chancho Health Centre Laboratory Technician, informs us. As a result, Chancho Health Centre was forced to transport the samples every week. “Despite the large demand, we appointed only 10 to 15 clients to give their blood sample to our Health Centre up until 9 am every Friday morning, since the collected blood samples had to be taken to Fiche right away.”

Some clients coming from far away could not reach to the Health Centre before 9am and missed their chance. They were then appointed to come back again the following week. Often, they did not get the opportunity to have their blood samples taken and felt helpless.

“I know a client whose CD4 count was found to be eight,” Abebe told us. “Now, thanks to the POCT machine, I can have the data and tell the exact status of my client’s CD4 count with confidence.”

The POCT services are now becoming popular, both at the government level and at the grassroots level.

“The Oromia Regional Health Bureau is committed to working with partners,” Asfaw Endebu, Woreda Health Office Head, told us with great pride. “The woreda cabinet knows about the service provided at this Health Centre and we have recently started introducing it to the Health Workers and Health Extension Workers. We are informed about the availability of the machine, and that is why other HCs and HPOs refer cases to this centre.”

With the support of partners, 45 sites with high patient volume, like Chancho Health Centre, have received POCT machines at the initial stage. This ensures that women, like Rediet, and children in remote areas especially will not have to spend time and resources in order to discover their results. This will remove delays and enable more individuals to receive the treatment they need.

*Name changed to protect identity

Global Hand washing Day (GHD) 2014 celebrated in Oromia, Ethiopia

By Kulule Mekonnen

Kimbibit woreda community welcomes participants of Global Handwashing Day participants colourfully with their decorated horses
Kimbibit woreda community welcomes participants of Global Handwashing Day participants colourfully with their decorated horses ©UNICEF Ethiopia/2014/ Sewunet

Hundreds of people marked Global Hand Washing Day with a colourful celebration at Garachatu School in Kimbibit woreda, Oromia region.

The region has been celebrating Global Hand Washing day since 2008, which was International Year of Sanitation.

Community members travelled to the event on foot and on horseback, wearing colourful traditional clothes to welcome government officials and invited guests to the celebrations.

The event is marked in many countries every year to underline the importance of handwashing in the prevention of common but potentially lethal diseases such as diarrohea, pneumonia, Severe Acute Respiratory Syndrome (SARS), Ebola and others.

The event at Garatchu School included the reading of poems by students, songs and performances, focusing on the importance of handwashing.

Dr Zelalem Habtamu, Deputy Head of the Oromia Regional Health Bureau, said: “We believe that we could prevent over 60 % of communicable diseases by implementing proper environmental health interventions. This is why we focus on advocating proper hand washing practices at critical times.’’

Oromia has made solid progress in improving hygiene, deploying 13,000 health extension workers and 4.5 million health development armies. These are small groups of women that meet regularly to discuss and solve issues relating to public health, socio-economic, environmental and economic concerns.

Students of Garachatu School perform a play on the importance of handwashing
Students of Garachatu School perform a play on the importance of handwashing at the Global Handwashing Day celebration ©UNICEF Ethiopia/2014/Sewunet

Dr. Zelalem added: “We are celebrating this year’s GHD in Garachatu School, with the school community and their families, with the intention of reaching every family, as we believe that students could carry on the positive hand washing behaviours learnt at schools with their families and their neighbourhood.”

Hand washing with soap removes germs from hands, preventing the transmission of infections when people touch their eyes, nose or mouth. It can also prevent germs getting into food and drink, as often happens when they are prepared by people with unclean hands. These germs can then multiply, risking the spread of infection to more people.

Germs from unwashed hands can also be transferred to objects like handrails, table tops or toys and spread easily.

Removing germs through proper hand washing helps prevent diarrhoea and respiratory infections and may also help prevent skin and eye infections.

Research shows that community hand washing education has a number of hygiene benefits. It reduces cases of diarrhoea by 31 percent, diarrheic illness in people with weakened immune systems by 58 percent and respiratory illnesses, such as colds, in the general population by 21 percent.

Figures released recently by UNICEF and the World Health Organisation show that in 2013 more than 340,000 children under five – almost 1,000 a day – died from diarrheic diseases due to lack of safe water, sanitation and basic hygiene. As the Ebola response takes its toll on the health services in the affected countries, the practice of hand washing is even more important to prevent these common diseases.

Participants washes their hands at the Global Hand washing Day celebration in Garachatu School, Kimbibit woreda of Oromia region, Ethiopia.
Participants wash their hands at the Global Hand washing Day celebration in Garachatu School, Kimbibit woreda of Oromia region, Ethiopia ©UNICEF Ethiopia/2014/Sewunet

UNICEF works with regional government and non-governmental organisations to improve access to safe drinking water, sanitation and healthy environments and better hygiene practices.

It also focuses on capacity building to eliminate open defecation and improve hand-washing facilities in schools and health centres, focusing on the needs of girls.

W/ro Zewuditu Areda, Head of the North Shewa Zonal Health Department, said: “Proper hand washing prevents disease and saves lives, hence hands should be properly washed.”

The event ended with a demonstration of 10 steps of proper hand washing by Belay Techane, a Kimbibit Woreda Health Worker. The steps include:

  • First hand should be rinsed and wet
  • Apply soap and thoroughly scrub hands and forearms up to elbow. Give special attention to scrubbing your nails and the space between your fingers
  • Rinse with generous amount of clean water flowing
  • Air-dry with your hands up and elbows facing the ground, so that water drips away from your hands and fingers
  • After the demonstration, all participants of the day practiced proper hand washing using soap as demonstrated by the health worker.

Divergent Journeys – Child Marriage and Education

 By Indrias Getachew

Famia Abadir and Rasso Abdella are teenage girls living in Sheneni Village of Dujuma Kebele, located 20 kilometers outside of Dire Dawa town in Eastern Ethiopia. They both share dreams of attending university and working as professionals to advance the rights of girls and women. To succeed, however, they must overcome substantial hurdles. Poverty, traditional views on gender roles and the practice of child marriage threatens to derail their ambitions. Their experiences illustrate some of the challenges that girls, particularly in rural areas, face as they strive to achieve their right to an education.

“No one told me to go to school,” recalls Rasso. “I used to spend my time in the hills with my friends shepherding goats. Some of my friends went to school in the mornings. They would write what that they had learnt in school on stones using charcoal. They would write the alphabet and when they asked me what ‘A’ is, I didn’t know. I told them that I wanted to go to school but I couldn’t afford to buy books. They agreed to share their books with me. That is how I was able to start school. I now go up the mountain to collect wood and prepare charcoal. I then go to town and sell it so I can buy my exercise books – that is how I am able to go to school.”

Kerima Ali, Gender and AIDS Expert at the Dire Dawa Bureau of Education (left) Famia Abadir (midle) and Rasso Abdela (right)
Kerima Ali, Gender and AIDS Expert at the Dire Dawa Bureau of Education (left) Famia Abadir (midle) and Rasso Abdela (right) ©UNICEF Ethiopia/2014Getachew

Overcoming economic hurdles is a challenge facing rural girls in their efforts to learn, however, the age-old practice of child marriage complicates things further.

In 2011, the dire warning by a rural religious leader that girls who didn’t marry that year would not be able to marry for the next seven years, set off a spate of child marriages that resulted in over 80 girls marrying and dropping out of Dujuma Primary School. Famia, 15 at the time, was one of them.

“I was a young student, still a child,” recalls Famia. “I was going to study with my friends and my cousin told me to come to her place as the elders were gathering there because she was going to get married. She took me from my home and handed me over to her uncle’s son to get me married to him. I did not want to get married. My wish was to go to school and learn, but they abducted and raped me and that is considered marriage. I had no choice.”

Famia Abadir, nine months pregnant
Famia Abadir, nine months pregnant ©UNICEF Ethiopia/2014/Getachew

Famia missed an entire year of school after she was abducted and raped, twice, in what turned out to be failed attempts to marry her against her will and the consent of her parents.

The events in Dujuma in 2011 led to a focused campaign of awareness creation and community mobilisation to end the practice of early marriage. Community discussions aimed at convincing community members about the importance of girls’ education were carried out throughout rural Dire Dawa. Awareness was also raised about the harm caused by child marriages with a view to fostering a consensus to end the practice.

Currently, school clubs are promoting gender equality and empowering the school community to respond in time to prevent child marriages through coordination with local government. Elders and religious leaders are also being engaged to convince the community to abandon the practice of early marriage.

According to local authorities, the efforts to end the practice of early marriage in Dujuma and other rural districts of the Dire Dawa Administrative Region have been successful. Indeed, Dire Dawa has the second lowest regional child marriage rate in Ethiopia after Addis Ababa. The practice is far more widespread in Amhara, Tigray and Benishangul Regions (EDHS 2011).

Transforming age-old customs, however, takes time. Returning to Dujuma in 2013, we found Famia to be nine months pregnant. Famia had left her husband and was once again living with her parents.

“After I give birth I will leave the baby with my family and return to my studies,” says Famia. “Getting married is what did this to me so it is better that I go back to school. Marriage was not good for me.”

Rasso, on the other hand, evaded all pressure to get married and was able to finish eighth grade at Dujuma Primary. Today, she is enrolled in high school in Dire Dawa town, living at the Girls’ Hostel set up by the Dire Dawa Bureau of Education with UNICEF’s support. The hostel enables girls from rural communities with no access to school to continue with their education.