The GESCOME difference : lessons learned from gestion communautaire de sante environnementale (GESCOME) -- the environmental health project II -- CESH [community-based environmental sanitation and health] Benin activity

The CESH approach is an effective instrument for stimulating community changes in health understanding, and probably health practices, as well as building and maintaining physical infrastructure for diarrheal disease prevention in rural towns. CESH combines participatory problem identification and analysis, solution finding, and health communication with a good governance component, and stresses coalition building between local government, civil society, and communities. CESH has: (1) used local communities' own traditions to generate and communicate vital health information rapidly; (2) included groups reflecting multiple sectors of the local society in all aspects of the participatory CESH process; (3) built broad support and trust among local administrators, technical service agents, civil society leaders, and communities to mobilize resources to construct and maintain latrines and water resource points; (4) given local communities a strong sense of ownership by giving them full responsibility to choose and manage their micro-projects; (5) provided appropriate low-cost technologies easily managed by people with relatively little formal education; and (6) reduced the need to use expensive external TA to supervise and manage local environmental health interventions. GESCOME showed that, with minimum external supervision, local communities can successfully establish and manage effective, decentralized, autonomous decisionmaking structures. To attain these results, communities must employ and master low- cost simple technologies that provide a desirable public service sustained and financed by public support. Elements in the decisionmaking structures included: effective linking of community groups and informal neighborhood groups with local elected officials, municipal/commune-level government and departmental administration; delegation of decisionmaking to local communities to manage microprojects as they see fit; and establishment and enforcement of rules ensuring transparency and accountability. Key elements that facilitate the CESH approach include: strong support at the departmental and municipal levels; a tradition of community-level participatory decisionmaking; presence of an enthusiastic development champion; perceived or easily perceptible advantages of adopting practices to decrease children's risk of diarrheal disease; local beliefs about diarrheal disease causation that do not have important symbolic or social meaning in local cultures; and reliable local resources to finance construction and maintenance of infrastructure (latrines, water resource points, etc.). Participatory projects should take into account seasonality factors that could affect participation and resource mobilization. The projects should be of sufficient duration (4-5 years) to ensure that sustainable institutions and knowledge generation and communication methods are developed. Key elements affecting the amount of time needed are detailed, as are suggestions for scaling up the CESH process to an entire country.