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F.1 Community Health Clubs (CHC)

Community Health Clubs (CHC) are groups of 30–100 voluntary members who improve local WASH practices through shared knowledge and understanding, resulting in positive hygiene behaviour change and social capital. In weekly health sessions, for at least six months, the group makes informed decisions and, together, improve their standards of hygiene and living conditions.

The CHC approach was developed by Africa AHEAD based on the assumption that all people, even those with few resources, can help themselves to prevent disease through improvements in hygiene. Health promotion is an entry point to longer-term development. CHC members are empowered to do as much as they can for themselves, minimising dependency on donor handouts, through a four-phase process known as AHEAD (Applied Health Education, Agriculture and Development). The first phase is the ‘software stage’ of health promotion, holding 24 two- hour weekly participatory sessions for six months covering common preventable diseases, with recommended practices for homework that can easily be done each week with few resources and no external material in- puts. It is completed when as many members as possible graduate with a certificate of full attendance and compliance with recommended practices. The second phase is the ‘hardware stage’ when water and sanitation facilities are upgraded, supported by inputs and technical sup- port from donors, NGOs or local governments. In the third phase, the CHC evolves into a FAN club (Food, Agriculture and Nutrition) and members share a communal nutrition garden enabling a balanced diet and healthy nutrition for all. The fourth phase includes a human rights component covering more complex functional issues such as gender equity, land rights, social inclusion, illiteracy, support of the vulnerable, domestic violence, substance    abuse and teenage pregnancy.

School Health Clubs (SHC) adapt the CHC approach to tar- get children at school. They are extracurricular clubs initiated by school teachers who are trained in the content. The syllabus is similar to the CHC’s so that children share their parents’ knowledge and understanding. In weekly sessions, school children learn how to improve hygiene and living conditions at home, leading to hygiene behav- iour change at school and at home for all generations. Schools are often the most effective means of network- ing with all families in an area as most households have school-going children. Parent-teacher committees can provide a springboard into the community.

Tools and Methods used

Participatory activities to stimulate dialogue and problem identification: 

  • WASH Committees T.55
  • Transect Walks T.52
  • Community Mapping T.7
  • School field projects doing spot Observation T.28 in the community
  • Ranking  T.39

Identifying appropriate local solutions: 

  • Transmission Routes and Barriers T.53
  • Three-Pile Sorting T.51
  • Songs and Stories T.47
  • Community Drama and (Puppet) Theatre T.6
  • Role Play T.41
  • Demonstration and Show and Tell  T.10
  • Peer Education  T.29
  • Competitions  T.8
  • Clarifying school responsibilities using Institutional Checklists  T.20

Community self-monitoring: 

  • Observation  T.28 in a household inventory with Household Visits  T.18


The standard CHC approach is highly adaptable but generally more suited to the stabilisation and recovery phase or as a development intervention. CHCs (and SHCs) are used in rural and urban communities and can be used in camps in post-conflict and emergency situations (eCHC, F.3) for local clean up and to support WASH projects. 

Main Requirements / Investments Needed

CHCs are often used in small NGO projects, though the model is most cost-effective when taken to scale using Ministry of Health structures (as evidenced in Rwanda’s national programme of 14,000 CHCs). The main inputs required are for the development and printing of toolkits (approximately 24 illustrated card sets) for the participatory training of CHC members, as well as some support forvillage-based CHC facilitators. Historically, few organisations have the time or expertise to develop a tool kit specifically for their project (unless, like Rwanda and Zimbabwe, a national tool kit is already available). To address this constraint, Africa AHEAD now offers organisations online training for CHC facilitators with materials that can be adapted to a local context. There is also an online CHC register to enable Monitoring M.2 of hygiene behaviour change using a ready-made Smartphone survey for Data Collection and Analysis A.4.

Evidence of Effectiveness

A recent review of the literature examined the evidence from WASH-focused CHC interventions in low and middle-income countries. It found that the most consistent evidence was linked to WASH behaviours and knowledge, with significant effects on defecation practices, handwashing behaviours and WASH knowledge. It also found evidence of impact on social capital and collective action and concluded that ‘the model’s holistic focus and emphasis on individual and collective change offer promising potential to address multiple health and development determinants’.


  • Aim to include over 80% of the targeted community in large CHCs (up to 100 members)

  • Ensure CHC facilitators are drawn from the local community for longer-term sustainability 

  • Ensure CHC facilitators are well trained and have a tool kit of visual aids 


  • Do not omit the use of the membership card and certificate as it is essential for community mobilisation

  • Do not reduce the number of training sessions (24), time for each session (2 hours), appropriate spacing of training sessions (weekly) and duration of the training (6 months)

  • Do not initially provide material inputs as it causes division between people

Practical Example

Within 12 months of establishing 37 CHCs in the rural areas of Chipinge District, Zimbabwe there was over 80% adherence to zero open defecation or hygienic latrines, functional handwashing facilities and soap, refuse pits, pot racks, safe water source, drinking water and bath shelters for 2,388 CHC members. Similarly, during one of the worst cholera epidemics seen in Africa (2008) with 89,000 cases and 4,000 deaths nationally, 36 CHCs halted the spread of cholera in Sakubva, a high-density urban suburb of Mutare, when 4,500 CHC members undertook a massive clean-up of solid waste and supported the widespread adoption of handwashing with soap and other hygienic behaviour leading to zero cholera deaths.

Key Decision Critria

Response Phase
Acute Response
Protracted Crisis
HP Component
Preconditions and Enabling Environment
Community Engagement and Participation
Assessment, Analysis and Planning
Social and Behaviour Change
Monitoring, Evaluation, Accountability and Learning (MEAL)
Target Group
Older People
Persons with Disabilities
Local Leaders
Society as a whole
Application Level
Individual / Household
Community / Municipality
Target Behaviour
Hand Hygiene
Sanitation Related Behaviour
Water Related Behaviour
Menstrual Hygiene
Food Hygiene
Personal Hygiene
Environmental Hygiene
Vector Control
Solid Waste Management
Infection Prevention and Control
Hygiene Away from Home


To improve health, hygiene and living conditions by empowering people to help themselves using a club structure


CHC training and materials

Africa AHEAD (undated): CHC Training Courses including Tool Kit of Visual Aids and Manual

CHC AHEAD (undated): Registry of CHCs for Implementing Organisations

Quick guideline for implementing CHCs

Waterkeyn, J. (2006): District Health Promotion Using the Consensus Approach, Africa Ahead, WELL

Text book on the CHC approach

Waterkeyn, J. (2010): Hygiene Behaviour Change Through the Community Health Club Approach: A Cost Effective Strategy to Achieve the Millenium Developments Goals for Improved Sanitation in Africa, Lambert Academic Publishing. ISBN: 978-3-8383-4491-1

Theory of the CHC model

Waterkeyn, J., Waterkeyn, A. (2013): Creating a Culture of Health: Hygiene Behaviour Change in Community Health Clubs Through Knowledge and Positive Peer Pressure, Journal of Water, Sanitation and Hygiene for Development. Vol. 3(2). Pages 144-155. IWA Publishing

Evidence of impact and cost-effectiveness

Rosenfeld, J., Berggren, R. et al. (2021): A Review of the Community Health Club Literature Describing Water, Sanitation, and Hygiene Outcomes, International Journal of Environmental Research and Public Health 18(4)

Waterkeyn, J., Cairncross, S. (2005): Creating Demand for Sanitation and Hygiene Through Community Health Clubs: A Cost-Effective Intervention in Two Districts in Zimbabwe, Social Science & Medicine 61. Pages 1958-1970

Waterkeyn, J., Matimati, R. et al. (2009): ZOD for all - Scaling up the Community Health Club Model to Meet the MDGs for Sanitation in Rural and Urban Areas: Case Studies from Zimbabwe and Uganda, Africa Ahead, Zimbabwe Ahead

Waterkeyn J., Matimati, R. et al. (2019): Comparative Assessment of Hygiene Behaviour Change and Cost-Effectiveness of Community Health Clubs in Rwanda and Zimbabwe, IntechOpen

Waterkeyn, J., Waterkeyn, A. et al. (2020): The Value of Monitoring Data in a Process Evaluation of Hygiene Behaviour Change in Community Health Clubs to Explain Findings from a Cluster-Randomised Controlled Trial in Rwanda, BMC Public Health 20:98

Whaley, L., Webster, J. (2011): The Effectiveness and Sustainability of Two Demand-Driven Sanitation and Hygiene Approaches in Zimbabwe, Journal of Water, Sanitation and Hygiene for Development. Vol. 1(1). Pages 20-36. IWA Publishing