 My name's Arnold Rosmarin. I'm at Stockholm Environment Institute. We have a rather interesting selection of speakers. We'll be talking about community-led approaches in Africa. There's a major focus on something called community health clubs. For those of you that don't know about this is a kind of a model of organizing people. It's a method if you'd like to achieve functionality in communities. Enabling, for example, villagers to manage their own health and development initiatives in a rather sustainable and integrated fashion. My own view is that this is not just for African villages. I believe this model is something that the entire world can learn something from. It's about people working together and communicating and sharing knowledge and wealth. It's the future of humanity, I would think, even in the largest city blocks around the world. That kind of self-help mechanism is something new. I think we can all learn from Africa. Rwanda is an interesting case. There'll be a lot of focus on that today. As you know, Rwanda went through a lot of changes, still going through many changes after the years of genocide and internal strife. It's a star, if you like, amongst African countries in terms of reorganizing itself. The model is working in the rural areas. I will actually be starting off with the paper that's timed at 10 after 10 on the revised agenda here. I will be giving Fidel Negapo's talk for him. He, unfortunately, had to stay home. Kei Galli has a reorganization occurring of his ministry. He had to stay back for very important meetings all next week. It's actually one of the success stories. The thing about success is that most people say, oh, it's a success. That's really good. The question is, do people understand why it's a success? So you can learn from it. Usually we tend to say, oh, it's something failed and we have to find out why. But if it's a success, there's often even more ignorance. Because people don't really actually sit down and try to understand what the success was all about. So we'll try to explain that a little bit. I will give this talk. I hope it will be done in about 10 or 15 minutes. And then we'll go on to the schedule with Juliette Waterkin and Anthony Waterkin. And after that, Dan Wolf. He's done all that before, but the tea break. So Dr. Fidel Negabo, he's the director of the Maternal Health Club Unit in the Ministry of Health. And you can see here that I'm always fascinated by the logo types. This is just an example of the integration that you need and the way of thinking. And I think there's a lot to be said about images. And you see in this presentation, in fact, all the papers today, they're full of illustrations. They've got a feeling of that integration that we're trying to achieve here. It's not sector, but it's multi-sector. The Community-Based Environmental Health Promotion Program. It's a Rwanda program. There's a lot of documentation on it. It uses the CHC approach and it reaches out to communities empowering them. There's this whole thing about identifying your personally domestic hygiene and nutritional needs of the environmental health requirements. It starts from drinking water, but it goes beyond that to toilets, to hand washing, to food safety, to cook stoves, to drainage, paths that are getting paved, and things like that. This particular program was launched in 2009 and it's continuing on for eight more years after the only 2009 2017. This report is, if you like, midstream as we go halfway through. And you can see that there are some focus problems, diarrhea-based problems, intestinal parasites, respiratory functions like indoor air and cooking stove problems. This whole aspect of how to lift communities up and develop beyond what they are today. If a community, for example, is affected by a threat like Ebola, this kind of unit would be how it should be organized to prevent it from spreading. We did try to get some Ebola specialists for this. The Swedish ones are very, very busy. They're in the Sierra Leone, so we're not going to turn this into an Ebola discussion, but it could easily be one. The CDC approach, it's a question of sitting and learning and talking. It's this long list, if you like, of over a six-month period with 24 dialogue sessions. That would be pretty well one a week. Key words like target group, inclusive, structured, reinforcing, participatory. Women-led is not there, but that's the case. Consensus, such an important thing in the base of governance. That people actually do homework, they get certified, they get a paper that says that they've actually gone through this training. There's monitoring of the changes. You get the feedback on a weekly basis, and it's fair. And it creates, if you like, equity and sharing. One of the things that it's been compared to is the so-called CLTS community-led total sanitation. Usually these communities have open defecation or dysfunctional water and sanitation, amongst other things that are dysfunctional. That's a name and shame approach that some people say has a big impact. The question is, does it have a long-term impact? The CHC model is showing that it does similar things, but it doesn't shame. It's not negative, and it has a much more resilient kind of effect. It's much more constructive in the long term. So this is a sort of model that integrates over environmental health. The whole national program on poverty alleviation and development. This whole thing about increasing the access to water and sanitation. And then enhancing human, as well as natural resources. So it's things like waste management, but it's also access to resources. Interesting way to integrate it. And of course, government fits in, and it's an interesting model here. We start, if you like, at the Ministry of Health at the top, but that doesn't actually, that's not where it really starts. It's also starting at the bottom. You can see the village head is well involved, and also the committee that the CHC is. So this is the thing, it has to be ground roots at the bottom, and then the middle part is informed, and then the top is brought in. So with that, you actually develop governance and sharing consensus. This is kind of a membership card that you can carry in your pocket, a green card. It's probably the best green card you can get. So these are all the topics, and then the practices. And for a communicator, this is gold. You have a topic like hand washing, and then you have a three word activity. There's nothing more powerful than actually trying to get things down to just a few words. So there's hours and hours of thinking and training behind each one of these. To me, if all citizens of the world knew about these things and practiced them, we'd have a completely different place. And you wouldn't have the risk of shaking hands with people this morning. We don't have the alcohol dispensers here, but they're in basically every healthcare center that has any money at all these days. I believe a place like this should actually have that as well, because we don't know where we've been the last few hours. So the promotion program has been implemented now in 18 of the 30 districts of Rwanda. Two districts are about to be starting. There's an establishment, if you like, in those districts of basically 100% functionality of the CHCs without training at 40%. I'm not sure what he means by that. That's a question to ask. There's fully functional CHCs, that's 27% of them. So there's probably a transition as time goes with the each CHC and its training curve. Supported with the dialogues and the tools and these weekly meetings. There's also this thing about timely reporting. So that's actually making sure that things are monitored as things progress. And here we see a picture of the minister actually during the handwashing campaign. This is a little too much to swallow all of him. I'm not going to go through it, but if you just look at the red columns, that's the baseline. So baseline is very important when you start the community health club. And then after three months time, you can see the differences and this is a percent improvements in 50 villages over the three months. This was in a western district in Rwanda. The ones that really stick out are actually something as simple as water being taken with one cup only. That's sharing the cup as much as before. Another one that is very significant is not sharing a hand wash bowl. That's interesting. The other one is washing hands with the tippy tap. And I can see another one as we go way over to the other side, a ventilated kitchen. Huge one is safe recycling of solid waste and also paving the paths. It's a very important thing about transmission of disease. And then nets, of course, to prevent mosquito born malaria. So these things you could say are just fundamental, but to actually get them going in villages, you need this kind of model. And so we can see some major changes just after just a few months. Spontaneous start-up savings. This thing is a very cost effective way of deploying resources. And I would expect the government is very pleased with the performance. It's linked with sharing of wealth. It's linked to income generating activities. There's cooperation within the clubs. If you get women led organizations, you tend to try to have constructive models and discussions. You tend not to sort of hack at each other and say, this is wrong, this is wrong. My child has diarrhea because of your bad habits talking to a neighbor or something. Instead of trying to speak about something that maybe is a solution. Mutual assistance. And of course, when you're sick, you're vulnerable and you want to talk about it, you want to get healthy again. So the drivers are all there. So this is capacity building and even though the health officers coming in, the environmental health officers are getting the kind of support feedback and monitoring that they need to. So they're actually succeeding at their work as well. So here's a summary of the changes that happen. And it's water source, it's drinking water, it's sanitation, it's personal hygiene, it's hand washing, it's kitchen hygiene, solid waste, the safety around the environment. There's malaria control and there's childcare. And it's in between those lines, a whole lot of other things. But these are the ten golden indicators that people are clearly knowledgeable about and aim for and improve. If you're familiar with the F-diagrams of all the vectors for disease, this is not an urban problem. I think it's a global problem. It's not just a real problem, it's urban as well, it's peri-urban. And we have a lot of learning, if you like, that humans are in the north, we're very ignorant about a lot of these things. People just take this stuff for granted. So finally we've got, I think, the achievements in these 50 CHCs in this western district. And you can see the data here and this is, there's 6,721 CHC households organized into the 50 CHCs. So they've got new latrines, improved the existing ones, they're being properly covered and maintained. There's bath shelters, there's hand washing facilities, there's compost pits, fuel efficient stoves. The yards are being swept. Sweeping is such an important part of respecting your yard and also preventing disease. More households are getting water safely handled and the drinking water is now being treated properly. So it's a high level of response by any standards at all. If any of you have worked in these kinds of conditions, you'll understand that to see these kinds of numbers, it's really quite a success story. And it's the reason why RAND is one of the only African countries that's met the MDG on water and sanitation. And this looks like it's something that is resilient. It's actually going to stay around. So Fidel, thanks for this presentation. It is being filmed and hopefully you can watch it. And on the dialogues, we'll be putting these things up on the SCI website and also on the sustainable sanitation website. I think there'll be some discussions about it. And if there's any questions, I think we have just a couple of minutes before we go to Juliet's paper. If you do want to say something, you have to be on mic. So I'm not sure if, I think they have to come up here, is that right? Yeah, I don't have that answer, but I would believe that either Juliet or Anthony might, since they have been working with Fidel, longer term monitoring. Is that something you have some data on you've published that? I think you can speak there. Hi, so the question was, is any long term monitoring going on? First of all, the randomized control trial that is taking place in RACC district is being funded by the Gates and being conducted by IPA, international poverty alleviation. Poverty alleviation, yeah. That is going on now. The baseline's been done and basically they're going to publish probably the end of next year and the year after probably be out in the public domain. We've had a couple of published papers on, you can find on our website, this Africa Head website. There's been quite a lot of published work in terms of our own research, but the Gates Foundation work that's going on now is the first external evaluation that's being conducted, but we have a long track record of monitoring, which we've done, which you can find on the website and that's Africa Head website. Any other question? One at the back. I don't have that data with me. If there is someone who has that data. Cost of CHCs compared to CLTS. That comparison is a good one. I know that UNICEF is collecting data on their CLTS. I'm not sure if George will be addressing that at the end of the day. I could just come in on the community health club side. We work on it under $5 per head for that integrated program. In Zimbabwe last year there were about 1,000 health clubs, just under 1,000 health clubs that were funded by USAID and the European through ACF. It came out at $4.42 per head. That was the gross project cost of the funding we received divided by the number of benefits of fisheries. It was 172,000 people in that one year period and it came out at $4.42 for that integrated package that you saw there. That's the training and I guess there's some assumptions there that the government health officers is already paid. They're already paid. If there is sector subsidies for things like cook stoves or latrines or things like that, that would be done separately as well. The main thing is you have a vehicle for creating consensus. That is worth gold in itself. It pays for itself. Of course knowledge about hygiene is as gold as well.