January 2017 Message from Dr Charles Holmes, Former CEO

Dear Colleagues and Friends,

After four great years leading CIDRZ, my family and I are transitioning from Zambia back to the US. I am thrilled to announce that Dr Izukanji Sikazwe, my Deputy for the last nearly four years, has been selected as my successor as CEO by the Board of Directors.

Dr Sikazwe is an extraordinarily talented Zambian public health leader, researcher and clinician, and I could not have asked for a better partner as we worked to transform CIDRZ into a strong and independent Zambian health organisation.

I would like to express my gratitude to the immensely dedicated CIDRZ staff and Board of Directors, and the many people and partners that have provided unfailing support to our efforts at CIDRZ over the past four years. Together we have made outstanding strides in turning the tide against HIV, TB, cholera, cervical cancer, childhood diarrhoea and emerging non-communicable diseases, addressed threats to maternal newborn and child health and made preparations for fighting Ebola. Our deep partnership with the Government of the Republic of Zambia has been central to our efforts to support sustainable health systems innovation, and study new medicines and vaccines to improve health in Zambia, and it has been a privilege to work hand in hand with talented colleagues from all levels of the Ministries of Health, Community Development and Home Affairs.

I am also extraordinarily thankful for support in many forms from the US Centers for Disease Control and Prevention (CDC), National Institutes of Health (NIH), the US President’s Emergency Plan for AIDS Relief (PEPFAR), the Bill and Melinda Gates Foundation, Mary Fisher and the Max M. and Marjorie S. Fisher Family Foundation, Absolute Return for Kids (Ark), Pink Ribbon Red Ribbon, M.A.C AIDS Fund, Comic Relief, ELMA Philanthropies, the Doris Duke Charitable Foundation, the Infectious Diseases Society of America, the European Union, and the University of Zambia/University Teaching Hospital, University of California, San Francisco and Berkeley, University of Alabama-Birmingham, Johns Hopkins University, and so many other friends, collaborators, mentors, and donors who have gone above and beyond to help strengthen CIDRZ during my tenure and support our lifesaving work.

I look forward to continuing to support CIDRZ as a US-based board member and as a contributor to ongoing programs and research.

Thank you again.

Charles Holmes, MD, MPH

CIDRZ: A Stronger Institution for Health and Development

Foreign Policy Association Blog by Dr Jim Quirk on 21 June 2016

CIDRZ Recovery: Stronger Institutions for Health and Development

HIV to Ebola to Zika, the effectiveness of public health responses has never been more critical, and organizations conducting this work are under increasing scrutiny. CIDRZ has addressed an issue shared by many developing-world health institutions: serious gaps in its organizational capacity to fulfill its mission. Read more here:

http://foreignpolicyblogs.com/2016/06/21/cidrz-institutions-health-development/

CEO Holmes speech to staff for 2016 National Labour Day

Today I’d like to share a few reflections on CIDRZ on this special 2016 Labour Day celebration. My reflections are on service, on our commitment to excellence and results, and about the great future we’re embarking on as the “new” CIDRZ, each of which contribute to this year’s national Labour Day theme of “Achieving national development through productive decent work, sustainable job creation, and social justice.”

On our service: Service can be difficult. It is never just putting in your time, it can frustrate you, it can tire you to the bone, and there is always a new challenge. A quote that is relevant to some of the challenges of service, and that has meant a lot to me over the years is from the 26th American President, Teddy Roosevelt. In a speech given in the year 1910 at a university in Paris, he said, It is not the critic who counts; not the man who points out how the strong man stumbles, or where the doer of deeds could have done them better. The credit belongs to the man who is actually in the arena, whose face is marred by dust and sweat and blood; who strives valiantly; who errs, who comes short again and again, because there is no effort without error and shortcoming; but who does actually strive to do the deeds; who knows great enthusiasms, the great devotions; who spends himself in a worthy cause; who at the best knows in the end the triumph of high achievement, and who at the worst, if he fails, at least fails while daring greatly…”

In the case of CIDRZ, we are serving a great mission every day we come to work. For example, by helping to establish the effectiveness of rotavirus vaccine in Zambia, and building a 359 piece cold chain for its distribution around the country in partnership with the Government, our collective work has protected an entire generation of children who will not get sick and potentially be lost to diarrhoea caused by rotavirus. It was not just one person or even one team that did this; it was the whole of CIDRZ. It was Fleet, it was Finance, it was HR and Procurement, it was Internal Audit, it was Facilities, and of course it was the project teams and their great leadership and partnership with Government.

The same goes for the launching of the GeneXpert, a better tool for diagnosing Tuberculosis, which thanks to the “whole of CIDRZ,” is now screening prisoners at high-risk for TB at Lusaka Central Prison and in clinical sites through programmes funded by PEPFAR through the United States Centers for Disease Control and Prevention.

None of this was easy, but the rewards of our service are truly life changing – not only for those we serve, but even for those of us who serve. Indeed scientific study after study demonstrates that serving others is one of the greatest predictors of happiness and fulfillment in life. When our service feels daunting or frustrating, or we face our own or other’s shortcomings, let us step back and think about what were are contributing to our friends and our neighbours – the people of Zambia.

On our commitment to excellence and results: As I said at our End of the Year Meeting last year, we have some of the most committed people in the world working for CIDRZ.  Every day I see people committed to excellence and bringing their best to their work. This has shown in our results in nearly EVERY programme this year, from our BetterInfo study targeting HIV programme retention, to our HIV, cervical cancer and TB programmes, to the Clinical Trials Unit and the Laboratory that consistently produces accurate results for doctors, nurses and patients who rely on them. Our awards ceremony later today will celebrate some of our Most Innovative, Most Outstanding, Most Cost-Efficient, and Most Committed and Hard Working people who have contributed to these results.

Lastly, I want to reflect briefly on the great future ahead for CIDRZ. It has been said that the last 3-4 years at CIDRZ were a turnaround process. The organisation truth be told, had fallen off track. With incredible leadership over the last few years from our Deputy CEO, and our entire Executive Committee and Leadership Team and Management Forum, we’ve cleaned up all of the serious issues that were identified at that time. We’ve settled our historical tax issues; become compliant with local Labour laws; moved towards university research partners that are most aligned to our mission of doing work that benefits Zambia and builds local scientific talent, and taken our Laboratory from being nearly closed in early 2013 to one of the best labs in the region in 2016, as evidenced in part by our submission for ISO accreditation, and the results of recent quality testing and audits. We’ve also made the organisation flatter – there are many more people involved in day-to-day decision-making now than in the past, and our leadership is largely local. We have also recruited a 10-member Board of Directors comprising a cross-section of Zambian society and global health leadership that governs the organisation and is truly invested in our future.

All of this allows us to better serve our mission. And it is not an abstract mission. Our successes and our service are felt by the little girl walking around Kalikiliki who is free from life-threatening illness from rotavirus disease because of the vaccination programme we supported the government to develop, and equally by the woman and mother of 3 who has been weakened by tuberculosis and yet didn’t know why she was unable to gather her usual strength and contribute to her family’s wellbeing until she received a diagnosis from a GeneXpert machine that we as CIDRZ placed, with support from our donors.

This service and partnership with Government, this commitment to excellence and results, and our successes in turning around this organisation gives us a bright future ahead. I just returned from the US where I met with three of our biggest partners and donors. I was told repeatedly that we are now viewed as one of their best and most productive partners, and I heard about their many exciting plans to support us in the years to come. So, on this Labour Day celebration, let us enjoy celebrating our successes and contributions, and congratulations to the “new” CIDRZ!

Dr Charles Holmes
CEO – CIDRZ
6th May 2016

CIDRZ Expertise Contributes to A Toolkit for Implementing Health Services

CIDRZ’s Director of Maternal Neonatal and Child Health contributed as a Senior Author to the Maternal Health Toolkit component of the UN Commission on Life-Saving Commodities for Women’s and Children’s Health “A Toolkit for Implementing Health Services”. The toolkit is already being used by the Neonatal Technical Working Group in revising national guidelines. The  Toolkit was sponsored by Amref health africa and Life Saving Commodities.

CEO Holmes Speech at the Official Opening of the Refurbished Chawama Clinic Lab

Photo Front Row L to R: Deputy Director Lab Services MOH Dr David Nsama, Dr Charles Holmes, Provincial Principal Clinical Care Specialist Dr Wajirovya Chilambo, Country Director CDC Dr Jim McAuley, District Medical Officer Dr Gideon Zulu

Official Handover of the Refurbished Laboratory of the Chawama Level One Hospital

24th September 2015

It gives me great pleasure to join you today as the Centre for Infectious Disease Research in Zambia – CIDRZ – joins with the United States Government represented by the Country Director of the Centers for Disease Control and Prevention Dr Jim McAuley, as we officially handover the refurbished laboratory to the Zambian Government through the Chawama First Level Hospital. This momentous event could not take place without the contributions and support for Zambia generously received from the United States and the solid partnership we have established with the Government of Zambia.

CIDRZ was established as collaboration between the University of Zambia, the University of Alabama, and the then Director of the Lusaka District Health Management Board, Dr. Moses Sinkala. CIDRZ became an independent Zambian non-governmental organisation in 2011, with assistance from the CDC and other organisations, and has a mission of supporting health program implementation, conducting locally-relevant research, and to serve as a resource for training the next generation of public health and research leaders locally. I am happy to say that each of the three legs of our mission are thriving and resting on a firm foundation of management practices and governance. Most importantly, all of this work is done with the closest collaboration with our colleagues in the Government of the Republic of Zambia, whose lead we take, and whose vision for a healthier Zambia we share.

A key interest of CIDRZ is to support the Zambian Governments’ efforts to strengthen healthcare training and systems so that high-quality clinical healthcare is available to ALL Zambians as stated in our Vision of  “a Zambia, and a region, in which all people have access to quality healthcare and enjoy the best possible health, including a life free from AIDS.

However, high-quality healthcare is not possible without high-quality laboratory testing services. Clinical laboratories are sophisticated and complicated environments and require sufficient space, light and infrastructure, specialized laboratory personnel and well-functioning and validated instruments, and a robust supply chain. When a patient agrees to having a blood test they do so with trust; they trust that their specimen will be treated carefully and seriously – that the laboratory specialist will quickly perform the correct testing so that an accurate and trustworthy result is provided to the clinician. The result of a single blood test can change a life and it is of utmost importance that the laboratory result is one that can be trusted, and that it is provided in as fast a time as possible. That is our challenge and our opportunity as we all support this work.

In 2014, the Government of the Republic of Zambia – as part of their ongoing support for improved maternal and child health services – constructed a new maternity wing to accommodate the growing population of Chawama. Chawama Hospital Management then approached CIDRZ and requested for assistance in renovating and refurbishing the old labour ward into a new and larger laboratory so as to increase testing space and overall lab capacity. With generous funding received from the United States President’s Emergency Plan for AIDS Relief (PEPFAR) through the Centers for Disease Control and Prevention (CDC), CIDRZ has been proud to contribute to this exercise so that now the Chawama First Level Hospital has a spacious clinical laboratory to better serve the local community.

Important work to refurbish existing infrastructure to provide the needed services such as this was made possible because it is part of the United States Governments’ CDC and PEPFAR program transition to local Zambian ownership. The refurbished laboratory that we will officially open today is a success story of collaboration and development, and heralds other similar transition work that is currently taking place – again through support of the U.S. government – at other CIDRZ-supported Government of the Republic of Zambia health facilities in Eastern, Western, Southern and Lusaka Province. In addition I would like to commend the work of CIDRZ colleagues Mpande Mwenechanya, Bernadette Nyemba, Mabvuto Phiri and Vina Chilengi who made this lab transition and this opening event today possible.

As is usual practice during any laboratory transition activity, the CIDRZ Lab Technical Mentors assist with training and systems, and will continue to support the Chawama Laboratory staff until all are comfortable with the requisite testing skills and there is a constant availability of reagents to ensure a seamless lab service to the community. Even after full transition to Chawama, CIDRZ will be available to provide technical support if, and as, necessary.

Prior to this refurbishment, the Chawama Health Centre laboratory was small and cramped, and samples from this populated community had to be transported across the city for testing at the CIDRZ Central Lab in Kalingalinga.

But now, with the refurbished laboratory, the Chawama Level One Hospital Lab personnel are able to perform on-site testing for haematology and chemistry and provide these results to patients, as well as CD4 T-cell count assays for new anti-retroviral treatment (ART) patient enrollees.

While laboratory personnel are perhaps less visible to the general public, and even to those that attend a health centre, we must all recognize that the work they do is crucial to the correct detection, diagnosis and treatment of disease. High-quality laboratory services are therefore a core pillar in the Zambian HIV/AIDS response.

I am pleased that CIDRZ has been able to play a role in the development of the Chawama Laboratory so that it is now becoming one of the largest Level 1 facility labs in the district. It will not only have the capacity to perform all laboratory testing on-site, but in the near future will have the capacity to even serve as a referral lab for other health centers in the District.

This is an exciting day and I am pleased that CIDRZ can be part of the country’s efforts to promote quality health care, including laboratory services. I applaud the Zambian and the United States governments and the other supporting partners many of whom are here today that made this success, and will make future successes possible as we continue to work together to fulfil our vision of bringing quality healthcare to all Zambians.

Thank you.

Dr Charles Holmes MD, MPH

CIDRZ Director and Chief Executive Officer

Dr Charles Holmes’ Speech on Launch of ZaPHSS Framework and Signing of MOU with Government of Republic of Zambia

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Speech delivered by CIDRZ CEO Dr Charles Holmes at the Official Launch of the Zambia Prisons Health Systems Strengthening (ZaPHSS) Framework and signing of the Memorandum of Understanding with the Government of the Republic of Zambia – 12th May 2015

Permanent Secretary Ministry of Home Affairs, Dr Chileshe Mulenga
Permanent Secretary Ministry of Health, Dr Davy Chikamata
Permanent Secretary Ministry of Community Development, Mother and Child Health, Professor Elywn Chomba
Ambassador and Head of the European Union Delegation to Zambia Mr Gilles Hervio
Commissioner of Prisons, Mr Percy Chato
Representatives of various government departments present
Chief of Party SHARe II Project, Dr Muka Chikuba McLeod
Country Co-ordinator United Nations Office on Drugs and Crime, Mrs Sharon Nyambe-Lesa
Representatives of various NGOs present
Members of the Press
Distinguished Guests

May I simply say “All protocols observed”

Ladies and Gentlemen,

On behalf of CIDRZ – and indeed on my own behalf, I am so delighted to be part of this landmark occasion where the Centre for Infectious Disease Research in Zambia is signing a Memorandum of Understanding with the Government of the Republic of Zambia through the Ministry of Home Affairs, Ministry of Health, and the Ministry of Community Development Mother and Child Health to cement our agreement of work to strengthen Zambian prisons health systems. The signing of the MOU today does not represent the beginning of a partnership between the Zambian NGO, CIDRZ, and the Government of the Republic of Zambia. Instead, it represents an important milestone that confirms CIDRZ’s commitment to continue collaborative work with government and other key stakeholders to sustain the implementation of the health systems strengthening task in the Zambian Prisons.

Since its inception in 2001, and its move to become an independent Zambian organization in 2011, CIDRZ has implemented multiple projects in partnership with the government. Four of these have been in prisons settings, and at present we have three more prisons-related projects submitted to various funders for future consideration. Over the last five years, approximately US 5 million dollars have been directed to Prisons-related research and programming.

The first CIDRZ Prisons-related program was supported by the World Health Organisation. More than 8000 inmates were screened for both TB and HIV in less than 12 months. Importantly through this initiative we learned that the rate of TB infection was 10 times higher – and the rate of HIV infection was 2 times higher – than the national averages.  Given the imperative to control the TB epidemic in Zambian prisons fuelled by the HIV epidemic, we initiated a project in ten prisons along the line of rail using a novel method for TB diagnosis by the Gene Xpert machine. This project was sponsored by the Centers for Disease Control and Prevention (CDC), and was in partnership with TB CARE through FHI 360 and was under the leadership of the MOH and MCDMCH.

However, we learned that conducting discrete projects each with a limited funding period was not sufficient to make sustained change. To deliver high-quality healthcare services requires a strong, sustainable health system. Therefore, under the sponsorship of the European Union-funded Zambia Prisons Health Systems Strengthening Program, CIDRZ has an overall goal to work with the government to “develop and capacitate a prison health system that will plan, manage and implement improved health services in Zambian Prison facilities.” To achieve this, a three-pronged approach was adopted:

  1. To strengthen the decision-making framework and management structure of prison health services in Zambia
  2. To develop the capacity of the Prison Health Directorate to assess, plan and implement health services in prison facilities
  3. To develop the capacity of facility-based Prison Health Committees to plan and implement sustainable prison health services

To date, CIDRZ through the EU-supported ZaPHSS project and in collaboration with key partners such as the Zambia Prisons Service, the SHARe II project, and the United Nations Office on Drugs and Crime, has produced the Zambian Prisons Health Systems Strengthening Framework being launched today. This Framework will be a yardstick for the health systems strengthening work in the Zambian prisons and this Framework will be operationalised by the Memorandum of Understanding being signed today.

Please allow me to mention some of the accomplishments that the ZaPHSS project has realized in collaboration with its partners:

  • Trained key members of the Zambia Prisons Service Command and the entire Health Directorate in Planning and budgeting, Coordination, Monitoring and Evaluation, and Media Relations
  • Trained 11 Prisons Health Committees, comprised of 45 Officers and 120 Inmates, in Health Needs Assessment, Entry Screening for TB and HIV, Peer Education, and Monitoring & Evaluation
  • Conducted a multi-phase research study in prisons; Understanding Zambian Prison Health: Inmate Health and Access to Health Care. This study was seeking to understand factors influencing health and health seeking behaviour in Zambian Prisons.

But the task in the Prisons-setting is not completed. We are currently working with the Government of Zambia in only 11 out of a total of 86 prisons. Therefore there is still an urgent need to expand the Prisons programs work and to do this we will require generous donors such as the EU, CDC, USAID, PEPFAR and others to continue to support and to even to expand their support – in addition to the Government of the Republic of Zambia’s commitment to prioritize Prisons health. The need for continued investment towards improvement of prisons health cannot be over emphasised. CIDRZ remains committed to supplementing government’s efforts in providing health services in Zambian prisons and the general community through various projects supported by various partners.

In conclusion ladies and gentlemen, allow me to extend my heartfelt appreciation to the European Union through His Excellency the Head of Delegation and Representative of the EU to COMESA, Ambassador Gilles Hervio for funding this great initiative. May I also sincerely thank the Government of the Republic of Zambia through the Permanent Secretaries present here for the cordial working relationship accorded to us over the many years of CIDRZ’s operations in Zambia.

Dr Chileshe Mulenga, PS Ministry of Home Affairs thank you so much for visiting CIDRZ on Friday afternoon. You helped our teams realize the importance of their efforts, and our shared vision for the work ahead. I thank you.

Dr Charles Holmes, Director and CEO

 

Message from CIDRZ CEO Charles Holmes on World TB Day 2015

Today we learned from the CIDRZ Director of TB Programmes, Dr Monde Muyoyeta, that 1.5 million people are still dying every year from TB despite there being an effective treatment regimen available. This is in large part because those suffering from TB are still not being properly diagnosed. We have known the cause of TB – the TB bacillus bacteria since 1882 – yet diagnosis remains a major challenge in resource-constrained settings such as ours where there is also the highest burden of disease. TB infection may be a missed diagnosis due to the long wait time to receive a lab-confirmed diagnosis; or be over-diagnosed by a clinical diagnosis because of lack of lab facilities or skilled lab technicians. Treatment also remains challenging because it takes many months, and can be compromised by poor drug adherence or drug side-effects.

However, today’s presentations on the CIDRZ TB Plus Up programme, the TB OpX, TB Vaccine, and TB Alliance studies, and the TB Lab delivered by our TB Department have been exciting! CIDRZ – and indeed Zambia – are attacking TB from multiple sides at once: diagnosis, treatment and prevention. Defeating TB will take more than drugs and I am incredibly proud that CIDRZ is looking at our programmes and research to support the Ministry of Health from a holistic standpoint. As we’ve seen with HIV, Ebola and other diseases, engaging in better ways of prevention, diagnosis and treatment is the only way to get ahead of an epidemic.

CIDRZ is:

  • Innovating better TB care delivery strategies by working in prisons and improving diagnosis rates among these vulnerable, high-risk individuals
  • Engaging with TB Alliance so that Zambians that need treatment – and may even have Multidrug resistant (MDR) TB – have access to the latest drug combination clinical trials
  • Incorporating better methods to diagnose TB into our programme strategies such as evaluating the GeneXpert MTB/RIF testing technology and providing world class TB diagnostics in our lab
  • Leading prevention of latent TB from becoming active through broader provision of Isoniazid Preventive Therapy (IPT); improving infection control efforts; and conducting the first clinical trial of TB vaccines, EVER, in Zambia!

Although TB rates are dropping by 2% per year, we can’t be satisfied with that and must collectively aim to do better! My sense is that in this Zambezi conference room there is the energy, knowledge and leadership to raise awareness of the regional and national emergency that TB continues to pose. I am proud of the extraordinary work that the CIDRZ TB Department has done, and I am confident when we come together to commemorate World TB Day next year that they will report even further success in driving TB rates down  and will be that much further down the road to the introduction of new drugs, diagnostics and vaccines.

WHO Policy Brief on Chronic Hepatitis B Guidelines recommends APRI to stage chronic liver disease

In Zambia, it is estimated that 6-8% of the population may have chronic Hepatitis B Virus (HBV) infection. Routine Hepatitis B immunization for infants protects the next generation, and the Zambia National Blood Transfusion Service routinely screens for HBV to prevent transfusion-related cases. However, access to hepatitis screening and treatment is still very limited in the region, and community knowledge about hepatitis is low. Many people are unaware of their HBV infection and present for care with advanced disease.

CIDRZ supports HBV screening in the Government of Zambia’s HIV Prevention, Care and Treatment programme in Lusaka District according to Ministry of Health guidelines.

In January, a group of investigators including Ministry of Health, University Teaching Hospital  and CIDRZ authors published the results of their collaborative study evaluating the association between significant liver fibrosis, determined by the now WHO-recommended assessment for use in resource-constrained settings, AST-to-platelet ratio index (APRI), and all-cause mortality among HIV-infected patients prescribed antiretroviral therapy (ART) in Zambia. They concluded that liver fibrosis may be a risk factor for mortality during ART among HIV-infected individuals in Africa and that APRI is an inexpensive and potentially useful test for liver fibrosis in resource-constrained settings. Dr Michael Vinikoor, CIDRZ physician and study lead, welcomes the WHO guidance on the management of HBV in low and middle-income settings, “having the WHO recommend the APRI will help to bring this research finding to policy.”

Read the paper here

Read the 2015 WHO Policy Brief Guidelines for the Prevention, Care and Treatment of Persons with Chronic Hepatitis B Infection here

CIDRZ Opt-Out Provider Initiated HIV testing and counselling paper referenced in the World Bank World Development Report 2015

A CIDRZ Integration Team paper on Provider-Initiated Testing and Counselling (PITC), originally published in the World Health Bulletin in 2011, was referenced in Chapter 8, Health of the 2015 World Development Report. Read the paper here >>> http://www.who.int/bulletin/volumes/89/5/10-084442/en/

Access the World Bank Group 2015 World Development Report: Overview Mind, Society and Behaviour Chapter 8, Health PDF here >>> 2015_WB_WorldDevelopmentReport_Chapter-8

And the full report here >>>

http://www.worldbank.org/content/dam/Worldbank/Publications/WDR/WDR%202015/WDR-2015-Full-Report.pdf

Florence Schokola

Rural Voices: Having a Toilet is a Big Thing

CIDRZ, with support from UNICEF, is assisting rural communities in the Lusaka Province of Zambia to meet Millennium Development Goal 7 for improved sanitation. By coordinating a Community-Led Total Sanitation effort in Kafue and Chongwe Districts of Lusaka Province, CIDRZ is contributing to a larger goal to create “open-defecation-free zones” for 3 million people living in rural Zambia. Here are what two villagers have to say:

 

Catherine Chifungula

Catherine Chifungula, Community Sanitation Action Group member, in front of her newly constructed latrine

“After the Community-Led Total Sanitation sensitisation by a village champion, a lot of households in my village now understood the importance of not defecating in the bush, and decided to build toilets with simple and inexpensive tippy tap handwashing set-ups.” 56-year old, Catherine Chifungula from Kapamangoma Village in Chongwe District recalled.
Catherine, a widow with 6 children, is a Sanitation Action Group (SAG) member in her village. SAGs monitor sanitation and encourage every household to build a toilet and a tippy tap – and emphasize using soap or ash to wash hands after every time of using the toilet.

She went on to say that “some women in other villages – those that had no husbands or men in the household – used the excuse that they didn’t have anyone to dig their pit latrines. So, they continued to defecate in the open, but this is just laziness. I take pride in my toilet! When I wake in the morning I clean the toilet and make sure that there is sufficient water, and soap or ash for handwashing. My children also know to keep the toilet clean and take turns to ensure there is always water in the tippy tap.” She says this smiling with pride, secure in the knowledge that she has taught her children the importance of cleanliness and sanitation from an early age.

34-year old, Florence Scholoka is another vibrant lady within the village. A widow with 5 children, she also expressed happiness at having her own toilet. She said that after the community sensitisation – especially after the ‘behaviour-change triggering exercise’ where fresh faecal matter and food were put close to each other. “It was so easy to see the risk of eating food that flies had touched just after they had come from touching stool. It was so disgusting to imagine eating that food; it changed a lot of resistant mindsets!” she laughed.

“My toilet is different from other toilets in the village. I made sure the man who constructed it put a toilet pan and a lid. I wanted to sit comfortably even though my toilet is still outside my house,” she exclaims. “Having a toilet is a big thing! It needs to be kept clean! Some visitors don’t like to use my toilet at first because they say that it is too clean, but after I explain the importance of a clean toilet and they space around it they become happy to use it.” she adds. “They start to agree that a toilet made out of bricks is better than a ‘grass toilet’; especially in the rainy season!”

Mrs Scholoka went on to claim that there are no more diarrhoeal cases in the village as everyone now has toilets. “Before the community sensitization, and the building of the pit latrines, so many children would always be at risk of developing diarrhoea.”