USAID Sustaining Partnerships to enhance Rural 
Enterprise and Agribusiness Development 
(SPREAD) Project
Integrated Community Health Program
Mid-Term Program Evaluation
May 2010
Irene Kitzantides 
Population, Health and Environment (PHE) Advisor
USAID Global Health Fellows Program 
Public Health Institute 

1 
Table of Contents
Abbreviations ……………………………………………………………………………..2 
Executive Summary ………………………………………………………………………3 
Introduction………………………………………………………………………………..6 
1. Purpose ……………………………………………………………………………..6 
2. Background ………………………………………………………………………...7 
3. SPREAD’s Integrated Community Health Program …………………………...8 
Methods ……………………………………………………………………………………11
1. Data collection ……………………………………………………………………..11 
2. Limitations ……………………………………………………………………........12 
Results ……………………………………………………………………………………...13 
1. SPREAD Staff Reflections ………………………………………………………...13 
2. Cooperative Leaders ………………………………………………………………20 
3. Community Health Workers- Agents de Santé Communautaire (ASCs) ……….24 
4. SPREAD-Supported Cooperative Health Agents (CHAs) …………………….25 
5. Local Partners: Health Centers, NGOs, Sector and District Officials ………...27 
6. Coffee Farmers (Male and Female Beneficiaries) ………………………………31 
7. Process Indicators and Cost Effectiveness ………………………………………35 
Discussion ………………………………………………………………………………….36 
Recommendations ………………………………………………………………………...41 
Bibliography ……………………………………………………………………………….44 
Program Documents Reviewed ………………………………………………………….45 
Monitoring and Evaluation Tools Used ………………………………………………..46 
2 
Abbreviations
ASCs Agents de Santé Communautaire (Government Community Health Workers)
AIDS Acquired Immunodeficiency Syndrome
CHAs Cooperative Health Agents (Coffee extension agents or Animateurs de Café and Peer 
Educators involved in SPREAD’ Health Program)
CWS Coffee washing station
FP/RH Family planning and reproductive health
GDA Global Development Alliance
GOR Government of Rwanda
HIV Human Immunodeficiency Virus
IGA Income-generating activities
ITNs Insecticide- treated bed nets
M&E Monitoring and evaluation
MCH Maternal and Child Health
MINISANTE Ministère de la Santé (Ministry of Health)
NGO Non-governmental Organization
NUR National University of Rwanda
PEARL Partnership to Enhance Agriculture in Rwanda through Linkages
PEPFAR President’s Emergency Plan for AIDS Relief 
PHE Population, Health and Environment 
PMTCT Prevention of maternal to child transmission [of HIV] 
SOPYRWA Societé du Pyrèthre au Rwanda (Rwandan Pyrethrum Company) 
SPREAD Sustaining Partnerships to enhance Rural Enterprise and Agribusiness 
Development 
TOT Training of trainers 
USAID United States Agency for International Development 
USG United States Government 
VCT Voluntary Counseling and Testing 
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Executive Summary
The Sustaining Partnerships to enhance Rural Enterprise and Agribusiness Development (SPREAD)
Project is a 5-year cooperative agreement (2006-2011) between USAID and the Texas A&M University 
Norman Borlaug Institute of International Agriculture. USAID has been the principal provider of 
technical assistance for developing Rwanda’s specialty coffee sector since 2001, and has been 
instrumental in turning the country into the highly-sought after specialty coffee origin it is today. 
Building on these agribusiness successes and lessons learned, SPREAD continues to support coffee as 
its largest program, and has also expanded to other high-value agricultural commodities-- pyrethrum 
and birds eye chili pepper -- through two Global Development Alliance (GDA) public-private 
partnerships. SPREAD has also included an integrated Community Health component for target 
farmer groups, which began full implementation in October 2008 (FY09) in the coffee areas of the 
Southern Province, and has since expanded to pyrethrum growing areas in October 2009 (FY10). The 
Health program provides education and services for HIV/AIDS prevention, family planning/ 
reproductive health and maternal and child health promotion, and strives to fully integrate these 
activities into Agribusiness structures, systems and activities in order to conserve Project resources 
while more holistically meeting community needs. 
The overall goal of SPREAD is “to provide rural cooperatives and enterprises involved in high-value 
commodity chains with appropriate technical assistance and access to health-related services and 
information that will result in increased and sustained incomes and improved livelihoods.” SPREAD is 
a unique example of integrated programming within USAID, a “wraparound” project that receives 
funding across several technical areas in Health and Economic Growth. SPREAD’s design has its roots 
in the Population, Health and Environment (PHE) approach to development, which promotes multi￾sector collaboration or “integration” to create synergy and improve project outcomes across programs, 
particularly at the community level. As this is a fairly new approach within both USAID and PHE, this 
evaluation aimed to reveal stakeholder perceptions thus far of the integrated approach, to improve 
interventions and sustainability efforts for the remaining life of the Project, to share successes, 
challenges and lessons learned, and to inform future funding of integrated programming.
This evaluation was conducted in February 2010 and focuses on the on the Health program in the 
coffee areas of 2 Districts in the Southern Province. Due to a lack of quantitative baseline health data 
and Project resource constraints, data are primarily qualitative and were collected through interviews 
and focus groups with various stakeholder groups: beneficiary men and women, program volunteers 
or Cooperative Health Agents (Animateurs de Café and Peer Educators), local health officials and service 
providers (both government and NGO), and SPREAD program staff across Health and Agribusiness 
programs. Program documents and routine monitoring data were also reviewed to understand the 
program’s history, its eventual scope and reach, and to estimate costs per person.
Overall, SPREAD’s integrated Community Health Program is well-appreciated by program 
beneficiaries, local authorities, cooperative leadership, SPREAD staff, Cooperative Health Agents 
(CHAs) and other health partners alike. All cited palpable program effects in regards to health 
knowledge increase and behavior change. Although it is impossible to attribute all of these effects to 
SPREAD alone, stakeholder groups reported improvements in personal and household hygiene, 
understanding and acceptance of family planning, increased uptake of HIV voluntary counseling and 
testing (VCT), increased condom use and other local health services, as well as shifts in gender norms 
affecting household revenue use, alcohol and reproductive health. The integrated approach is esteemed 
by agribusiness stakeholders as a means to more holistically meet farmers’ goals of increased incomes, 
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improved lives and livelihoods, as healthy families lead to higher quality coffee and stronger 
businesses. CHAs, beneficiaries and cooperative leaders feel they and their communities have benefited 
from the health program, and have also learned that coffee is a valuable entry point to discuss health 
topics. Health partners appreciate SPREAD’s community-based approach, which has increased access 
to local farming populations who are very much in need of health information and services. 
Stakeholders across sectors value the Peer Education strategy and believe it to be more effective for 
changing behaviors. Thoughtful planning and collaboration with local health centers, community 
health workers, hospitals and NGOs has allowed SPREAD to complement rather than duplicate 
existing public health efforts. A key to program success has been the strong support and supervision 
SPREAD provides CHAs, such as equipping them with appropriate information, education and 
communication (IEC) materials, conducting consistent monthly training and field monitoring, as well 
as the institution of a sound planning and reporting system. 
Community critiques were few, the main weakness being communication with partners (NGO, Health 
Center, administrative Sector level) as SPREAD does not typically create quarterly reports for this local 
level. At times there is also a lack of implication of these local partners in implementation and follow￾up. Program challenges include the short program lifespan which both limits the ability to lay a strong 
foundation for the continuation of health activities post-Project, and which also will leave a large 
remaining need, particularly in the pyrethrum areas around Volcanoes National Park where activities 
have just begun. Challenges within the community include cultural and gender norms where men are 
often seen as barriers to reproductive health and make poor spending decisions. Male spending on 
alcohol rather than family needs can contribute to a host of issues such as sexually transmitted 
infections including HIV, gender-based violence, food insecurity and conflict within households and 
should be kept in mind when designing livelihoods interventions. 
At the Project level, true integration and collaboration to build synergy across Agribusiness and Health 
programs proves consistently difficult. The concept of integration was not well-articulated at the outset 
of the Project, nor was it reflected in SPREAD’s overall strategy and workplans. Staff are spread 
throughout the country, and the onus is on them to come up with collaborative strategies and a more 
streamlined M&E system reflecting this integration on their own time. Evaluating health and 
integrated outcomes has also been difficult due to a lack of baseline data. Strict USG vertical funding 
streams do not lend themselves to integration and at times inhibit meeting beneficiary needs. 
Partners and beneficiaries alike request the continuation and expansion of SPREAD’s services. In 
addition to continued health and coffee-related services, farmers require capacity-building for creating 
savings plans and accounts, assistance to develop income-generating activities outside of coffee season, 
more youth-specific interventions and diversified community mobilization and education strategies.
Prospects for sustainability are limited due to the short time span of the program, as well as a lack of 
stable source of financial and technical assistance post-Project. Several ideas emerged regarding how to 
continue SPREAD-initiated health interventions, such as through the creation of a cooperative Health 
budget subsidized by Fairtrade funds and member contributions, and for RWASHOSCCO to 
eventually include health as a service for its member farmer groups. Health partners could continue to 
provide services to cooperative members as relationships have been established. Although certain steps 
have been taken, a concrete exit strategy is required, including building ownership of the program on 
the part of cooperatives and local service providers. 
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Recommendations are implicit throughout this report as participants offer suggestions and results are 
discussed. However, the principal recommendations based on findings of this evaluation are:
1. (SPREAD) Incorporate interactive and dynamic teaching strategies, youth-specific activities and 
collaborative efforts to address agribusiness and health linkages.
2. (SPREAD) Strengthen communication with local health partners and authorities to ensure 
complementary service delivery and contribute to sustainability.
3. (SPREAD) Formulate a clear exit strategy with partners and stakeholders in remaining year and 
a half of Project.
4. (Program designers) Ensure integration is evident in program design and articulated in Project 
goals, workplans, organizational structure and M&E.
5. (Donors) Funding mechanisms should accommodate integrated programming, including the 
support of quality M&E, sharing of best practices and lessons learned, and increased flexibility 
to best meet local needs.
6. (Donors) Consider another round of funding to establish a stronger foundation for 
sustainability of SPREAD’s integrated health and agribusiness interventions.
7. (All involved in Economic Growth activities) Health is a critical aspect of the success of income￾generating activities and should figure into any livelihoods development strategy. 
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Introduction
Purpose
The USAID SPREAD Project is a unique example of integrated Agribusiness and Health programming 
with roots in the Population, Health and Environment (PHE) approach to development. Since the 
1990s, PHE projects have aimed to address the complex linkages between human health, 
environmental management, poverty and population pressures in order to solve development 
problems. PHE projects traditionally work to increase access to family planning and health services
while simultaneously helping communities manage their natural resources in ways that improve their 
health and livelihoods, as well as conserve critical ecosystems.1 The SPREAD project is distinctive in 
that it integrates USAID Economic Growth and Health funding streams, aiming to create sustainable 
agribusinesses through value-chain management while improving health of Rwandan farmers to more 
holistically meet farmers’ needs of improved lives and livelihoods. Although USAID Agribusiness 
interventions through PEARL (SPREAD’s predecessor project) and SPREAD are celebrated among 
donors, the Government of Rwanda (GOR) and other industry players for their development of the 
specialty coffee sector and economic growth of rural communities, the integrated community health 
component is new and its effects relatively unknown. As this integration is a unique model within 
USAID, the field of PHE and both health and agribusiness sectors, SPREAD managers, Rwandan 
partners, donors and the PHE community worldwide are interested to learn the successes, challenges 
and lessons learned over the last year and a half of integrated implementation.
The purpose of this evaluation is to improve SPREAD’s current health program strategy and contribute 
to the strengthening and sustainability of positive health interventions, to inform future funding of 
integrated initiatives, and to share lessons learned with donors, partners and other practitioners in the 
field of PHE, Health and Economic Growth/Agribusiness. 
The specific objectives of the evaluation are to:
1. Explore community perceptions regarding program impact and appropriate targeting of 
interventions 
2. Assess the added value of SPREAD’s integrated Health and Agribusiness approach related to 
the primary assumptions upon which the program is based: 
 Coffee revenue could feasibly be spent on family health needs, given appropriate access 
to health information and services
 Integration would lead to programmatic synergies across Health and Agribusiness 
(Coffee and Cooperative Development) programs
 Integrating community health into coffee/coop activities would enable the rapid access 
to otherwise underserved, rural, income-generating populations
3. Determine the extent to which participants, cooperatives, local authorities and other
stakeholders have assumed ownership of the Health program and its implications for 
continuation of the health activities
4. Identify lessons learned, including strengths and weaknesses of the program
 
1 De Souza, Roger-Mark. The Integration Imperative: How to Improve Development Programs by Linking 
Population, Health and Environment. FOCUS on Population, Environment and Security. Woodrow Wilson Center 
for Scholars, June 2009. 
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Background 
SPREAD’s coffee initiatives are built upon 6 successful years of USAID projects PEARL I and II 
(Partnership to Enhance Agriculture in Rwanda through Linkages), which took place from 2000-2006 
and was housed at Michigan State University but with the same Project Director, Tim Schilling. 
Rwanda boasts almost ideal growing conditions for Arabica coffee, the variety which produces 
finer/specialty-grade coffees if cultivated, harvested and processed correctly. Coffee has been the 
country’s leading export and one of the major sources of rural income since its introduction in the early 
1900s, yet prior to 2001, Rwanda was still unknown to specialty coffee importers, roasters and 
consumers, as it was traditionally producing mediocre quality semi-washed Arabica coffee. Due to 
USAID-funded technical assistance, training, and targeted financial support, by 2005, Rwanda had 
become a highly sought-after origin of specialty coffee, and its coffees were being sold through over 30 
renowned specialty coffee roasters and importers in the U.S., Europe and Japan. As a result over 20,000 
Rwandan farmers doubled their incomes and some 2,000 jobs were created with coffee washing 
stations.2 
Rwanda is the most densely population country in Africa, and land holdings average less than 0.5 
hectares per capita. The average number of coffee trees per farmer runs from 150 to 300, compared to 
Central American small-holder farmers who have on average 12,000 trees, or 80 times the productive 
capacity. It is thus more economically viable for these micro farmers to pool their efforts and 
production via cooperatives in order to attempt to meet export market demand, which currently 
exceeds supply. These cooperatives should ideally have quality extension systems set up to organize 
groups of around 1,000 farmers, to reliably extend coffee information, inputs and other services, such 
as processing at coffee washing stations.
In order to ensure the sustainability of PEARL’s services to Rwandan coffee cooperatives as Project 
doors were closing, the Rwandan Small Holder Specialty Coffee Company (RWASHOSCCO) was 
established in 2005 as a farmer-owned marketing, exporting and roasting company that also provides 
key technical assistance and services to small-holder cooperatives. RWASHOSCCO brings together 11 
cooperatives of close to 20,000 farmers owning 19 coffee washing stations throughout the country, and 
also operates Rwanda Roasters based in Kigali which roasts and domestically sells Café de Maraba. 
The company’s shareholders are the cooperatives themselves, who pay an annual fee of 2.5% of their 
gross sales, and all of RWASHOSCCO’s profits are to be distributed back to the farmers. The company 
is currently in the process of re-structuring to ensure greater efficiency and profits. SPREAD’s 4 target 
farmers groups for health interventions are all under RWASHOSCCO.
Directly after PEARL, the SPREAD Project began in 2006 as a development alliance made up of U.S. 
and Rwandan Universities, enterprises and NGOs, focusing on continuing earlier agribusiness efforts, 
including continued support to RWASHOSCCO and target farmer groups. SPREAD also aimed to 
apply its lessons learned to develop other high-value agricultural commodities and also responded to 
USAID’s Request for Applications (RFA), which included a new community health component. 
Although PEARL managers and SPREAD program designers appreciated the value of integrating 
health into agribusiness activities, USAID did not lay out a specific integration strategy in the RFA, 
leaving its implementation up to the winning project to elaborate (personal communication with Tim 
Muzira, prior USAID Rwanda Economic Growth Technical Officer). As SPREAD managers were 
Agribusiness experts with no experience in public health, initial plans envisioned sub-contracting the 
 
2 Chemonics International. Report: Assessing USAID’s Investments in Rwanda’s Coffee Sector; Best Practices and 
Lessons Learned to Consolidate Results and Expand Impact. December 2005.
8 
Health program out entirely to health experts Population Services International (PSI). The health 
program was thus more of an add-on and not in the true spirit of integration where Project goals, 
interventions and M&E are conceptually linked and operationally coordinated in the field (personal 
communication with Heather D’Agnes, PHE Advisor, USAID Washington). Due to sub-contracting 
regulations from PSI headquarters, this partnership never materialized, and after a couple of sporadic 
mobile clinic events in 2007, PHE Advisors conducted a rapid needs assessment and re-designed the 
program in 2008. 
The new program design took into account the broader context of both the seasonal calendar of farmers 
and coffee activities, as well as the assets of existing cooperative structures and extension systems in 
order to take advantage of integrating health and access to these large groups of farmers at all available 
opportunities. Qualified local health staff were then recruited and full implementation of the 
integrated health program began in 2008. After one year of successful execution, the health program 
was also expanded to be integrated into the revitalization of the pyrethrum sector and farming 
cooperatives in the Northern and Western Provinces around the Volcanoes National Park through the 
GDA program with U.S. company SC Johnson and the Rwandan partner SOPYRWA.
The SPREAD Project is a unique example of integrated programming, designed with the PHE approach 
to integrated development in mind. PHE recognizes the linkages between various development areas 
of focus, such as human health and conservation, or in this case livelihoods and community health.
Increased incomes alone are not enough to improve lives and livelihoods. Unmanageably large family 
sizes, preventable illnesses and misuse of family revenue supporting activities like alcohol abuse and 
prostitution can be counterproductive to family health and development—yet at least basically 
addressed through simple behavior change communication (BCC) activities. SPREAD receives around 
$5 million in Economic Growth funds for Agribusiness development, and close to $1 million for Health,
primarily PEPFAR funds for HIV/AIDS prevention (close to 60%), as well as Population/Reproductive 
Health money for Family Planning and Maternal and Child Health funds. SPREAD has also received 
additional funds through the GDA, and close to $2 million in additional support, primarily from 
individuals and companies involved in the U.S. and UK specialty coffee industry. This approach of 
mixing funds across several USAID funding mechanisms is unique within the agency, and there is 
some skepticism regarding whether these smaller wraparound projects are as cost-effective as larger 
single-sector initiatives.
SPREAD’s Integrated Community Health Program 
Rwanda’s national HIV prevalence is 3%, with higher rates among women than men, and in urban 
(7.3%) versus rural areas (2.2%), (2005 Rwanda Demographic and Health Survey). Despite the relatively 
low disease burden compared to the rest of the region, trends of rapid urbanization, alcohol abuse, 
gender-based violence, high-risk sexual behavior and low condom use are significant issues which 
could rapidly escalate Rwanda’s epidemic. Other health priorities include addressing unmet need for 
family planning (36%) and improving maternal, newborn and child health, including increasing uptake 
of timely antenatal care visits and births in health centers, and preventing and treating malaria, 
intestinal parasites and diarrheal disease. 
Early on in the Project, USAID advised SPREAD to fill gaps in community health and outreach, as there 
were several U.S. Government (USG)-funded actors in place already providing clinical support. The 
program was initially conceived based on the assumptions that (1) coffee farmers have increased 
incomes from coffee, thus could feasibly spend more money on family health services, such as health 
insurance (mutuelle) and health commodities; (2) a cooperative’s community engagement structure 
provides a ready mechanism for rapidly disseminating health information and services to rural 
9 
communities; (3) meeting the health needs of farmers helps achieve the overall SPREAD goal of 
improving farmers’ lives and livelihoods in a holistic manner, and could create synergy by increasing 
member buy-in and thus enhance cooperative development and coffee quality. 3 
 
Anecdotal evidence suggests that coffee revenue may often exacerbate family health problems, due to 
cultural/gender norms that men control coffee money, and use it for alcohol and transactional sex 
rather than for family health and nutritional needs. Men also often exhibit reluctance to undergo HIV 
testing, to learn about reproductive health, and to discuss and make joint decisions with their wives
about sex and family planning. Health education and BCC activities were thus seen as a vital 
accompaniment to SPREAD’s income-generating activities, in order to increase knowledge and to 
transform high-risk behaviors to prevent HIV transmission and promote family health.
The overall goal of the Health Program is “to improve health of SPREAD-supported farmers and their 
families by increasing access to education and services for HIV/AIDS prevention, family planning and 
maternal and child health promotion via existing cooperative structures and extension channels, and 
by strengthening linkages to local health care providers.” 
The Health Program was designed based upon the following approach: 4
o Leverage SPREAD’s productive relationships and unique access to rural, income-generating 
populations as a means to rapidly disseminate health information and services
o Integrate activities into SPREAD cooperative development goals, as well as into the existing 
cooperative system of management, extension and coffee activities, in order to achieve synergy 
and conserve resources across programs
o Build strong collaborative partnerships with local government, health institutions and service 
providers for implementation in alignment with local priorities and targets
o Utilize behavior change communication (BCC), information, education and communication 
(IEC) techniques, social marketing of health products and reinforcing linkages to local health 
service providers as primary strategies to improve community health
Rather than re-invent the wheel and create new structures, interventions and materials, SPREAD’s 
health program built on existing local and national resources, such as utilizing training and educational 
materials from the Ministry of Health (MINISANTE), PSI and the International Planned Parenthood 
Federation in Rwanda (ARBEF), promoting PSI Rwanda’s social marketing campaigns, and linking 
farmers to existing community health services. 
SPREAD’s integrated coffee/health program has been implemented since October 2008 and has 
focused on 5 major activities: (1) training and mentoring existing coffee extension agents (Animateurs de 
Café), as well as new Adult and Youth Peer Educators, to promote health- promoting behaviors among 
cooperative members and their families; (2) encouraging uptake of services via referrals to local health 
centers via Animateurs de Café and Adult Peer Educators; (3) facilitating the sales of PSI products Sur
Eau (drinking water purification solution) and Prudence (condoms) via cooperative offices, coffee 
washing stations (CWS) during harvest season, and more recently through community-based 
distribution (CBD) by Animateurs de Café and Adult Peer Educators; (4) coordinating with local health 
centers to conduct mobile VCT and family planning clinics at locations convenient to where farmers 
sell or process coffee cherries during harvest season; and (5) integrating health messages into the 
 
3 USAID Population, Health and Environment (PHE) Fellow Heather D’Agnes. SPREAD Integration 
Recommendation Report, 2007.
4 SPREAD Project Community Health Program Design, FY 09/COP 08. 
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weekly coffee talk-show produced by the National University of Rwanda’s (NUR) Radio Salus, Imbere 
Heza. Other activities include the provision of safe drinking water (Sur Eau, jericans, cups) and hand￾washing equipment (Canacla5, soap and towels) at target CWS and offices, and supporting 2 of the 
target cooperatives to fulfill Fairtrade requirements through provision of First Aid training and 
supplies. SPREAD has also leveraged strengths of local partners towards target coffee farmers, such as 
mobilizing Africare’s mobile cinema to show HIV prevention-related films in Nyamagabe District, and 
facilitating community theater activities for health advocacy with Health Unlimited in Nyaruguru 
District.
 
5 Canacla are portable, low-tech hand-washing equipment which also reduce water consumption
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Methodology
Due to a lack of baseline data, the short time span of the intervention, as well as the resource-intensive 
and complex nature of measuring behavior change and attributing these changes specifically to 
SPREAD, this evaluation employed primarily qualitative methods. Focus groups and in-depth
interviews with various stakeholder groups explored experiences with and opinions of the program
and sustainability, as well as perceived program impact, both positive and negative. A program 
document review was also conducted to include routine monitoring data and budget information in 
order to depict the reach of the various services, and to estimate the cost of the intervention per person.
Data Collection 
The 2 target areas of the evaluation were the ABAHUZAMUGAMBI Cooperative (Maraba Sector, Huye 
District) and BUFCAFE private enterprise (Nyamagabe District), as these farmer groups have been 
involved with the Health Program and receiving health interventions the longest, since the program’s 
initial activities in 2007 followed by its full inception in October 2008. Sampling was purposive, in order 
to gain the perspective of those individuals and groups from both sites who were known to have been 
involved in program activities.6 Certain participants were selected as they had been involved in the 
Health Program from its needs assessment phase onwards, in order to gain the richest feedback. Only 
Youth Peer Educators were not included so as to limit the scope of the discussions, although some 
youth-related recommendations emerged. Recruitment was conducted by SPREAD Project staff in 
collaboration with cooperative/business leadership and health agents. 
The following table illustrates the qualitative data collection plan:
Maraba BUFCAFE Total
Focus Groups (7-11 participants) 4 4 9
Beneficiaries – Men 1 1 2
Beneficiaries – Women 1 1 2
Cooperative Health Agents (CHAs): mixed group of Animateurs de 
Café, Adult Peer Educators, men and women 1 1 2
Community Stakeholders: mixed group of Health Center staff, Sector￾level local authorities 1 1 2
Ministry of Health Community Health Workers: mixed men and 
women from both intervention areas 1/2 FG 1/2 FG 1
In-Depth Interviews 19
Cooperative/Business leaders: President, Executive Secretary, part￾time Health coordinator 3 3 6
SPREAD Staff: Management (2), Health Team (2), Cooperative 
Development (1) and Coffee Program (2) 7
District Officials: HIV/AIDS Coordinator (CDLS), District Health 
Coordinator
1 1 2
Local Health Partners: PSI (2), ARBEF, Huye District Hospital 
(Kabutare) VCT Coordinator 4
SPREAD staff worked with stakeholders on recruitment, training and logistics of data collection. All 
focus groups and interviews, with the exception of those with SPREAD staff, were conducted by 
 
6 Devers, KJ and Frankel, RM. Study Design in Qualitative Research-2: Sampling and Data Collection Strategies. 
Education for Health. 2000; 13 (2):263-271. Accessed Feb 2, 2009. 
http://www.educationforhealth.net/EfHArticleArchive/1357-6283_v13n2s15_713664908.pdf
12
trained field enumerators in Kinyarwanda. Each focus group was conducted by either all-male or all￾female research teams, with the male team conducting the all-male focus groups and the female team 
conducting the all-female focus groups. No audio or video recordings were used due to lack of time for 
transcription and translation, and also to ensure that facilitators and note-takers pay close attention to 
participant responses and take detailed notes. No one involved in program implementation was 
present during data collection to ensure least biased responses, with the exception of the SPREAD staff 
interviews which were conducted by the PHE Fellow in French and English. 
Ethical Considerations
This study used standard consent procedures and participation was voluntary and anonymous. 
Because of the low levels of literacy of many participants, enumerators read consent forms out loud in 
Kinyarwanda and requested verbal or written consent where appropriate. Participants remained free 
to withdraw at any time. They were also informed that everything discussed would be strictly 
confidential and no identifying information would be shared with SPREAD or be included in the 
report. Reimbursement was offered for transport costs, which was stated in advance during informed 
consent procedures.
This study protocol and all evaluation materials, including consent forms, focus group and in-depth 
interview guides, were reviewed by faculty at the National University of Rwanda (NUR) to ensure that 
this study met standards for research with human subjects, and that materials were written at a level 
understandable for an adult population with minimal formal education. 
Analysis
Enumerators expanded focus group and interview notes in Kinyarwanda immediately following data 
collection events, and translated notes into French within one week following data collection. The PHE 
Fellow typed interview notes directly in English during SPREAD staff interviews, and then translated 
French notes into English while entering them into Excel by question or theme. Notes were then
analyzed thematically, by stakeholder group, to determine perceived program impact, lessons learned, 
and recommendations for program improvement and sustainability.
Limitations 
This evaluation includes a few important limitations. First, this small study is limited to only 2 of the 4 
coffee cooperatives/ private enterprises where the Community Health program has been implemented. 
The Health program has also this fiscal year been expanded to be integrated into pyrethrum 
development activities in the Northern and Western Provinces, which has not been included in this 
evaluation. The results can therefore not be generalized to all integrated health program sites.
However, the fact that the program strategy and approach are similar across sites, and that the coffee￾health intervention areas share common cultural/ geographic characteristics, as well as administrative 
and health service provision boundaries, offer some degree of confidence that results may also be 
analogous at least among coffee areas. Assessing the pyrethrum-health sub-program will require an 
additional evaluation upon Project completion in 2011, and baseline data is currently being collected. 
Secondly, this evaluation is a post-test only design; a lack of baseline information limits the ability to 
ascertain true changes over time. Evaluating health outcomes and impacts is regardless impossible at 
this early stage of program implementation, as these changes require several years to take effect. 
Additionally, attributing any changes to SPREAD interventions alone would be extremely difficult, 
given the context of Rwanda’s rapid efforts towards improving health indicators and the multiple 
health interventions occurring in the community from the government, media and other service 
providers. All conclusions described are based on reported and perceived health impacts described by 
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respondents, who often may not be able to differentiate impacts of SPREAD interventions versus those 
of others. However, the inclusion of multiple perspectives concerning program impact strengthens the 
validity of these findings. 
Results
Stakeholder Group: SPREAD Staff Reflections 
Open-ended staff interviews occurred with 2 members of the Management Team, 2 from the Coffee 
program, 1 from Cooperative Development and 2 members of the Health Team. Interviews were held 
either in groups of 2 (with Management and Health Teams) or individually, in order to enable group 
reflection and discussion of the past year and a half of integrated implementation. 
Accomplishments
Overall, Agribusiness and Health program managers feel the health program has been well 
implemented despite pressures to act quickly due to restructuring of the program in Year 2, and agree 
that much has been accomplished since then in a short amount of time. 
Management and Coffee staff also appreciated the Health program’s ability to truly “reach the 
community where they are” with consistent outreach services and education. Health staff cited specific 
accomplishments such as reaching large amounts of people with health messages, program expansion 
to the pyrethrum areas, and efforts to build the foundation for sustainability. As this was the first time 
implementing this kind of program that there was “a lot of good effort and learning involved in 
practice.” 
Staff across programs felt that although it is too soon to judge true program impacts, voluntary 
counseling and HIV testing (VCT) services and increased knowledge of and access to condoms have 
been successful activities. Farmers turning out in large numbers during harvest-time mobile services 
indicated an existing need and demand for such services, and placing them near coffee harvest 
activities saves people’s time, as farmers are able both to conduct their coffee work while accessing 
important health services.
Exposing communities to culturally and traditionally taboo topics of sexuality, condom use and 
reproductive health, especially for youth “who are the future of the country” was also deemed a 
success by SPREAD program managers. The fact that cooperatives are accepting to sell condoms 
through their own structures and channels, and that CHAs are creating community dialogue around 
these subjects, indicates a newfound openness and is thus a significant step.7 
Unexpected Positive Results
Some unexpected positive program results also occurred outside of the stated program targets. One 
group of SPREAD-trained Youth Peer Educators decided to begin their own club to be able to continue 
to animate community theater, dance and soccer games as a way to pass health messages, even after 
the Project is over. Another group of Youth Peer Educators decided to use half of their allotted 
transport costs each month to go towards a revolving microcredit fund within their group. The latter 
group also sought and received a plot of land to grow their own coffee to sell through the cooperative. 
 
7For ease of explaining the results and analysis, both target farmer groups (cooperative and private enterprise) 
will be termed “cooperatives.” and “CHAs,” or Cooperative Health Agents, will refer to the combined group of 
both Adult Peer Educators and Animateurs de Café. 
14
There has also been a decrease in health service referrals by CHAs over the life of the Project. Although 
a decrease in health service referrals could indicate a problem in implementation, CHAs report that 
farmers seek out referrals slips to go to health centers for care less and less, as they have been 
mobilized and educated enough about the existence of local health services to seek care on their own. 
Program Strengths
Both Health and non-Health staff felt the successes mentioned above are attributed to the following 
main program strengths:
1. Peer education approach. Building capacity of farmers (Animateurs de Café and Peer Educators) 
to become Cooperative Health Agents (CHAs) is a powerful strategy for outreach and 
education, as they understand local lives and situations; the community selects them, knows 
them and CHAs are trusted. 
2. Strong support and supervision of CHAs. SPREAD’s Health Program equips CHAs with 
continuous training to improve their knowledge/skills, educational materials and motivational 
items (small transport reimbursements for monthly meetings, bags, umbrellas) CHAs need to 
do their jobs well. Close monitoring through monthly reports and meetings, combined with 
regular field supervision visits to observe educators in action is also instrumental, both for 
program M&E, as well as for motivating CHAs to continue the demanding work that they do.
3. Meeting existing community health needs. Farmers were in need of BCC activities, as 
evidenced by the low initial health knowledge of the target population, positive community 
response, and their increased uptake of existing local health services as the program progressed. 
Changes in uptake of health services is evidenced in the gradual reduction in referrals by CHAs 
over time, as mentioned above. CHAs, also, have been active volunteers and the true drivers of 
the program, expressing their desire to further their own health knowledge and skills and to 
train others within their community. 
4. Integration. Farmers desire both coffee and health information and services, and facilitating 
cooperative leaders and staff to extend and receive both services simultaneously is believed to 
save time and more holistically meets farmers’ needs.
5. Strong program design and leadership. Re-designing the program led to the creation of a 
sound workplan that addressed GOR, USG and farmers’ priorities, and maximized Project 
resources. Bringing on a strong health team led by an experienced health coordinator who could 
work, plan and implement well together was also key to accomplishing as much in a short time. 
Integration and Synergy
As the Health program came a bit later than the Agribusiness activities and was not fully integrated 
from the Project start, in a sense, non-Health coordinators had to also be sensitized as to the importance
of health to their work in agribusiness and encouraged to collaborate and integrate on their own time 
as the Project progressed. Currently, managers and staff across SPREAD programs believe full 
integration would be ideal and cost-effective at both the Project and cooperative/beneficiary level, 
would broaden coordinators’ horizons, enable them to support each other to better meet farmers’ 
needs, and would contribute to overall sustainability of Project activities. Several SPREAD staff 
mentioned that the integrated approach saves time and resources, and reinforces complementary 
rather than conflicting priorities. 
“It’s a great idea, ‘good’ reduces strength. The ultimate goal for increasing incomes is 
improving welfare; cannot improve welfare of someone without any notions on health.” 
(SPREAD Agribusiness Manager) 
15
Another described their appreciation for this unique approach as follows: 
“It is very important to integrate…One thing is clear- everything we are trying to do is make 
individual/family impact. Production and health are two important things, and you can’t have 
one without the other, the two are married…. We used to talk about growing coffee, making 
money, buying material things like bikes, not about problems like malaria, HIV/AIDS, etc. 
Someone could have 5 million Rwf in the house but could suffer from malaria where medicine 
cost 500 Rwf, due to ignorance. You have to teach people about [coffee] production and 
improving lives, you have to also think of their health, as well…It’s important to think about 
both how to improve their livelihoods and how to keep them healthy. That’s the objective and 
that’s what I appreciate so much.” (Agribusiness Manager) 
Program managers felt that there have been some synergistic effects of this integration. Peer Educators, 
who were selected and trained initially for health outreach, have also become slowly integrated into 
coffee activities once cooperative managers understood their value as extension agents. In Maraba 
cooperative, Unités de Production have been developed around CWS in each growing zone, made up of 
local Animateurs, Peer Educators and washing station managers, as a strategy for better organizing the 
over 1200 member farmers in the area. Coffee and Coop Development staff have also capitalized on 
Peer Educators, health meetings and refresher trainings of CHAs to relay information on Fairtrade 
standards, other cooperative issues and local coffee roasting and brewing techniques. 
Contributing to the good health of coop members was seen as an asset for Coffee and Coop 
Development programs, because less time spent on ill family members means more time to spend on 
farms improving coffee quality and quantity, as well as more availability for meetings to deal with 
other cooperative issues. 
“Agribusiness depends on high volumes of quality products from farms and the good health of 
farmers is key to delivering these products on a consistent basis.” (Agribusiness manager)
Integration Challenges
In practice, however, integration has proved challenging according to all staff interviewed. All 
described integration as “very difficult” as it was “never planned from the beginning” and is not well￾reflected in workplans and reporting documents. There is a conflict between aiming to be more 
integrated in the field, yet “having to separate in the reporting stage.” Most staff mentioned time, 
distance and resource constraints as significant challenges to integrated program implementation, 
especially since managers are split across offices in different areas of the country, have few support 
staff, and demanding program objectives to fulfill. The responsibility for striving towards integration 
has thus fallen on the shoulders of Coordinators, primarily the Health Team who is seen as more 
“naturally integrated” in their scope of work, and who also have more dedicated staff and resources. 
An additional challenge to integration is that the Health Program focuses on only a portion of the 
agribusiness cooperatives and private enterprises SPREAD supports throughout the country, which 
complicates workplanning and M&E. 
Efforts over the last couple of years however have contributed to more successful collaboration and 
integration, such as SPREAD planning retreats, joint training activities of extension agents on coffee, 
health and coop development issues, and the organization of youth soccer members to serve as 
mobilization events for both coffee and health. 
16
Perceived Community Impact
Health staff have witnessed significant changes among the CHAs themselves in terms of personal 
hygiene, knowledge increase and positive attitude changes. Some used to come to trainings and 
monthly meetings without shoes, wearing dirty clothes and/or smelling like smoke, and now Health 
staff witness CHAs attending meetings well-dressed and clean. Youth Peer Educators and others used 
to be extremely timid, and are now comfortable asking many questions during trainings and speaking 
freely to a group without having to refer to their health education reference materials. “I am proud of 
them,” says the Health Coordinator, “these changes happening in them gives me the idea that really 
something is happening in the community.”Health staff also cite that demand for condoms is 
increasing in communities, according to youth Peer Educators, also evidenced by the recent stock-outs 
of Prudence condoms at the cooperative level.
Program Weaknesses and Challenges
The first fundamental program weakness of the integrated Health program is timing; as opposed to 
technical assistance for coffee which has spanned close to 10 years, the Health program has only been 
in full implementation for close to 2 years. Although extremely positive about what has been 
accomplished in a short amount of time, program managers and staff feel that the remaining year and a 
half of the Project is not long enough to lay an adequate foundation for sustainability and to enable 
local partners and stakeholders to continue these activities after the Project’s closure.
At the intervention level, Health staff cited issues with the hand-washing equipment at CWS not being 
used or managed properly (frequently out of water or soap), the health “kiosks” (selling Prudence and 
Sur Eau) suffering stock-outs, and keeping up with field supervision as problematic. For this last point, 
targets were set quite high for this year, at 90% of the over 300 CHAs supervised in the field during 
education sessions, which has proved difficult with a small staff of two people, 1 vehicle and other 
program activities occurring simultaneously. A strategy the Health team has come up with is to further 
engage partners who helped train Peer Educators, PSI and ARBEF, to assist in observing these 
educators in the field, which would both keep these organizations more engaged as well as free up 
valuable SPREAD Health staff time. 
Monitoring and evaluation was also mentioned as a weakness across SPREAD. Few resources make it 
difficult to dedicate enough staff time to the Health program and its M&E responsibilities to both USG 
and GOR alone, let alone to measure integrated indicators of success incorporating data from various 
programs. It was suggested that a trained or experienced staff person be in charge of M&E at SPREAD 
full-time, rather than part-time responsibility for all. 
Targeting of Intervention
Several Project managers mentioned the need for USG funding to be more flexible to the needs of target 
groups. People felt that creative solutions to address malnutrition, access to clean water, hygiene and 
reproductive health are bigger concerns among SPREAD-supported farmers than HIV prevention, the 
majority of SPREAD’s health funding. Strict prescriptions on use of funds within USAID maternal and 
child health funding mechanisms also impose barriers to truly addressing farmers’ needs, particularly 
restrictions on infrastructure developments which could allow access to clean water and sanitation, and 
assistance for home gardens which could improve household nutrition.
Other BCC areas which need to be addressed in order to fulfill Project goals of improving the lives and 
livelihoods of Rwandan farmers include: education and life skills to improve savings, money and 
resource management, gender equity, and issues related to alcohol and malnutrition within the 
household. At times coffee revenue will be spent all at once, on alcohol by men, for example, or 
17
splurged on a large portion of meat, rather than partially saved and planned to spread benefits over 
time on a variety of household needs. 
Program managers and outreach staff feel that farmers could benefit also from learning how to initiate 
other small income-generating activities (bee-keeping, raising chickens or silkworms, making 
handicrafts) to gain revenue outside of coffee season, which provides income only once per year. One 
program manager also emphasized empowerment as a key component to ensure success of any of the 
above activities; helping people to not only have the requisite technical knowledge and skills for 
income-generating activities, but also feel empowered to solve their own problems.
Sustainability
Although there are some positive signs indicating cooperatives’ and partners’ appreciation for 
continuing health activities, in general staff were not very confident that at this point activities could 
continue after SPREAD’s completion. This is largely due to the instability of most cooperatives to even 
maintain themselves as functioning businesses, the newness of health interventions combined with the 
required resources and technical capacity to sustain them, as well as uncertainty around the 
government’s financial capacity and willingness to support such activities among numerous other 
competing priorities. 
One program manager who has worked with cooperatives for several years characterizes the situation 
of helping cooperatives become capable of contributing to health and social services as bleak:
“I see a sense of responsibility of government- who tends to think more at the macro rather 
than the individual level- and coops…local government is also supposed to be involved. Things 
don’t always go as they are supposed to go. We always push coops to do the work they are 
supposed to do. The engine that turns everything is outside coops right now, we are trying to 
shift it. I am not very confident.” (Agribusiness manager)
Another Coordinator felt that the most cooperatives could currently handle in regards to providing 
health benefits for their member farmers would be the payment of the mutuelle, or annual health 
insurance, which some are already paying for member farmers and their families. 
One manager mentioned that ideally, RWASHOSCCO, as umbrella organization for all target 
cooperatives, would take on supervision of health and agribusiness support activities. Given the 
current stage and priorities of RWASHOSCCO’s business restructuring, however, their capacity to 
assume additional tasks at this point in time is unlikely. It could be a possibility for the future, 
however, as a strategic plan is in the process of being laid out which would include a roadmap for the 
inclusion of community health and development activities. 
If existing program activities were to be sustained and expanded to those mentioned above, program 
managers agree it will depend upon shared cooperation and responsibility among all partners. 
Cooperatives must be in charge of coordinating continuing health education of their members, and 
allot specific funds for health from their own operations. Fairtrade-certified operations could use those 
funds stipulated for community development activities. Cooperatives must also build upon 
partnerships with government and NGO service providers, namely Districts, health centers, Sector￾level authorities and local NGOs like PSI and ARBEF who already have established relationships with 
beneficiaries. Health centers could perhaps continue to provide VCT and other mobile services to 
farmer groups, for example, utilizing cooperative structures for mobilization, whether or not these 
occurred during harvest time. Currently some health centers are using SPREAD-initiated sites for 
18
mobile services during government outreach campaigns, after witnessing the large community turnout. 
ARBEF and PSI could similarly utilize their access to and experience with CHAs to continue to work 
with cooperative youth and adults in cooperatives on BCC activities. Theater groups and soccer teams 
which are currently being formulated among youth and adults were also considered possibly self￾sustaining after the Project ends, as their services are already highly valued and will likely be utilized 
by the local community. 
Many program managers and staff felt that an additional round of donor funding would also be useful 
to strengthen existing initiatives and partnerships, given the short time frame of integrated health 
implementation of integrated health interventions. These funds could either formulate a new Project or 
somehow be funneled through and managed by RWASHOSCCO. 
Despite the aforementioned challenges, staff across programs recommended spending the remaining 
year and a half of the Project building capacity of cooperative staff to take over coordination and 
monitoring of health activities and strengthening their existing relationships with local health and 
social service providers, both government and NGO. It was recommended that SPREAD’s Health 
program first share reports with cooperatives and local partners to demonstrate the added value and 
successes of health activities. They then would facilitate collaboration between stakeholders in 
planning, implementation and follow-up, in preparation for when Project resources are no longer 
available. 
Lessons Learned
Certain program managers felt that there was potential and interest among local partners to integrate 
community health into other agribusiness initiatives, such as with tea cooperatives in Nyamagabe 
District. When asked what kinds of lessons or best practices from their experience working with 
cooperatives and private enterprises they would share with others in Rwanda or elsewhere interested 
in integrating Health into Agribusiness, the following recommendations emerged:
1. Support strong cooperatives. Program managers described the foundation for successful 
integration of health activities into agribusiness structures is to help build and support a strong 
cooperative in regards to ownership, leadership, engagement and accountability. Maraba 
Cooperative is a case in point: 
Maraba is an example where the cooperative was created out of the will of the local population, not 
by government or other external forces, as was the case with the formulation of many cooperatives 
throughout Rwanda in the late 1990s. After almost failing in 2006, subsequent restructuring and 
new leadership, Maraba has become a model cooperative across many fronts. The cooperative has 
kept consistent relationships with foreign buyers, sought and maintained Fairtrade certification for 
several years, and made profits enough to pay off all short-term bank loans, as well as provide the 
mutuelle for its member farmers- all considerable accomplishments. Today, Maraba exhibits a solid 
organizational structure, effective extension systems for reaching its over 1200 members, and 
“permeable” leadership, where members take more of an active role in decision-making and 
demand accountability of those in charge. A key to Maraba’s success is attributed to its strong 
Executive Secretary who is dedicated, capable and well-compensated, and who is engaged in 
planning, implementation and follow-up of all cooperative activities, including SPREAD-supported 
health interventions. 
19
2. Facilitate and encourage cooperative ownership. Program managers recommend spending time 
helping cooperative members and leaders to take responsibility for all cooperative activities 
themselves, and the health program is no exception. This is easier to do when the cooperative itself 
was born of a grassroots nature, rather than created by external forces, yet consistent member 
education and outreach is required to help farmers understand their rights and responsibilities as 
coop members. 
3. Understand differences between private enterprises and cooperatives. In the SPREAD experience, 
working with a cooperative, such as Maraba, was quite different than with another large target 
group, BUFCAFE, which is a privately run enterprise that purchases coffee from several local 
associations and cooperatives. Decisions tend to be more democratic in the cooperative setting, and 
generally facilitated health activities. For example, condom sales via BUFCAFE have been slow to 
start, due to the resistance and religious beliefs of the single owner and ultimate decision-maker; 
whereas in Maraba the decision to sell condoms was taken as a group and sales began immediately. 
4. Identify someone within the cooperative to coordinate and advocate for health activities, yet still 
engage all key people appropriately, such as Board members, managers and extension agents. 
The coop Health Coordinator can do this as a part-time position, while maintaining other 
cooperative duties which will increase chances of the sustainability of a health coordination role. 
Health coordinators among SPREAD target coops include washing station managers and 
accountants. It is also necessary to engage other coop leaders and key staff. Currently there are 
additional people involved in managing stocks of health products, in making up a First Aid 
Committee, and acting as coffee-health extension agents for example. Executive Secretaries and 
Board members are also involved in community mobilization activities and in monitoring and 
supervision. As mentioned above, a strong Executive Secretary can be instrumental to the success 
of health interventions by raising morale of CHAs, supporting their work, asking for reports and 
integrating health into the cooperative structure for better chances of sustainability. 
5. Work with authorities and partners at all levels to ensure success of community-based activities.
It is essential to consult and plan together with all partners (government and NGO service 
providers) and stakeholders, cooperatives and local authorities to determine the program activities, 
M&E and sustainability strategies early on. 
6. Be aware that cooperatives are dynamic. “They are changing all the time, it’s very challenging—
you can never predict these guys,” says one manager. It is important to work consistently close to 
target cooperatives, to be aware of what is happening in the broader context of the agribusiness, to 
institutionalize consistent monitoring, follow-up and capacity-building with an eye towards 
sustainability throughout the process. The Health team also advised that it be established up front 
on what would happen should the cooperative fail or be suspended for a period of time. Would 
health activities continue and if so, on what terms? 
Nyakizu cooperative is an example where mismanagement and theft of cooperative funds forced 
the organization to dissolve for a time, SPREAD agribusiness teams to relinquish support, and by 
consequence, SPREAD Health activities came to a halt. This was disappointing due to the dynamic 
nature of the trained coffee/health extension agents and their avid interest to continue working. 
SPREAD plans to assess the feasibility of restarting health activities with Nyakizu in FY11, pending 
their cooperative status after this year’s coffee season.
20
Stakeholder Group: Cooperative Leaders 
Three representatives from each target farmer group were interviewed, consisting of managers, health 
coordinators and the President of Maraba cooperative and owner of BUFCAFE.
Perceived Impact of Health Activities
All 6 cooperative leaders interviewed described active participation in SPREAD’s various health 
activities and spoke favorably of the effects of the health program on target farmers. Positive hygiene 
and sanitation behavior changes were cited across almost all cooperative leader interviews as a 
perceptible impact made on the community, specifically improvements at the household level and 
purchase/use of Sur Eau to treat drinking water. Coop leaders also cited positive behavior and attitude 
changes for reducing HIV/AIDS transmission, especially around condom use and people receiving 
VCT, which they believed helps farmers know their status as well as adopt safer behaviors. Several also 
described people’s increased understanding of family planning and its benefits. Increased uptake of 
health services was also cited by most of cooperative leaders interviewed as a program outcome, 
evidenced by large numbers of people accessing VCT and FP mobile services during harvest season 
and the increasing sales of condoms at the cooperative level. 
Another perceived and positive impact was that time was also thought to be more available for 
investment in coffee activities. Farmers’ lives in general are believed to have improved from these 
outreach activities, as well as their financial situations, demonstrated by improved clothing and more 
children attending primary and secondary school. Other impacts cited include improvements related to 
household harmony especially around gender balance and resource utilization. One cooperative 
manager stated: 
“SPREAD’s Health program has had a significant impact on health and improvement of the
quality of life in general. The population no longer comes to us to seek emergency loans; the 
disagreements/ conflicts within families have reduced. There was a time when we gave a loan 
to a household, and the next day, a member of the same household would come and complain 
that the money was misused. Women now play a role in deciding how family resources/money 
is spent.” (Cooperative manager)
Cooperative leaders themselves also explained their personal benefit gained through the Health 
program. They themselves learned about their community’s health, and gained capacity to train others 
on hygiene, condom use, family planning and VCT. One cooperative manager claimed: “Now we 
understand that there are health problems in the population, we didn’t understand that before.”
Although all segments of the coffee farming population and their families are said to be impacted by 
Health program interventions, women and youth were cited several times as having received special 
benefits; women in particular for receiving education and services for family planning, antenatal care 
and VCT, which affect the whole household. 
“A large number of women are clients of FP, which helps the entire family…when there is a 
climate of sharing and peace in the household, the children are in good health, it is the women 
who benefit most and the entire family progresses.” (Cooperative leader)
Youth were also specifically mentioned as “they know in advance how to protect themselves against 
AIDS and what FP measures to take once they are married.” A couple of people (both men) mentioned 
that men were also affected by the program, becoming more involved in family and reproductive 
health issues some even having become community-based condom distributors (CHAs).
21
Program Strengths
Several coop leaders also lauded the Peer Education approach, which educated CHAs, who are farmers 
themselves, significantly and to the point where they are able to train their peers to improve their own 
health and prevent certain illnesses. One specifically appreciated the fact that CHAs also do home visits 
which greatly contributes to the participation of the community in health activities. In general, Peer 
Education was seen as a powerful strategy for getting key messages across:
“The fact that it's farmers speaking with and educating their neighbors means that the message 
is well-taken; they understand one another's problems…the idea is great, very relevant. The 
major reason is that the CHAs live with the population; they were used to sensitizing on coffee, 
but now they integrate topics of health promotion, water and sanitation, all during the same 
meetings that used to be held on coffee.” (Coop leader)
Cooperative managers also appreciated the Health program’s rigorous M&E of health activities. 
Monthly reports and field supervision visits help establish that the messages are truly reaching farmers 
and their families, and cooperative engagement in these activities brings leadership closer to the 
population and their member farmers.
Barriers to Services
A couple of coop leaders cited men as barriers to reproductive health improvements; specifically 
related to condom use as a family planning method for married couples, and a persistent lack of male 
understanding of the importance of family planning and a reluctance to become involved. Sharing 
money management authority between husband and wife was also viewed as problematic, as there 
“are always men who believe their wives have gained the upper hand in managing the household,” 
thus have difficulties accepting shared decision-making.
Some couples felt that mobile VCT activities during harvest could have reached more adults, but that 
often farmers will send their children to sell cherries if quantities are small for that day. Despite 
increases in numbers of people tested, fear is still believed to be an obstacle for many to get tested. 
Integration of Health and Coffee Activities
All cooperative leaders interviewed very much support the integration of health outreach into coffee 
and cooperative activities, with one manager saying: “the program designers had a long vision￾improved health of producers means better coffee production.” The overwhelming majority cited the 
hefty inputs of time and energy required to produce both high quality and large quantities of coffee 
that would be impossible to dedicate if a farmer is sick or caring for an ill family member, or for too 
many children. Time of farmers is also saved when health, coffee and cooperative development 
outreach extension occurs simultaneously, which cooperative leaders feel is easy to do through CHAs, 
who “are like the motors of the community,” serving many purposes at once.
Several cooperative leaders also mentioned a synergistic effect, and that carrying out activities that 
support coffee production as well as health promotion helps achieve “a greater impact” on the family 
and the producer. One business leader reflected on his several years of organizing coffee farmers, prior 
to his involvement with SPREAD, and saw himself as being preoccupied with production during that 
time, yet not achieving expected gains due to existing health issues unbeknownst to him: 
“…At the end of the day, I didn’t realize that I wasn’t attaining a palpable impact because I was 
forgetting the important element; the health of the farmers.” (Cooperative leader)
22
A couple of coop leaders also talked about the importance of family planning so that coffee revenue can 
satisfy the needs of the farmer’s family. One concluded: “the planning of births in the household 
should be coupled with [the amount of coffee] production.” 
About half of cooperative leaders interviewed also mentioned improvements in members’ buy-in or 
engagement in cooperative activities due to the additional health services they now receive. There is 
increased attendance at general assembly meetings at the cooperative, and more selling of cherries to 
their member cooperatives’ washing stations.
Suggestions
One coop leader mentioned it would have been good to have the Project plan laid out to stakeholders 
before beginning, so that producers, cooperative leaders and other partners could have included other 
priorities. About half of cooperative leaders interviewed also stated capacity building of CHAs as a key 
priority, in terms of training and gradually increasing their responsibility in health. Additional 
thoughts were to increase education sessions and trainings for farmers, to organize soccer games and 
youth-specific activities, and to work on sensitizing men about the importance of family planning.
Advice for others interested in integrating community health and coffee
When asked to share lessons learned through this process of integration with others interested in 
integrating agribusiness/coffee activities and community health cooperative leaders wholeheartedly 
recommended it, citing health benefits for the entire household, the synergistic effects, and the 
complete feasibility if activities are well-planned. One person also mentioned these health activities 
have also strengthened relationships with local government officials and service providers.
“I learned that the entire household is who benefits. Without this approach, there would be 
things that they would have gained [income] but that they would not achieve [longer term 
benefits]…If someone else were to ask my advice on integrating health activities into those 
promoting coffee production, I would discuss the health improvements of the farmers and the 
positive results of this approach. I would advise him to increase basic health knowledge of 
producers on matters of basic health because when a farmer is healthy, this has direct impact on 
his agricultural production. I would tell him also that coffee extension agents can easily play the 
role of community health educator as well.” (Cooperative leader)
“The big lesson I learned is that you cannot achieve your coffee production objectives at 100% 
without addressing the health of the farmers.” (Cooperative leader)
“The first lesson is that anything is possible if it is well-planned, and that these health activities 
are not too expensive…Advice I would give is to not be afraid of integrating a health program 
into the coffee work. This health program [also] reinforces existing relationships between 
producers and buyers because producers understand that what unites you to the buyers is not 
simply money for coffee, but also health and human relationships which allow you to stay in 
contact with the coffee producers for a long time. So, it ensures the durability of actions 
undertaken. Also, these activities help us approach/become closer to local authorities.” 
(Coop leader)
Additional needs of target farmers
Several of the cooperative leaders identified farmers’ need for more financial means to have a better 
life. They suggested increased incomes could result from higher coffee prices or other non-coffee 
activities. Several cooperative leaders raised the issue of coffee revenue spending on alcohol, and 
23
emphasized the need for awareness-raising, education and capacity-building on how to manage, spend 
and save coffee revenue to ensure success of any income-generating activities:
“…we have some farmers that will make over 100,000 Rwf at one time during coffee season. 
They will then sit and drink beer every day and after one month, this same person will come to 
the cooperative and ask for a loan.” (Cooperative manager)
Several cooperative leaders mentioned the need for improved nutrition through education, (“as certain 
households drink beer more than eat well,”) as well as support to maintain small livestock and 
vegetable gardens at home. A couple of those interviewed also mentioned insecticide-treated bed nets 
(ITNs) for malaria prevention as an additional need of farmers.
Sustainability: Life after SPREAD
In discussions regarding SPREAD’s closure in 2011, about half of cooperative leaders interviewed were 
hopeful that certain health activities will continue, although perhaps not to the same degree of quality 
or frequency as when SPREAD was involved. 
“The coop members and coffee farmers have learned things which they can pass on to other 
community members. Even if some members will feel unmotivated, abandoned, the 
coops/businesses supported by existing community health services will maintain certain 
important health activities begun by the Project.” 
A couple of cooperative leaders were more dire about outcomes post-Project, predicting decreases in 
health knowledge and education and, as a result, negative impacts on coffee. 
Sustainability was widely believed to hinge on support from government health centers and NGO 
service providers, who already provide similar outreach services and who could target these particular 
farmer groups. Cooperatives themselves should ensure an independently functioning health program, 
with its own budget, and health centers could lend support for technical expertise and coordination. 
Cooperative leaders need SPREAD’s support to evaluate current strengths and weaknesses of 
cooperatives’ ability to sustain activities, and to appropriately build capacity of staff of coops and 
CHAs before the Project’s closure in 2011. One person even recommended that members of the Health 
program return post-project to follow up on the cooperative’s progress after a certain period of time, to 
confirm the durability, or lack thereof, of SPREAD’s Health interventions.
The first step taken towards sustainability thus far, according to cooperative leaders interviewed, is the 
current integration of health activities into routine coffee work. The fact that CHAs are actively raising 
awareness and providing reports to coop managers, and that the coops have in place a part-time health 
coordinator, are seen as solid steps towards institutionalizing the program for both groups. “There is a 
sense of ownership,” one person said, “because before doing other things in the cooperative, we begin 
by talking about health.” Both cooperatives also already pay some or all of the mutuelle, annually 
renewed health insurance, of farmer members.
Although generally speaking, these leaders were hopeful about the continuation of activities, a 
common sticking point remains financing. Several mentioned the need for additional funds post￾Project to cover costs of logistics, materials and equipment for further trainings, increasing the stock of 
Prudence and Sur Eau to stock kiosks, as well as fuel costs and transport for outreach and supervision. 
The source of these funds after SPREAD, however, was not completely addressed. Only one manager 
felt that health activities are not prohibitively expensive, and that the cooperative itself could 
24
financially support health activities. He suggested using Fairtrade funds allocated for community 
development, and potentially through small contributions by member farmers. 
Stakeholder Group: Community Health Workers - Agents de Santé Communautaire (ASCs) 
This one focus group encompassed both male and female government community health workers 
(ASCs) who live and work in both target Districts where SPREAD intervenes. 
Familiarity and Collaboration with SPREAD’s CHAs
The majority of ASCs were familiar with SPREAD’s health interventions in the community, and 
mentioned collaborating with CHAs on certain raising awareness activities, such as for hygiene and 
VCT. Only a couple of people in the focus group had not heard of SPREAD’s Health program, which 
may be because these ASCs work in a Sector in which the SPREAD-supported CHAs do not.
“Yes we know the program…it works with coffee farmers; they have a health program which 
sensitizes using community health workers who work like us through the coops.” (ASC)
“We have worked together with SPREAD’s CHAs on raising awareness of the population on 
clean drinking water and VCT.” (ASC)
The ASCs felt that their work and that of SPREAD’s CHAs is similar, that they both work on health 
promotion and complement rather than compete with one another in the community. The main 
difference cited was that CHAs work with coffee farmers, whereas ASCs are under health centers’ 
direction and thus work with the entire local population.
“We complement each other- our work and that of the CHAs.” (ASCs)
“I know SPREAD’s Health program helps us with health promotion, and actively participates to 
implement national health policy.” (ASC)
The ASCs seemed to appreciate SPH very much, for its holistic approach to meeting farmers’ diverse 
needs, and especially for its VCT activities and education on HIV/AIDS prevention, family planning, 
and hygiene. They also appreciated that the program is “very close its beneficiaries, more so than other 
programs” they had seen, and seemed to envy the support, supervision and materials SPH provides to 
CHAs for health outreach. ASCs also appreciated SPREAD’s integrated approach:
“Combining health with cooperative activities is a good idea, because SPREAD is looking at 
saving the entire person and his/her family.” (ASC)
Suggestions to program managers for improvement include more engagement of youth, such as 
through games or other creative strategies to deliver messages. 
Overall, the ASCs value SPREAD’s services, and said they would like to see the Project, or at least its 
current activities across health and coffee, continue. However, ASCs also recommended SPREAD 
expand its scope to target the entire local population, not just coffee farmers, by training CHAs to 
intervene in each cell, and allow local health authorities to take responsibility for trainings, which 
would be an expansion of MINISANTE’s strategy. They also requested SPREAD teach them local 
roasting and brewing techniques, in order for ASCs to also be able to drink their own coffee at home at 
lower cost than purchasing at the market.
25
SPREAD-supported Cooperative Health Agents (CHAs) 
These 2 focus groups were held by target farmer group, 1 for BUFCAFE and 1 for Maraba Cooperative. 
Each group was a mix of men, women, Adult Peer Educators and Animateurs de Café. 
Targeting of Intervention
CHAs felt that the community responds well to all health topics and activities, but especially those 
related to family planning, HIV prevention and hygiene. In regards to the most important health topics, 
CHAs felt that hygiene and sanitation education was of utmost importance, but overall that all topics 
concerning family planning, reproductive health, HIV/AIDS and nutrition are necessary and valued by 
the community. Malaria interventions were at times considered less important in areas with lower 
prevalence, although it was mentioned that malaria prevention and education should continue.
Barriers to success of behavior change efforts included low use of Sur Eau because it has a “bad smell,” 
convincing people to purchase condoms when they are available for free via other service providers 
(health centers, some local NGOs), and mobilizing youth participation in adult education sessions. 
Perceived Program Impact
CHAs felt there have only been positive health effects across all segments of the target population, and 
spoke very highly of the program’s impact, listing improvements across almost all health areas. 
However, as mentioned in the study limitations, it is virtually impossible to attribute all of these 
community changes to SPREAD’s interventions alone, given the multitude of other health outreach 
activities occurring in the communities from both government and NGOs. 
According to CHAs, condom use has been increasingly normalized; the belief that condoms are only 
used by prostitutes is changing, and youth are practicing less unprotected sex. Stigma around 
HIV/AIDS is decreasing and understanding and acceptance of family planning is on the rise, especially 
benefiting women. Personal hygiene is improving. Gender impacts include couples making joint 
decisions on how to spend family revenue and initiating family planning. Men are reducing harmful 
behaviors of forcing women in sexual relations or “causing insecurity” in their families.
“There has been a positive impact; before, people used to think condoms were only for 
prostitutes. Now people know how to use them and realize that they are important for 
preventing HIV and for family planning.” (CHA)
 
“Hygiene is gaining ground in households…people wash themselves, use Sur Eau or boil their
water before drinking, they have built latrines and wear shoes even in the field.” (CHA)
CHAs perceive changes across all of SPREAD’s target health areas. People have a better understanding 
of family planning methods and side effects, and men are also increasingly involved in reproductive 
health education and accepting of contraception. HIV/AIDS prevention changes include reduced 
stigma, acceptance to openly get tested, take ARVs, and to buy and use condoms. Related to hygiene, 
farmers are more likely to practice personal hygiene, practice safe water treatment and good hygiene 
and sanitation in households. Maternal and child health changes include increased births in health 
centers, better nutrition, growth monitoring, vaccination rates, and treatments for parasites and 
reduced micronutrient deficiencies in children.
“People now understand that family planning does cause fatal side effects.” (CHA)
26
“Positive impact regarding HIV/AIDS; people are now longer afraid to get tested. AIDS used to 
be confused with a poison, now people living with HIV/AIDS are more comfortable to live 
their lives.” (CHAs) 
“Men are now sensitive to the problems of overpopulation and come together with their wives 
to plan births together.” (CHA)
CHAs and their households have also personally benefited greatly from SPREAD’s interventions, both 
through producing higher quality coffee and “having a better life.” In regards to health specifically, 
CHAs affirm increased health knowledge, learning to give a balanced diet to their own children, to 
practice good hygiene, to use condoms and family planning themselves, and to have overcome 
embarrassment in order to train others on sexual and reproductive health. One woman described the 
Health program’s impact on her own sexual relationship with her husband, saying she gained courage 
to discuss matters with him and now sex is consensual, no longer solely driven by her husband. 
CHAs expressed such a remarkable difference in their lives and those of their peers since SPREAD’s 
integrated Health Program, that they were considerably worried about losing support services at the 
Project’s completion, especially related to loss of training, supplies to continue education sessions and 
adequate stocks of Sur Eau and Prudence for community-based distribution.
Complementing Local Public Health Services
When asked regarding their relationship with MINISANTE – supported ASCs in their area, CHAs also 
feel that both groups have similar goals and responsibilities to educate communities on various health 
topics. CHAs also described differences that ASCs give medicines, whereas CHAs do not; that CHAs 
have materials to use during education session (condom demonstration equipment, brochures, flip 
books) which helps people better understand messages, which ASCs do not. They also recognize that 
ASCs report to health centers, while CHAs give reports to SPREAD and to their cooperative, and that 
CHAs also do coffee and cooperative extension in addition to health. Overall, CHAs seem to think they 
work well with ASCs in their communities; they complement one another’s work and collaborate on 
raising awareness sessions or on special community projects, such as helping the indigent: 
“In our zone, there was a woman who was very poor, she didn’t even have a toilet. We got 
together with the ASC and we decided to build her a latrine.” (CHA)
“We hold consultation meetings so that our activities don’t diverge, but that they complement 
each other. This also avoids the problem of rivalry.” (CHA)
Integration
CHAs greatly support the concept of integrating health and coffee/agribusiness, as they feel that good 
health and wealth go hand in hand, increasing revenue has positive effects on the health of the farmers, 
and without being healthy, one cannot perform all the intensive labor required for high-quality coffee 
production. They described their activities as integrated in practice, explaining how they take 
advantage of cooperative meetings, home and field visits to discuss both coffee and health.
“When I go in the field to sensitize on coffee promotion, I can’t leave without speaking a bit 
about health.” (CHA)
CHAs felt that farmers are also always interested in learning more about coffee which equals revenue, 
thus attend meetings called by Animateurs de Café who hold the most up-to-date coffee and cooperative 
27
information. Coffee is thus an appropriate entry point for discussing health; one CHA mentioned that 
he prefers to begin a meeting with health content and end with coffee, to ensure participants who may 
be likely to leave during the health portion stay and listen to the entire session.
Sustainability: Life after SPREAD
CHAs are committed to continuing their mobilization of the community around health, and would like 
this program to continue even after SPREAD’s closure. To do this, they suggested a variety of 
strategies: the government continue Health program activities, with local authorities helping to train 
more CHAs; cooperatives take responsibility for integrating the health program into routine coop 
activities; that CHAs create a new cooperative in order to continue their activities, and that generally 
speaking the “decision-makers at every level should integrate SPREAD’s Health Program in their 
action plans each year so that once SPREAD is over, the activities can continue.” CHAs felt that the 
current formulation of community theater groups and the soccer teams and tournaments which are 
currently being organized, as well as the integrated coffee/health awareness-raising they have been 
conducting over the past year and a half are all positive steps taken towards sustainability.
Suggestions
CHAs suggested that the health products they sell for the cooperative (Sur Eau, Prudence) be given in 
larger quantities to the CHAs themselves, rather than kept at the coops, to increase community access. 
Those who had not yet been trained also asked to be equipped with First Aid equipment and training 
to help prepare for accidents in the field. CHAs requested more health and coffee trainings, to enable 
them to better work with farmers, and to receive either means of transportation or higher transport 
reimbursements to cover their actual costs to attend monthly meetings and conduct outreach work. 
CHAs also support diversifying teaching strategies to increase community interest and knowledge, 
such as using films or community theater techniques. Youth anti-AIDS clubs need to be reinforced, 
and SPREAD should also consider distributing condoms for free, similar to some other local NGOs and 
health centers. They also advised the Health program to work more closely with Sector-level 
authorities to ensure more seamless collaboration and cooperation. 
Stakeholder Group: Local Partners: Health Centers, NGOs, Sector and District Officials 
Two focus groups were held per District, with a mix of both Sector-level authorities and Health Center 
staff. In-depth semi-structured interviews were also held with District-level officials and partners, from 
both government and NGOs. 
Collaboration and Interaction with SPREAD
Almost all local authorities and health centers, and certainly both NGOs, were aware of several of the 
Health Program’s activities and have worked well together, citing excellent collaboration in planning 
and implementation. Health centers and District partners appreciate SPREAD’s community health 
approach and their contribution to helping them meet their own goals and targets through support 
with awareness-raising, as well as getting services out to hard-to-reach communities by facilitating 
mobile VCT and FP services, which are District Health priorities. 
“The fact that SPREAD uses a community health approach enables us to work with populations 
who were previously difficult to reach…We’ve collaborated with SPREAD on mobile VCT, 
coordination meetings with CDLS, planning meetings for our activities. Over the past couple of 
years, our collaboration has been excellent, SPH honors its engagements, we collaborate on VCT 
and its supervision, SPH also takes care of the nurses and pays their per diem during this 
activity.” (District Official)
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“Reaching the population in their own communities where they live as a strategy is a major 
asset for increasing indicators.” (District Hospital)
Government authorities also appreciated SPREAD’s flexibility in supporting local priorities outside of 
SPH-specific workplans, such as the training of family planning clubs in one area.
“Health partners are usually at the national level, when you have a local partner with whom 
you can plan together, who will support you at any time, this is very advantageous.” (District 
Hospital) 
NGO partners also described advantages enhancing their own services they have gained through SPH 
collaboration, such as access to local authorities and to the rural coffee farming population: 
“We work in the same intervention zone, so we profited from SPREAD’s access to the 
population to fulfill my targets, also to take advantage of access to people to sell products, I had 
an interest in this collaboration; I was also aired on their radio program, which allowed me to
do promotion of our own Center…I was lucky to contact and work with local Sector officials 
and health centers through SPH, because our zone was too big so getting to know all local 
authorities is difficult. SPH’s cooperative contacts also helped us select our own group of out￾of-school Peer Educators in rural areas with whom we continue to work today.” (Local NGO)
Another NGO described application of lessons learned through SPH collaboration regarding 
monitoring and supervision of community health agents. District officials are also interested in 
applying this approach of integrating health into agribusiness initiatives in their area:
“SPREAD’s Health program has changed the behaviors of coffee farmers in regards to health 
and their quality of life has improved. We don’t do anything differently currently, but we are 
planning on how to integrate the health program in different cooperatives and associations. 
Once we have a proposal for a health project we will propose that they also integrate into other 
activities as SPREAD has done.” (District official)
Only a few of the local Sector authorities expressed discontent regarding collaboration, feeling 
excluded from SPREAD’s planning and unhappy at the lack of Sector-specific reports, which led to 
some difficulty in responding to certain focus group questions. The Health program did in fact 
implicate Sector-level authorities in workplanning and implemented activities, and suspect the high 
turnover of local officials in rural areas and the multitude of projects going on in their zone created 
challenges in relaying information about current projects to new officials. Certain health centers and 
Sector officials did express a lack of understanding regarding SPREAD’s activities (that they go beyond 
coffee season and mobile services, why the limited scope of a few health facilities and not the entire 
District), indicating a need for better communication and reporting at the Sector and Health Center 
level. SPREAD recognizes that Sector and Health Center reports are rarely done, due to the high 
volume of reporting requirements at District and national levels and limited program staff and 
resources. Subsequent meetings with officials have led to the agreement that Health program will email 
Sector-level reports from now on, as most administrators now have some internet access. 
Perceived Program Impact
Although partners reiterated that it is too early to ascertain the impact of SPREAD’s Health 
interventions, and it is difficult to parse out SPREAD’s contribution versus that of other health service 
providers, many partners said they have noticed positive behavior changes in the community as a 
29
result of SPREAD, specifically in regards to family planning, openness in discussing reproductive 
health issues, VCT uptake, condom use and hygiene. Specific behaviors observed included women 
returning to health centers to discuss side effects of contraception, rather than abandoning completely; 
couples discussing family planning together and making a decisions together and, relatedly, women no 
longer having to seek FP counseling in secret. Hygiene has improved, whereby people wash 
themselves after working in their fields more frequently and after going to the toilet. VCT mobile 
services have encouraged more people to overcome fear and to get tested.
Appreciation of SPREAD’s Approach
District officials appreciate SPREAD’s approach of using peer farmers, which “facilitates good 
understanding,” and the community-based nature of activities which make services more available to 
the population at the community level. An NGO partner felt the program was well-designed in terms 
of its alignment with GOR priorities, such as a focus on youth, as well as leveraging interventions 
going on in their zone, such as PSI’s social marketing campaigns and products.
Health partners also appreciate the holistic and integrated approach of addressing people’s multiple 
needs of improved incomes/ livelihoods and health.
“The quality of life of people has improved thanks to this program, because if farmers are 
healthy, they are able to do their coffee activities no problem which increases their income.” 
(District official)
“The best way to battle HIV/AIDS is to give youth something to do, which SPREAD is 
doing.”(NGO) 
Other benefits to integration include that coffee was also seen as a “center of interest,” thus an effective 
entry point to discuss health. Additionally, targeting cooperative members makes access, monitoring 
and follow-up much simpler. These farmers should technically have some increased revenue from 
coffee, also viewed as an asset for health promotion.
 
Filling Gaps in Community Health
Partners spoke similarly to other stakeholder groups in regards to the similarities and differences 
between CHAs and ASCs. Their work is similar as both groups raise awareness about health, and the 
main differences are that CHAs work more specifically with coffee farmers rather than the general 
population, and that they report to different coordinators, either SPREAD or Health Centers.
Health partners felt that SPREAD’s Health Program is complementing the work of health centers and 
ASCs and reinforcing existing MINISANTE activities. The activities SPREAD undertakes are not new, 
but the integrated approach is, which helps fill gaps by meeting an existing need among coffee farmers 
for health services. Sound planning and collaboration helps avoid duplication of services. 
 
“This program arrived on time, is meeting a need, because during each campaign for mobile 
services, people are there, the demand is high.” (Health Center)
 
“Coffee farmers/coop members needed this program; they didn't know much about health 
before. They benefited from increased access thanks to this program. (Health Center)”
30
“SPREAD did not bring anything new, but their interventions come to complement existing 
services of VCT and FP in our health facilities, which were not reaching a large number of 
people as we have now with SPREAD.” (District Official)
 “We work together during mobilization for and implementation of VCT. SPREAD's activities 
complement ours, there is not duplication as we plan together and the activities are very well￾coordinated.” (District Hospital)
Suggestions, Priorities and Next Steps
In general, partners encouraged close partnership and collaboration with local partners to take 
advantage of each other’s strengths, and to continue to use the community health approach of reaching 
people where they live with frequent, high-quality health education. Partners felt all of SPREAD’s 
current activities would be priority to continue, and wished to see it expanded to benefit more 
members of the community. Nyamagabe District in particular requested specifically for Kibumbwe 
Sector, as coffee farmers from some of the target groups also live there. Mobile service partners would 
like these activities to be more continuous throughout the year, and not simply during coffee harvest 
season. 
Partners also recommended enhancement of certain services. Specifically, a complete package of HIV 
prevention (including VCT, and one person also suggested supporting PMTCT twice/ month at each 
health center), family planning and MCH (including nutrition) are vital. For hygiene partners 
suggested SPREAD also include support for the use of home-built hand-washing devices, kandagira 
ukarabe, a MINISANTE priority, into their outreach work. Other ideas included more outreach focus on 
gender awareness, working with PSI’s local youth center to animate community youth events, inviting 
Hospital staff to help with training CHAs, to celebrate and give prizes for farmers who put in practice 
healthy behaviors, and to provide the mutuelle de santé for the indigent.
Several NGOs and District representatives mentioned concerns related to SPREAD remembering to 
implicate partners for follow-up and supervision after initial activities have been co-implemented. 
Sectors would also like to see more of a SPREAD presence at Sector-level meetings.
Sustainability
Several ideas emerged as to how to continue and sustain SPREAD’s health interventions: integrate 
them directly into cooperative and/or Sector activities who will help coordinate; CHAs and ASCs 
should work closely together as of now and ultimately be supervised by Health Centers who could also 
provide training and materials; cooperative members should contribute funds; local NGOs could begin 
selecting among the existing target groups for their next groups of Peer Educators; SPREAD could give 
Districts funds to begin coordinating and monitoring activities in order to become familiar with 
program beneficiaries and continue working with them after the Project is finished. Certain Sector 
officials felt that the Health program should take the majority of the responsibility in “telling people 
what steps to take and what path to follow,” and should “give more trainings and more money.”
As for progress already made towards sustainability, most partners did not know or did not feel much 
has been accomplished, aside from initial discussions and brainstorming. One exception was a District 
Official, who felt that Health Centers were already beginning to utilize the mobile VCT and FP sites, 
which are close to coffee farmers, and felt “little by little they are taking ownership.” Overall it will 
require time spent in the remainder of the Project evaluating interventions and exploring options with 
multiple stakeholders, in order to elaborate a solid exit strategy:
31
“All stakeholders need to sit down and look at the strengths and weaknesses of activities which 
were undertaken; plan activities for each group and develop strategies for implementation. But 
what's most important is [first] the mobilization of these various groups.” (District Official)
Stakeholder Group: Coffee Farmers (Male and Female Beneficiaries) 
Four focus group discussions took place, one with all-male beneficiary group per and one with all￾female group per target farming cooperative.
 
Program Interaction
Beneficiaries, both men and women, were familiar with most all of SPREAD’s outreach activities, 
having participated in education on all health topics, community-based distribution of health products 
Sur Eau and Prudence, VCT mobile services and referrals to local health centers. Education topics they 
have participated in included all of the usual HIV/AIDS, FP/RH and MCH topics; additionally people 
mentioned discussions on savings, “harmony in the household” (female beneficiary), and gender 
through “trainings on life and health within a good household, with man and wife working together, 
sharing management of household resources,” (male beneficiary).
Program Satisfaction
Beneficiaries were satisfied with and greatly appreciate SPREAD’s interventions, and they and their 
communities find the program important. One of the men’s focus groups especially discussed 
appreciation of health integration into coffee sector development. Several comments also described the 
good example set by SPREAD’s CHAs in the community.
“Thanks to the health education and the good examples set by the CHAs, ignorance has been 
reduced.”(female beneficiary)
Targeting of Intervention
Although all topics and activities addressed through SPREAD’s Health Program were deemed 
important, many comments, from both male and female beneficiaries, revolved around the significance 
of family planning messages. Hygiene trainings were also very useful, as was the VCT program and 
HIV/AIDS prevention education. No topics or activities were deemed less valuable or unimportant.
Beneficiaries felt that education is something continuous; therefore they would like to receive sessions 
regularly. They suggested recruiting and training more CHAs, and regularly building their capacity, as 
well as utilizing more radio and educational/ community theater to pass health messages.
Perceived Program Impact
Similar to the CHAs, beneficiaries cited a vast list of perceived positive health impacts and health 
behavior changes since SPREAD, but as mentioned in the study limitations, it is difficult to truly 
ascertain whether these positive changes occurred because of SPREAD’s interventions alone, or due to 
a confluence of other community factors and efforts by other service providers. Beneficiaries attribute 
an increase in health knowledge to the Health program, especially for HIV prevention, reproductive 
health/family planning, condom use and hygiene. 
“Training on hygiene [has been most important], because thanks to this many illnesses due to 
hygiene have decreased.” (male beneficiary)
32
“Training on family planning has been most important because we did not know how to space 
our children; I no longer have unplanned/unwanted pregnancies as before.” (female 
beneficiary)
“Family planning [has been very important], because we give birth to children we are capable 
of raising, and can pay school fees and the mutuelle.” (female beneficiary)
“FP is very important because it has allowed us to put some of our money into savings.”
(female beneficiary) 
“VCT-- I am at ease now that I know my status.” (female beneficiary)
“Mobile VCT has been very helpful for us because it took place in our cell, close by to our 
homes. Those who tested positive can now seek medication nearby.” (female beneficiary) 
 “FP-before it was difficult because men only knew about the natural method of contraception. 
Now using condoms within a couple is no longer a problem.” (female beneficiary) 
 “… now we are capable of teaching our children about RH without shame as before.” (female 
beneficiary)
In summary, male beneficiaries cited “a change in mentality” around family planning and a reduction 
in unwanted or unplanned pregnancies. Women say they are beginning to use FP, that they know how 
to improve coffee production and savings activities, and they are able to work and get paid because 
they have more time thanks to less children through contraception. Men discussed a shift in gender 
norms; men are no longer mistreating or being unfaithful to their wives, disagreements or conflicts 
regarding condom use occur less frequently, and money management decisions are now discussed 
amongst couples. Both men and women explained that understanding about HIV/AIDS prevention 
and treatment has increased and that HIV-related stigma has been reduced. They are no longer afraid 
to get tested for HIV, especially men, and condom use has increased for both youth and adults. 
Other comments described the benefits of increased access to health services via the mutuelle, and that 
family hygiene has improved through practices such as drinking treated water, covering latrines, 
installation of hand-washing mechanisms. People are living in improved housing and can purchase 
better clothing. Both women and men described improvements in maternal and child health, as women 
are getting regular antenatal care (with husbands in attendance), and have a better understanding of 
the importance of proper nutrition and childhood vaccinations. Women also mentioned a decrease in 
birth complications as women are increasingly choosing to give birth in Health Centers. Men also said 
people are preventing malaria by using ITNs and cleaning up around their homes.
Life Before, During and After SPREAD
Both men and women described life before SPREAD as “not good” or “not how it is today.” They 
described life as difficult, where people “were ignorant” about health, had little access to health 
services because they would not seek them out from health centers. One man said “Coffee money was 
poorly spent; we spent a lot of money on alcohol.” Beneficiaries expressed that since SPREAD, “we 
have noticed a big change in a positive way.” 
33
During SPREAD, both men and women expressed that life is better in regards to both health and 
incomes. Men stated “we plan our activities envisioning our families’ interests much more.” One man 
again discussed a positive shift in gender norms below:
“There is no longer this notion of ‘I am the man, I must make all decisions.’ Decisions about 
health and about money in the family are made together, within the couple. Women are the first 
signatories on their husband's accounts.” (Male beneficiary)
When asked what life will be like after SPREAD, all comments across beneficiary groups were positive, 
and seemingly confident that they can continue health improvements once the project is finished, using 
the knowledge and skills they have gained.
“We will be teachers of others, thanks to the training SPREAD has given us.” 
(Female beneficiary)
“We will not go backwards.” (Female beneficiary)
“We are not afraid of the future. We will have created a savings account in order to continue 
our activities.” (Female beneficiary)
CHAs and ASCs
Beneficiaries also feel that the work of CHAs and ASCs complement one another, and is similar in that 
both promote health via education on similar topics. Differences cited were that ASCs give medicines, 
whereas CHAs do not, that CHAs focus much more on HIV prevention, and that they also do more 
home visits, whereas ASCs do their awareness-raising usually during community meetings such as 
umuganda. CHAs are thought to do sessions more regularly, to go more in-depth into health topics 
using educational materials (condom demonstrations, brochures), whereas ASCs are irregular and do 
not have educational materials. The peer farmer approach was also appreciated:
“When peer educators educate youth like them, the message is successful and passes more 
quickly than [via the] ASCs.” (Female beneficiary)
Coffee and Household Income
Beneficiaries do feel that their incomes have increased since the advent of the specialty coffee sector 
developments (i.e., arrival of coffee washing stations), although to varying degrees. They realize the 
impact of trainings on quality and better agricultural practices on the price fetched for coffee, the 
reduction in heavy workloads and the stable market and better prices provided by the washing stations 
and cooperatives. They report coffee revenue is spent on a range of items, from the mutuelle and school 
fees, purchasing food or livestock, to opening up savings accounts or further investments in agriculture 
or other income-generating activities.
Gender Differences around Spending Coffee Revenue 
When probed to explore whether there are any differences in spending of coffee revenue between 
women and men, women’s groups stated that many men prefer to spend on alcohol, whereas women 
prefer to save and invest in the family. Women also mentioned that “there are men who sometimes 
hide coffee money from their wives; they don’t tell them they have received any,” but did acknowledge 
that “some men put money in the bank and make investments for their family.” Men, by contrast, felt
that men and women generally now share the responsibility and decision-making over how these 
resources are spent. 
34
Men did recognize that some men continue to use money poorly, for example in alcohol and 
prostitution, but stated that this mentality is wrong. They felt that it is not in fact a very common 
problem any longer, and that it is “the men who have not known SPREAD’s Health program that have 
these practices.” One man, (who, according to enumerators presented drunk at the time of the focus 
group discussion), described the cultural practice below:
“Normally, a man cannot live without chatting, without going and discussing with others 
around a glass. After resolving family needs, a small sum goes to buying beer.”
(Male beneficiary, drunk at the time of discussion) 
According to women, the scope of the problem varies; some felt that it is no longer a major problem in 
the community, whereas others still felt that many men spend do spend money on alcohol, which often 
results in gender-based violence.
“After having received coffee money, men go drink beer and upon coming home beat their 
wives in a defensive manner; whereas women take into account family needs first.”
(Female beneficiary) 
Both men and women cited negative consequences from this type of spending, mainly conflicts in the 
household and increased poverty, children’s suffering and HIV/AIDS or death as a result of 
frequenting prostitutes. One woman also described the negative impact on coffee such spending 
patterns may have:
“The couple will no longer take seriously the idea of cultivating coffee of high-quality because
the woman will no longer benefit from the harvest. It will be a man's work only.” 
(Female beneficiary)
Both men and women seem to think spending behaviors and life in general are improving, likely due to 
a range of factors. Women described people’s increasing ability to purchase livestock or a bicycle, to 
renovate their homes and wear better quality clothes; “things necessary to have a better life are there,” 
one woman said. Men described positive changes such as being able to connect to electricity, and again 
the changing character of men who drink less beer and their wives benefit as a result.
Integration
Beneficiaries find the integrated Agribusiness and Health approach very useful, as the two are 
interrelated and complement one another.
“Coffee constitutes monetary security for men and the family in general. When we have a coffee 
plantation we are secure in terms of health because we are able to pay the mutuelle.” (Male 
beneficiary)
“It is a good idea b/c it is necessary to have good health in order to be successful in coffee 
activities. The life of members has changed since this program.” (Female beneficiary)
“We have good health, and thus are able to develop ourselves and our country.” (Female 
beneficiary)
“Work and health go hand in hand.” (Male beneficiary)
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Sustainability
Beneficiaries would like to see the program continue indefinitely and on a regular basis, and 
recommended recruiting a permanent staff member to coordinate health activities at the community 
level. Both men and women advocated for more trained CHAs- to do both coffee and health extension￾and to reinforce existing programs across all health topics and activities. They also strongly requested 
specific interventions aimed at youth, such as soccer games, to help mobilize them around HIV 
prevention and health in general, as they were concerned youth are not adequately reached.
Process Indicators and Cost-Effectiveness
Routine monitoring data indicate that over the past year and a half of integrated implementation, 
SPREAD’s Health Program trained 303 Animateurs and Peer Educators, and has led to the purification 
of 248,000 L of drinking water (through sales of Sur Eau) and 1,428 condoms sold via cooperative 
facilities and community-based distributors. Around 124,000 farmers- men, women and youth (around 
60,000 men and 64,000 women)- were reached with HIV prevention messages, including condom 
demonstrations and discussions about abstinence, fidelity and life skills. Over 88,000 farmers (31,959 
men and 56,228 women) were reached with Family Planning and Reproductive Health messages. At 
least 39,000 people (10,326 men and 29,250 women) were reached with Maternal and Child Health 
messages, including safe water, hygiene and malaria education. Mobile VCT services resulted in 3,639 
farmers tested (1,228 men and 2,411 women) and 347 women became family planning users (referrals 
and mobile services combined; this number could be much greater as many women were no longer 
seeking referrals for services, rather they were going on their own.) CHAs referred 395 people for 
family planning services at local health centers, 429 for VCT and 217 for antenatal care. Over 35,000 
MINISANTE health brochures were re-printed and distributed by CHAs during educational activities, 
and 36 health messages were played over the radio via the coffee talk show Imbere Heza. The Program 
also installed 12 CANACLA hand-washing mechanisms at coop locations, trained 15 community 
theater groups among coffee farmers and treated over 1,000 people (mostly children) for intestinal 
parasites.
Budget estimations (see table below) show that with a combined PEPFAR budget of $240,000 over the 
past year and a half, SPREAD’s outreach program cost less than $2 per person. Family Planning and 
Reproductive Health, with its budget of $85,000 combined over the year and a half period, cost less 
than $1 per person reached. Maternal and Child Health messages cost a little over $2 per person. These 
costs are for the Peer Education and outreach alone, and do not yet include other SPREAD health 
activities, such as mobile services, community theater and product sales/promotion.
Rough Costs for SPREAD Health Peer Education
Funding area Budget Year 3 and 
half Year 4
Total # people 
reached to-date Cost/person
PEPFAR $240,000 124,000 $1.94
Family Planning/ 
Reproductive Health $85,000 39,000 $2.18
Maternal and Child 
Health $60,000 88,000 $0.68
36
Discussion
The following section is a summary and highlights overall themes and key findings. More specific 
details regarding program effects, sustainability and recommendations and input from each 
Stakeholder group can be found in the Results section.
Stakeholders perceive positive effects of SPREAD interventions and request continuation and 
expansion of current activities. Farming families have additional needs.
Stakeholders perceived many and varied positive effects of SPREAD’s health interventions related to 
increased knowledge and behavior change across all technical areas of HIV/AIDS prevention, family 
planning and maternal and child health. Men, women and youth have profited in slightly different 
ways from SPREAD’s Health interventions, but in general the entire population is believed to have 
benefited. Although impossible to attribute to SPREAD alone, specific outcomes included people 
adopting safer behaviors for HIV prevention, especially the normalization and increased purchase and 
use of condoms and increased uptake of VCT services as stigma and fear of getting tested has reduced. 
There is a greater openness in discussing issues of reproductive and sexual health, and relationships 
between farmers and health centers have been strengthened. People have a better understanding of 
family planning and side effects, and its importance related to family health, wealth and coffee 
activities, which has also increased uptake of services. More women are giving birth in health centers 
and personal and household hygiene and safe water practices have improved, evidenced in part by 
increased purchase and use of Sur Eau, and farmers bathing after field work and going to the toilet. 
Other attitude and behavior changes included shifts in gender norms where men are increasingly 
sharing decision-making responsibility with their wives regarding contraception, sexual relations, and 
household revenue spending. Fewer women are seeking family planning in secret from their husbands. 
People are learning more about savings and men are spending less money on alcohol. Cooperative 
leaders and CHAs also value the health knowledge they have gained, as well as the capacity to make 
changes in their own lives and train others on health topics. Farmers believe they have more time now 
thanks to health and family planning improvements to invest in their coffee and cooperative activities, 
and that their overall quality of life has improved thanks to improvements in the specialty coffee sector 
and health support. 
In general, farmers and partners value SPREAD’s community-based approach and activities and would 
like to see them continue, to increase in frequency, to expand to reach more people and provide 
additional services. Suggestions included adding services such as PMTCT support for health centers, 
to train and equip more CHAs and give them increasing levels of responsibility, to facilitate mobile 
service support throughout the year and not simply during coffee season, to work with partners on 
more youth-focused events as well as to enlarge the intervention area to reach other target farmer 
groups. 
Farming communities still face many barriers to improved health, such as overall poverty and need for 
increased incomes. Many men are still reluctant to learn about reproductive health/family planning 
and accept contraceptive use, as well as to share decision-making responsibilities with their spouses. 
Although spending of coffee revenue on alcohol by men is reportedly decreasing, it remains an issue 
for much of the coffee-farming population, and likely for other rural income-generating communities 
throughout Rwanda. Behavior change work targeting relationships between gender, reproductive 
health, revenue spending, alcohol and violence are required. Life skills for how to use and increased 
revenue wisely in order to maximize its benefit for farmers and their families should be a requirement 
for any Economic Growth work directly with communities, to mitigate potential negative impacts of 
37
increased incomes on farming families. Additional farmer needs include further training on coffee, 
nutrition and home gardens, the creation of other income-generating activities outside of coffee season, 
continued SPREAD-supported health education and services, and the inclusion of dynamic teaching 
strategies such as community theater, films, youth-specific activities, and debates to relay health 
information and change behaviors. Empowerment was also raised as a key need at all levels to ensure 
the success of any of the above activities, so that individuals, families and cooperatives feel able to 
solve their own problems. 
Program complements existing public health efforts by a strong community-based approach that 
reaches underserved rural communities with quality information/services in a cost-effective manner 
SPREAD’s strengths lie in its ability to consistently reach farmers one-on-one with quality health 
information and services. The over 300 CHAs in the coffee areas each conduct at least 1 small group 
education session per week, as well as home visits, and some are currently in the process of learning 
how to animate community theater for health advocacy events. CHAs are respected and seen as role 
models in their communities, and their close Peer Educator relationship with farmers is valued across 
all Stakeholder groups as an effective means to relay information and effect change. Consistent 
messaging through meetings and home visits, regular refresher training, and frequent supervision and 
follow-up by SPREAD’s Health staff are key to the success of the program. SPREAD’s community 
outreach is reinforced by sufficient educational materials (brochures, condom demonstration 
equipment, planning and reporting tools) and motivational equipment (bags to carry materials, 
umbrellas and minimal transport reimbursements to facilitate field work). Regular monitoring, 
communication and field supervision of CHAs strengthens data accuracy, and allows time for CHAs to 
ask questions, learn new material and improve the quality of their outreach. 
SPREAD also works closely with all partners-- cooperatives, local health and government authorities, 
NGOs—to plan and implement activities together that are in alignment with both GOR and USG 
priorities. Health service providers often have difficulty finding the resources and avenues to access 
rural populations, and many now realize that agribusiness cooperatives provide a valuable entry point 
and are considering expanding the approach to other agriculture initiatives. CHAs reaffirmed that 
coffee is a center of interest to the target population, and beginning coffee meetings with health 
discussions allows reaches farmers who may not otherwise attend health education sessions, such as 
men. Local government community health workers (ASCs) in SPREAD’s target areas know the Project, 
have collaborated with CHAs on community activities, and appreciate the SPREAD’s holistic approach 
and how close the Project is to its beneficiaries, more so than other NGOs. ASCs and SPREAD’s CHAs 
feel that their work complements each other and supports national health policy, and that working 
together avoids rivalry. Through careful collaboration and community engagement, SPREAD is seen as 
complementing rather than duplicating existing public health efforts, and also as providing additional 
resources to the community with health centers often cannot afford: whereas ASCs provide medicines 
to the population and conduct sporadic education sessions mostly after community meetings, CHAs 
possess IEC materials and brochures, condom demonstration materials, and conduct regular and 
consistent outreach. SPREAD facilitates the access of local health service providers to target farmer 
groups, thereby helping MINISANTE and NGOs meet their own goals and targets (such as extension of 
PSI social marketing campaigns), and establishing vital relationships with populations that were 
previously difficult to reach. Target farmers appreciate the increased access to education and services, 
and have strengthened their relationships with existing service providers, seeking care from local 
health centers more and more. 
Although the general rural population may not be considered high-risk or particularly vulnerable by 
HIV/AIDS prevention initiatives (which target drivers of the epidemic such as commercial sex workers 
38
and truck drivers, for example,) these farmers were indeed sorely in need of health information and 
services as evidenced by the extremely low initial health knowledge, positive community response, 
increased demand for condoms and uptake of SPREAD-supported mobile health services and referrals. 
Farmers and coop leaders alike recognize positive effects of improved health on agribusiness activities, 
explained below. Cost estimates show that these communities can be reached at less than $2/person, 
indicating the program is a cost-effective strategy to provide basic health information to reduce 
preventable illnesses and create stronger, more productive agribusinesses. 
Integrating community health and agribusiness promotes synergy across sectors and more 
holistically meets farmers’ needs for improved lives and livelihoods
True synergistic effects are difficult to measure, as there were no combined or integrated indicators
established at baseline, yet SPREAD staff and stakeholders value the concept and practice of 
integration. Time and energy are perceived to be saved when farmers are healthy and have manageable 
family sizes allowing for further investments in coffee and cooperative activities. Costs are conserved at 
the Project level, as SPREAD staff take advantage of health trainings and field visits to build capacity 
around Agribusiness issues, such as preparation for the Cup of Excellence (national competition for 
coffee quality), local roasting, Fairtrade, and member rights and responsibilities. Cooperatives realize 
the feasibility of training CHAs to extend coffee, coop development and health education
simultaneously and think that combining both health and agribusiness has a greater mutual impact 
that one program alone. Cooperative managers also see that farmers have an improved quality of life 
and household harmony is improving, and cite fewer cases where the coop must intervene in family 
affairs for emergency loans and conflict resolution. Some mentioned also improved buy-in among 
members since health activities began. Peer Educators, initially brought on for Health, are also being 
integrated into coffee activities, such as Maraba’s new Unités de Production organized by coffee washing 
station. Stakeholders appreciate the ability to more holistically meet community needs and achieve the 
overall Project goal of improving farmers’ lives and livelihoods through integration, and that it 
contributes to overall sustainability. 
Lessons for others in Rwanda interested in initiating health activities with agribusiness 
cooperatives
SPREAD program managers who have years of experience working with cooperatives shared lessons 
learned for ensuring success of any cooperative activities, including health promotion. First, it is 
important to encourage strong cooperatives with transparent, honest and engaged leadership who are 
supported by a member base that know their rights and responsibilities, take an interest in cooperative 
affairs, make joint decisions and demand accountability on the part of their leaders. Secondly, it is 
necessary to spend time facilitating true ownership by the cooperative, so that they take responsibility 
for all cooperative activities, and that planning for the ultimate sustainability of health activities begin 
from the start. These characteristics are generally easier when the cooperative is born of a grassroots 
nature, where the population themselves elects to organize and form a business, rather than imposed 
from government or outside forces. Cooperatives interested in creating a health component should also 
select a part-time coordinator who will be responsible for health activities in addition to his or her other 
tasks. Additional coop members and leaders who can make up a sort of a health team, including the 
cooperative manager, should support this coordinator. This team must be engaged and aware of health 
activities, participating and implementing when possible and helping to monitor and evaluate. It is 
vital that those working to strengthen cooperatives stay close and aware of coop dynamics and 
evolution, as they are constantly changing, and to come up with contingency plans for when problems 
arise. 
39
In addition to sharing the synergistic effects mentioned above, cooperative leaders encourage others to 
implement health activities in conjunction with coffee, as they are in fact feasible when planned well, 
not too costly, and beneficial to both the farmer members and the business itself. Health activities have 
also strengthened relationships between cooperatives, local authorities and health service providers.
Challenges include integration, M&E, funding restrictions and communication with Sector-level 
authorities 
The fact that the Health Program was added on as a sort of extra component within SPREAD, rather 
than conceptualized together with Agribusiness goals and objectives, has created certain challenges of 
integration at the Project level. SPREAD’s Agribusiness initiatives take place throughout the country 
for coffee, pyrethrum and birds- eye chili pepper production, whereas the integrated Health Program 
focuses all of its resources on a relatively small geographic area in 2 to 3 Districts in each of the coffee 
and pyrethrum areas. This makes true integration at the overall Project level challenging, as separate 
planning activities have to be conducted for Agribusiness and integrated Agribusiness/Health. Yet this 
focusing of resources on a few target groups, which are located close to Health staff offices in Butare 
and Musanze, has likely served the Health program well, as staff are able to work closely and regularly 
with the same farmers and CHAs, and continuously apply lessons learned, improving the quality of 
interventions. Better cross-sector collaboration and opportunities for synergy could be facilitated 
through institutionalizing integration at the beginning of the Project, so that it is reflected throughout 
program goals, workplans and M&E systems. M&E is a challenge across SPREAD, as it is difficult to 
find someone with both appropriate expertise and time to dedicate to consistently updating and 
revising the system, to improve efficiency and accuracy, as well as to respond appropriately to 
evolving USG and GOR reporting requirements. 
USAID funding mechanisms may also inhibit true integration and the ability to best meet farmers’ 
needs, as each funding stream has its own set of prescribed indicators, workplanning and reporting 
requirements to different technical officers, as well as little flexibility for adjustment to the local context. 
For example, combining nutrition education and assistance for home gardens could meet both 
economic growth and health goals by providing a source of income for farmers outside of coffee 
season, as well as improve household nutrition, yet was not allowed under SPREAD’s MCH funding. 
Additionally, severe water shortages and lack of sanitation facilities due to the volcanic geology around 
the pyrethrum areas was also difficult to address given USAID restrictions on the use of allotted 
water/sanitation funds, which allowed only education and no infrastructure developments. 
Other challenges include a lack of consistent reporting, communication and implication of partner 
NGO, Sector and Health Center in implementation and follow-up. SPREAD Health staff are few, and 
reports quarterly and annually to USG, District and national-level, so often reports to Health Centers, 
Sector and NGOs is overlooked. Finally, Health staff themselves feel that they have difficulties keeping 
up with certain targets, such as the high percentage of CHAs to be observed in the field, ensuring the 
hand-washing equipment are in proper use at cooperatives, and dedicating time to improve the 
efficiency of the health kiosks which are experiencing stock-outs. 
Although there are positive indicators for sustainability of integrated health and agribusiness 
interventions, further financial and technical inputs are required 
All stakeholder groups indicated positive evidence for the sustainability of health interventions, such 
as current implementation of integrated interventions at the cooperative level, the existence of a part￾time health coordinator at the cooperative level, the involvement of stable local health partners in 
planning and implementation, and the overall value the community assigns to SPREAD-initiated 
health interventions. Farmers themselves feel that the knowledge they have gained will continue to 
40
serve them and their communities. Health centers have begun using some of the mobile service sites 
that were initiated under SPREAD for their own outreach activities, due to the successful community 
response. Youth Peer Educators have created revolving micro-credit funds to continue their activities 
and have also received land to grow coffee and contribute to cooperatives. District officials are 
considering suggesting the integration of health services into other agribusiness initiatives, such as 
with tea cooperatives in Nyamagabe District. Cooperative management, CHAs and member farmers as 
well all see the added value of health linked into their coffee activities, and have high hopes and 
desires to continue what has begun. RWASHOSCCO in its restructuring process has begun drafting a 
roadmap for how to integrate health into its overall strategic plan. Although this assumption of health 
activities by RWASHOSCCO may take some time given the other pressing business challenges, the 
strategic plan will help pave the way forward for future possibilities. 
However, stakeholders, especially SPREAD program managers and CHAs, are concerned about the 
sudden end to technical and financial support upon the Project’s closure, given the lack of a concrete 
exit strategy. Although several cooperative leaders are confident that health activities will continue 
post-Project, although perhaps not to the same degree of quality or regularity/frequency as before, 
there is doubt as to whether the cooperatives, local government and public health structures have 
adequate resources to do so given competing priorities and the short time health interventions have 
been implemented. Finances are required to cover transport, logistical, training and equipment costs 
for implementation, as well as for planning, supervision and follow-up, and thus far the only concrete 
health accounts existing at the target coops have few funds from profits of health product sales. 
Several ideas emerged as to how the various partners can continue health activities after the Project is 
completed. Cooperatives should keep their health coordinators and allocate a health-specific budget 
that could come from Fairtrade funds, member contributions and health product sales. Coops should 
also build upon their new partnerships with local health authorities and service providers, even after 
the Project’s completion, and invite them to continue education, outreach and mobile services for 
member farmers. Districts and Health Centers could provide training and IEC materials, and continue 
with mobile services at sites, utilizing cooperatives to mobilize the population. NGOs such as ARBEF 
and PSI could integrate SPREAD CHAs, particularly youth, into their ongoing Peer Education and 
outreach programs. Some partners suggested integrated CHAs’ activities directly into Sector-level and 
Health Center responsibilities for coordination and supervision. SPREAD’s role in the remaining life of 
the Project will be to first bring together the various stakeholders and share reports, successes, 
challenges and lessons learned of the Health program thus far. Then together SPREAD must help this 
group define a clear exit strategy, build capacity of cooperative staff as necessary, especially o take over 
coordination and monitoring roles, and facilitate collaboration and strengthening of partnerships
between coops and health service providers in the remaining life of the Project.
41
Recommendations
Recommendations are implicit throughout this report, as evaluation participants offer their suggestions 
in the Results section. The following highlights the principal recommendations based on findings of the 
assessment, with the intended audience for each recommendation specified in parentheses, but readers 
are encouraged to consider previous sections for more in-depth feedback. 
(SPREAD) Incorporate interactive and dynamic teaching strategies, youth-specific activities and 
integrated efforts to address agribusiness and health linkages
Now that CHAs are fairly comfortable as health educators, and a basic level of health education has 
been established among CHAs and many farmers, BCC interventions should be enhanced to 
incorporate more varied and dynamic teaching strategies, to both increase knowledge and also to 
encourage reflection and transformation of harmful behaviors and cultural/gender norms. These types 
of activities could include community debates around gender-sensitive issues related to coffee money 
being spent by men on alcohol, gender-based violence, decision-making responsibilities within the 
household and sexual/reproductive health; films (PSI’s Sinigurisha is currently being utilized to 
counteract cross-generational sex); community theater (certain groups are currently being trained); and 
more youth-friendly activities (a soccer tournament is also being planned for coffee season, where both 
coffee and health topics will be promoted). Farmers also have a great desire to learn more about coffee, 
improved cultivation and organic techniques, and local roasting/brewing at home. An integrated 
coffee/health refresher training for CHAs is in preparation for after this coffee season, which will allow 
for discussions on savings, money management, income-generating activities outside of coffee season 
and aforementioned gender/health issues. These and other collaborative community activities and 
strategies should continue to occur as consistently as possible in the remaining year life of the Project, 
with proper monitoring and evaluation techniques applied. When M&E questions arise, SPREAD 
should consult the USAID-supported Monitoring and Evaluation Management Systems (MEMS) 
Project who are available in-country to provide technical assistance.
(SPREAD) Strengthen communication with local health partners and authorities to ensure 
complementary service delivery and contribute to sustainability.
SPREAD has been successful in the eyes of local partners due to its careful engagement throughout the 
process of program planning and implementation, which has led to the lack of duplication of services 
and mutual reinforcement of agency goals. However, gaps remain in regards to follow-up and 
reporting at all levels. SPREAD should regularly involve local partners in field supervision, follow up 
and reporting activities. Cooperatives need to be more involved in the coordination, implementation 
and follow-up of health activities to create ownership. NGOs PSI and ARBEF should also be engaged in 
field supervision activities, both to free up limited SPREAD staff time to dedicate to other health 
activities as well as to keep them engaged for sustainability purposes. Regular reports should be shared 
also with all stakeholders, especially NGOs, health center and Sector-level staff, in order to provide 
pertinent data for their own programs (i.e., PSI product sales and people reached through films shown 
via cooperatives) and to keep them informed and engaged of all SPREAD activities in their zones, to 
improve buy-in and pave the way for sustainability. Since these reports are outside routine reporting 
calendars for USG, GOR and Districts, institutionalizing a routine system of reporting (via email for 
example) and communication with these partners would be helpful.
(SPREAD, Donors) Share lessons learned, success and challenges with others in Rwanda and 
elsewhere interested in integrating Health into Agribusiness and cooperative work
Lessons learned regarding successes and challenges of integrating Health and Agribusiness could be of 
interest to others at all levels of government in Rwanda or other service providers in either sector. Keys 
42
to success such as encouraging democratic cooperatives, strong and transparent cooperative 
leadership, sound business plans, member buy-in and solid extension systems could be helpful to 
anyone working with cooperatives both in Health or Agribusiness. Cooperative managers and farmers 
are enthusiastic about the feasibility and importance of health activities to improve their own 
agribusiness initiatives, and their testimonies could encourage others to do the same. SPREAD should 
begin by advocating the successes and value of the Health program to-date to cooperative leadership, 
local partners and RWASHOSCCO in order to galvanize support for sustainability.
(SPREAD, Partners and Donors) Formulate a clear exit strategy with partners and stakeholders in 
remaining year and a half of Project.
SPREAD is in a unique position of receiving an increase in Health funding in its remaining Project year, 
which creates a juxtaposition of having to intensify activities while simultaneously handing over 
responsibility to the community and local partners. SPREAD should ensure that sufficient resources are 
spent on creating and carrying out the exit strategy in the remaining life of the Project. First, SPREAD 
should communicate the successes over the last year and a half of integrated health implementation 
with cooperatives and partners. Discussions with the range of stakeholders must take place in order to 
determine available resources, priority activities and the support required to facilitate the handover of 
health responsibilities once the Project is completed in 2011. Advocacy should happen at all levels, 
from target cooperatives, to local authorities, health centers and NGOs, to RWASHOSCCO, donors and 
other agencies. Reports should also be shared with Sectors, Health Centers, PSI, ARBEF, and District 
Hospitals – who are left out of routine reporting systems—and these partners should be invited to 
collaborate on program implementation and follow up as much as possible. SPREAD should facilitate 
partners to come up with solutions to fill financial and technical gaps, building off ideas that emerged 
in this evaluation, such as creating a health-specific budget within the cooperatives that could partially 
be fed by Fairtrade funds or a percentage of cherry sales, or by having PSI continue to work with some 
of the SPREAD-trained Peer Educators. Finally, efforts should be spent building requisite capacity of 
health service providers and target cooperatives to work together to plan, implement, monitor and 
evaluate health activities. 
In light of existing technical and financial weaknesses, donors could also consider another round of 
funding to help cooperatives establish a stronger foundation in order to continue SPREAD-initiated 
integrated health and agribusiness interventions.
(SPREAD and other Program Designers) Ensure integration is evident in program design and 
articulated in Project goals, workplans, organizational structure and M&E.
Although it is impossible at this phase of the Project to change original program plans, this 
recommendation could be partially implemented and also kept in mind for future integrated program 
designers. Create time in the beginning of the Project, both managers and Coordinators, to articulate 
the overall Project goals and discuss best ways to integrate across sectors and programs, so that overall 
programs are conceptualized together in order to best conserve limited time and resources and more 
holistically meet community needs. The ideal scenario would have integration as a key concept at 
Project outset, so that managers support it and it is reflected in goals, objectives, workplans, as well as 
staff time, expertise and M&E systems. Think through the implementation, and M&E of this 
integration, i.e., does it make sense to have one person in charge of successful integration or would 
there be people dedicated on each team to ensure cross—sector collaboration, for example? Does a 
Project have enough resources to create and validate integrated IEC materials? 
It would also be to the Project’s advantage to engage or train someone as an M&E manager, to ensure 
that the system is streamlined to avoid duplication across objectives, is simple enough to be feasible yet 
43
rigorous enough to gauge measurable progress. This is likely a full-time job, as there is significant time 
demand to meet with and report to USG and GOR, to revise the system according to changing policy, 
as well as to work with staff and partners in the field on data collection activities. 
Certain steps to improve integration could also be taken now at SPREAD. For example, more and 
frequent communication across SPREAD Agribusiness and Health program staff, such as a 
institutionalizing a system of quarterly Coordination meetings, would be useful to facilitate joint 
planning, implementation and M&E where possible. As mentioned above, coordinators across 
programs should continue to collaborate and develop essential community outreach training and M&E 
tools together, encompassing key health and agribusiness topics for more holistic messages to farmers, 
dedicating adequate staff time and resources for implementation, follow-up and evaluation.
(Donors) Funding mechanisms should accommodate integrated programming, including the 
support of quality M&E, sharing of best practices and lessons learned, and increased flexibility to 
best meet local needs.
Donors should support increased financial and technical assistance to explore the mounting evidence 
of the value added through integration, in the interest of creating stronger and more sustainable 
programs that better reflect people’s lives and more holistically meet community needs. First, funding 
mechanisms must be flexible to allow for more integration at the Project and field level, and certain 
individualized indicators for integrated Projects could be created in collaboration with the various 
technical officers to reflect cross-sector goals. Rigorous M&E and operations research should also be 
supported to investigate outcomes, impact and cost analyses of integrated approaches, such as 
comparing agribusiness-only projects with agribusiness/health interventions. Funding streams should 
also be flexible enough to allow for a range of activities within technical areas that could be tailored to 
best meet community needs, such as community gardens combined with nutrition education and 
gender activities to improve maternal and child health, and water and sanitation infrastructure 
combined with education and the creation of community maintenance systems in areas with severe 
access issues, such as in pyrethrum growing zones around Volcanoes National Park.
(All) Health and Agribusiness donors, development practitioners and local partners should consider 
integrating in order to better meet community needs and create synergy across sectors. Health is a 
critical component to the success and sustainability of income-generating activities and should figure 
into any livelihoods development strategy, to ensure people have appropriate knowledge and life skills 
to enable wise savings and investments. Although communities may not be deemed “high-risk” in 
terms of typical disease-focused health and prevention programs, a high unmet need exists for basic 
health information and services in Rwanda’s rural areas. Agribusiness cooperatives create a valuable 
platform for disseminating health information and services and should be considered as an entry point 
for accessing hard-to-reach, rural, income-generating populations to address health and broader 
gender issues. Clearly, farming families need more than simply increased incomes to improve their 
lives and livelihoods, and the results of this evaluation strongly suggest that it is indeed feasible, cost￾effective and worthwhile for agribusinesses to combine health outreach with cooperative extension 
activities.
 
44
Bibliography
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Best Practices and Lessons Learned to Consolidate Results and Expand Impact. December 2005.
De Souza, Roger-Mark. The Integration Imperative: How to Improve Development 
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Mack, N and Woodsong C, et al. Qualitative Research Methods: A Data Collector’s Field 
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Available at: http://siteresources.worldbank.org/KFDLP/Resources/461197-
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45
Program Documents Reviewed
Compiled annual budgets; annual and semi-annual reports for USAID and PEPFAR from Year 3 and 
half of Year 4 of Project: October 2008 – March 2010.
RWASHOSCCO PHE Organizational Development documents.
SPREAD Full Proposal and Technical Application.
SPREAD Health Program Design documents.
SPREAD Integration Recommendation Report, 2007 by USAID PHE Fellow Heather D’Agnes.
SPREAD Health Program Evaluation documents, FY09, after first year of full implementation.
46
Data Collection Instruments and Tools Used
1. Focus Group Guide for Beneficiaries
2. Focus Group Guide for CHAs
3. Focus Group Guide for Health Centers and Sector Officials
4. Focus Group Guide for MINISANTE Animateurs de Santé Communautaire
5. In-depth Interview Guide for SPREAD Program Managers
6. In-depth Interview Guide for Partners (NGOs, Districts)