This new video In Her Shoes, made by Oxfam, highlights the drama faced by so many women and young girls in using communal latrines.
What is Sani Tweaks?
Recent research across our refugee response programmes has shown that a worrying number of women and girls are not using the latrines we provide. Low sanitation usage rates mean that we are not meeting the needs of the communities we work with and will additionally result in increased public health risks in emergency situations.
To address this, the Oxfam WASH team has developed a series of communications tools that seek to promote best practices in sanitation. The ‘tweaks’ highlighted by the series are intended to inform technical staff, to encourage continuous improvement and ultimately inspire a more effective approach to the design and construction of latrines. For it is such small improvements that will make the difference between whether a woman or girl uses the latrine or not.
Who is it for?
The series is aimed at technical WASH staff at field level, with the aim of encouraging proactive and practical implementation of the best practices highlighted. It is also very much intended to be used as universal guidance by all agencies and adapted to suit individual needs.
This issue contains recent studies, reports, blog posts, and webinars that discuss water utilities and COVID-19 on a global, regional, and country basis.
USAID Water, Sanitation and Hygiene (WASH): Strategic Approach to COVID-19 Response. USAID, April 2020. This document provides a comprehensive overview of USAID’s strategic approaches to WASH within the context of COVID-19 across health, emergency, and longer term recovery programming.
Utilities in Developing Countries, in Financial Tailspin, Try to Keep Water Flowing During Pandemic and Beyond. New Security Beat, June 2020. The global coronavirus pandemic is precipitating a financial crisis for water utilities in low- and middle-income countries as many of these service providers face drastic cuts in revenue and rising costs to respond to the public health emergency.
Supporting Water Utilities During COVID-19. World Bank, June 2020. This blog post links to reports and tools which discuss challenges faced by water utilities during the pandemic.
COVID-19: A Utility Leaders’ Response. International Water Association (IWA), May 2020. This online discussion brings together water utility leaders to share their perspectives, experiences, and response to COVID-19 challenges, the lessons being learned in adapting to a changing situation, and the main messages they are communicating to their customers.
The Unsung Heroes of the COVID-19 Pandemic. WaterAid, June 2020. The COVID-19 pandemic has drawn attention across the world to the vital roles of key workers such as those employed in health care and sanitation. This article highlights the daily dangers sanitation workers, who are often doing their jobs with minimal protective equipment, faced prior to the coronavirus and how the pandemic has exacerbated these working conditions.
What Water and Sanitation Operators Can Do in the Fight Against COVID-19. Global Water Operators’ Partnerships Alliance (GWOPA), March 2020. Water and sanitation service providers (small-scale providers, utilities, and local authorities) can be instrumental in stalling the advance of COVID-19. Public utilities should work closely with local health officials and other relevant bodies to launch awareness campaigns about COVID-19 transmission.
Read the complete article.
Market-based solutions are increasingly seen as having an important role in filling gaps in public services provision and bring increased efficiency to humanitarian assistance. UNHCR partnered with the Bill & Melinda Gates Foundation (BMGF) to investigate waste-to-value sanitation solutions for areas with difficult ground conditions in protracted refugee camp settings in East Africa. In response to a call for sanitation solutions for difficult ground conditions in refugee settings, Sanivation introduced an innovative market-based solution with a waste-to-value component to Kakuma Refugee Camp in Kenya.
This report examines the business model and financial model that Sanivation developed during the project and illustrates some of the real world challenges and opportunities for waste-to-value sanitation. It is hoped that the insights from this research will provide a useful reference for potential investors and entrepreneurs, as well as humanitarian practitioners looking to design self-sustaining waste-to-value sanitation services in refugee and low-resource settings in the future.
CKM’s role in managing the Emergency WASH Network will end later this year so we are searching for organizations that would be interested in managing the Network in the future. Please contact me if this is something you would like to discuss.
Also, let us know if you have research, reports or upcoming events that can be featured in the next biweekly update.
From Michelle Tran – email@example.com
A Survey on Faecal Sludge Management in Emergencies: University of Oxford – Purpose of Survey: This survey inquires about the importance of FSM in WASH responses during first-phase emergencies (approximately the first 6 months of the response) and whether later stages of the FSM chain are prioritized in emergencies. The results of this study will estimate demand for FSM products and guidance among WASH practitioners. Survey results will be shared within the wider emergency WASH sector after publication of this research (September-November 2020).
July 14 (in English and French) Make Me a Change Agent: An SBC Resource for WASH, Agriculture, and Livelihoods Activities – USAID’s Bureau for Humanitarian Assistance (BHA)-funded SCALE and PRO-WASH awards invite you to this interactive webinar to dive into the Make Me a Change Agent: An SBC Resource for WASH, Agriculture, and Livelihoods Activities training manual, and discuss how these fundamental skills can improve your WASH, agriculture and livelihoods programming.
Culture, Context and Hygiene Promotion for COVID-19. This is a free interactive online module, delivered live by RedR UK’s hygiene promotion experts. You will learn the key public health risks related to COVID-19 and how these can be addressed by appropriate hygiene promotion.
USAID’s Bureau for Humanitarian Assistance Fact Sheet, June 2020 – BHA leads and coordinates the U.S. Government’s humanitarian assistance efforts overseas. The Bureau responds to an average of 75 disasters in more than 70 countries every year.
Twelve finalists in the running for the EIC Horizon Prize for Affordable High-Tech for Humanitarian Aid. European Commission, June 2020 – LORAWAN monitoring by United Nations High Commissioner for Refugees (UNHCR), real-time solutions for water tanker and water reservoir remote monitoring to improve the effectiveness of water trucking programming globally. WATER4HUMANITY by Tel Aviv University, a new circular economy solution allowing ultra-filtration of water using discarded “artificial kidney” filters.
WASH in Humanitarian Situations
Lebanon: Menstrual Hygiene Management Among Syrian Refugee Women in the Bekaa. Oxfam, June 2020. The research provides potential solutions and recommendations for integrating menstrual hygiene management in humanitarian responses, particularly targeted at the WASH, protection, education and health sectors.
Emerging Learning Brief: Strengthening Local Governance of Watershed Management for Water Supply and Irrigation in the Dry Corridor of Honduras. Global Communities, June 2020.
Under the Dry Corridor Alliance Program (ACS-USAID), the Government of Honduras and USAID aim to reduce extreme poverty and malnutrition in rural areas of Honduras.
Since 2017, Global Communities has been implementing the “Watershed Management and Conservation” component of ACS-USAID in the departments of La Paz, Intibucá and Lempira, working with national government agencies, local and regional governments, communities and water organizations to address weak management of watersheds, which often results in severely deforested lands.
The Project provides grants to communities to reduce rates of degradation and reforest the watersheds, providing sustainable access to water for consumption and irrigation.
Global Communities also provides technical assistance to strengthen the capacity of local communities and organizations to manage water resources.
This Learning Brief describes the Project’s participatory approach, shares results to date and identifies key emerging lessons that will help to strengthen the Project moving forward.
Below is an excerpt from the Water Currents issue on WASH and financing and the complete issue is on the Globalwaters.org website.
How Improved Financing Enhances Water and Sanitation Service Delivery . Global Waters Radio, March 2019. How can better financing help extend water and sanitation services to those most in need? To answer that question, Global Waters Radio speaks with two experts: Ella Lazarte, senior water and sanitation advisor at USAID, and Barbara Kazimbaya-Senkwe, global knowledge management and communications lead with the USAID–supported WASH-FIN program.
Reform and Finance for the Urban Water Supply and Sanitation Sector . World Bank, August 2019. This summary note integrates three lines of work—utility reform, sector reform, and sector finance—for readers to understand the critical links among the three spheres.
Utilities in Developing Countries, in Financial Tailspin, Try to Keep Water Flowing During Pandemic and Beyond . Circle of Blue, May 2020. Water utilities are experiencing a “double hit” in their finances that could hinder operations into the future.
Rethinking the Economics of Rural Water in Africa . Oxford Review of Economic Policy, January 2020. The findings conclude with policy recommendations to network rural services at scale, unlock rural payments by creating value, and design and test performance-based funding models at national and regional scales.
Channeling Financial Flows for Urban Water and Sanitation . Center for Strategic and International Studies, November 2019. New sources of financing are needed to provide clean water and sanitation for citizens around the world. The challenge is particularly acute in cities where population growth and urbanization are stretching resources and deteriorating living conditions.
Financing for Water—Water for Financing: A Global Review of Policy and Practice . Sustainability, February 2019. The relationship between the water and financial sectors is explored through a review of past and current policies and practices, and new needs driven by growing water insecurity (i.e., drought and floods) and climate change.
Read the complete issue.
The challenges of developing an 'Indian' protocol to monitor COVID-19 in sewage.
Testing sewage can be an effective tool for monitoring the spread of the Sars-nCoV-2 virus in populations. An 'Indian' protocol is needed that takes into account the poor quality of sewage systems, challenges in transportation and testing of samples, and supports city and state governments to communicate with the public. A thematic online discussion hosted by the Sustainable Sanitation Alliance (SuSanA) in May-June 2020, elicited information on the components and challenges of such a protocol. This report synthesises the online discussion as well as the findings of a webinar on "Addressing stakeholder concerns around testing sewage for COVID-19" jointly organised by SuSanA, WaterAid India, IRC and the India Sanitation Coalition on 22 May 2020.
Following the start of a new four-year programme funded by Sida, the Institute of Development Studies (IDS) launched the Sanitation Learning Hub website on 22 June 2020.
The website is divided into into three main sections:
Watch this video introduction to the new website.
Sanitation Learning Hub
Center for Water and Sanitation (C-WAS), CEPT University in India – CEPT’s Center of Water and Sanitation (CWAS) works on urban water and sanitation related action research. In Maharashtra, the C-WAS team works closely with the state government and local government to support implementation of the Swachh Bharat Mission. There is also a link to C-WAS at CEPT University.
Selected reports and resources include:
Policy Brief: Financing and Business Models for Faecal Sludge and Septage Treatment for Urban India. CWAS, July 2019. This policy brief identifies the possible financing options and business models for setting up Faecal Sludge Treatment Plants (FSTPs) as a part of citywide FSSM services. The research findings highlight that capital financing requirement for FSTPs is only a small proportion of the total urban sector outlay at both the national and state levels. Thus, there is a need to create better awareness at both national and state levels to explicitly incorporate FSSM related components in national programs.
Exploring Development Impact Bonds: Faecal Sludge and Septage Management (FSSM). CWAS, July 2019. In this Roundtable Discussion, participants shared preliminary ideas on DIB in FSSM, assessed opportunities and challenges and discussed the potential impact on investors and outcome funders.
Development Impact Bonds for Urban Sanitation in India. World Water Week, Stockholm, Sweden 2019. Development Impact Bonds or a Social Impact Bond (SIB/DIB) can help unlock private financing while focusing on social outcomes. This video discuses CEPT and partner initiatives to develop SIB/DIB for urban sanitation in small towns in India.
15th Finance Commission: Covid-19 Warrants Rethink of Local Government Allocations. Ideas for India, April 2020. In this post, Meera Mehta and Dinesh Mehta provide suggestions with regard to increasing allocation for sanitation, and making available more untied funds for urban local governments to enable them to meet exigencies of Covid-19-like situations.
Sanitation Taxes for Waste Treatment Plants and Pay-for-Success in Desludging. OECD. Technical assistance provided by CEPT enabled municipal governments in Wai and Sinnar in the India State of Maharashtra to establish a sanitation tax as part of existing property taxes and to introduce city-wide fecal sludge and septage management services. The approach uses a public-private partnership to deliver scheduled emptying and establish fecal sludge treatment plants.
USAID’s Water Team is pleased to introduce a new series of technical briefs that provide guidance for developing and implementing water and sanitation activities in support of the U.S. Government Global Water Strategy and USAID’s plan under the strategy.
These are intended to be used by staff working in the water, sanitation, and hygiene (WASH) sector, both within and outside of USAID. The first set of technical briefs cover:
These briefs draw upon the latest evidence from USAID’s research and learning activities, our ex-post evaluation series, and other WASH sector studies. USAID WASH technical experts developed the briefs to highlight key considerations for activity design on a specific topic and provide recommendations for implementation and monitoring.
Each brief puts current practice into context with a discussion of programming approaches that have and have not worked in the past, includes concrete examples from the field, and suggests additional resources for further reading. Readers will have a better understanding of how to put the latest technical guidance into practice in the context of a USAID activity.
The rural water brief describes the important roles of national governments, service authorities, and service providers in delivering sustainable water services beyond first-time access. It describes various water service delivery models as alternatives to the traditional approach of volunteer community water management committees which has failed to sustain services in the past.
The rural sanitation brief focuses on how to address governance, financing, markets, and behaviors to achieve areawide coverage of sanitation. It also notes the need to leave space for failure and learning, as the sector does not yet have all the answers in this area.
The brief on WASH and nutrition outcomes summarizes the evidence of how WASH services and behaviors affect nutrition, given recent results from the Sanitation Hygiene Infant Nutrition Efficacy (SHINE) and WASH Benefits trials. It recommends key approaches to achieving the type of transformational WASH that is likely to lead to benefits for child nutrition.
We hope these briefs are helpful to those designing and implementing WASH programs. Additional briefs will be released in the coming months. Look for new additions on Globalwaters.org.
By Elizabeth Jordan, Water and Sanitation Advisor, USAID RFS Center for Water Security, Sanitation and Hygiene
In this newsletter we are pleased to announce the forthcoming launch of our new website! We also offer timely advice to sanitation and hygiene practitioners in the second edition of our Handwashing Compendium for Low Resource Settings: A Living Document.
You may already know, here at the Sanitation Learning Hub, we’ve been working hard on a new website and branding, following the start of a new four-year programme funded by Sida. From Monday June 22nd the site will be available at https://sanitationlearninghub.org/
The compendium is a living document which will be updated regularly as more examples and good practice emerge. It has been developed and disseminated quickly so immediate, relevant and timely actions can be taken.
This version is the second edition. This updated version includes new sections on:
Since the coronavirus began spreading throughout the world, few things have been unaffected by the COVID-19 pandemic. Our activities to develop markets for WASH products and services are no exception.
We’re all figuring out how to shift and adapt to contribute to the prevention of this deadly virus. Naturally, water, sanitation, and hygiene (WASH) are at the centre of these efforts. The USAID Transform WASH team in Ethiopia has learned some important lessons about how to make these shifts and stay true to the central objectives of the project.
Most emergency situations, such as natural disasters, affect WASH markets both negatively and positively. They can disrupt the market supply of WASH products and services, and humanitarian responses that include free distribution of WASH products can unintendedly create long-term damage to markets by reducing customers’ willingness to pay for such products. But emergencies can also be a blessing in disguise as key messages on good hygiene and sanitation practices reach a larger proportion of the population and are more likely to be adopted as people seek to reduce their vulnerability. This can, in turn, increase demand for WASH products and services, benefiting well-prepared businesses that are able to deliver to their household customers as well as to emergency response programmes.
For Transform WASH, the team has observed a range of negative impacts on their activities caused by the coronavirus pandemic:
However, we have also seen positive effects of the pandemic. While demand for sanitation products has declined as a result of the outbreak, there has been a surge in household, business, and institutional demand for hygiene products, such as handwashing stations, soap, alcohol-based hand sanitisers, and personal protective equipment, like gloves and masks. This sudden high demand did not come without challenges and has placed a strain on supply chains, and it has been difficult to procure priority items centrally and distribute them where needed.
For example, plastic handwashing stations, which had previously seen low consumer demand but reasonably steady institutional demand from NGOs and international agencies, were suddenly potentially attractive in the household consumer market, yet supply chains hardly existed outside of larger cities. Manufacturing inputs for these products have been in short supply due to the increased challenge of importing raw and some finished materials (such as plastic water taps) into the country. In addition, high demand has led to price escalations, putting the cost of many of these items out of reach of both businesses and consumers. Though the government has attempted to control prices during the outbreak, the focus has been primarily on fast-moving consumer goods like food items.
These supply disruptions and shortages, and other logistical challenges caused by the outbreak, have highlighted the important role that an active private sector for WASH products and services can play when most needed. Interventions such as USAID Transform WASH, which seek to improve distribution systems and the operational capacity of small businesses, ultimately help Ethiopia meet current demand and build capacities to address similar types of public health emergencies in the future. However, it is important to start identifying the lessons emerging from the COVID-19 crisis now, such as:
“We no longer need to convince the community about the importance of sanitation and hygiene. We have to diversify our product options creatively and respond to the huge demand created by COVID-19.” - USAID Transform WASH Business Advisor
As the pandemic arrived in Ethiopia, USAID Transform WASH had just started, as part of our planned goals for the year, to support local manufacturing and distribution of handwashing stations. To date, in two short months, our business partners have sold 4,000 handwashing stations to household customers. Many more are in the pipeline, but with nearly 50 million Ethiopian people lacking access to this basic facility in their homes, the market has nowhere to go but up.
About Transform WASH
USAID TRANSFORM WASH sets out to improve water, sanitation and hygiene (WASH) outcomes in Ethiopia by increasing access to and sustained use of a wide spectrum of affordable WASH products and services, with a focus on sanitation. It does so by transforming the market for low-cost, high quality WASH products and services: stimulating demand at community level, strengthening supply chains, and building the enabling environment for a vibrant private market.
USAID TRANSFORM WASH is a USAID-funded project implemented by PSI in collaboration with SNV, Plan International, and IRC. The consortium is working closely with government agencies including the Ministry of Health, the Ministry of Water, Irrigation and Electricity, the National WASH Coordination Office and regional governments.
Report of a webinar organised by the SuSanA India chapter, WaterAid India, IRC and the India Sanitation Coalition.
This blog was written by Shiny Saha and Nitya Jacob.
Indirect detection: Infected people shed the virus in their stools, and sewage samples, can indicate the viral load in the community (Photo Credit: Courage Kosi Setsoafia Saba, University for Development Studies, Ghana)
Traces of the coronavirus have been detected in sewage. As per a guidance document (23rd April ’20) by the World Health Organization, there has been no evidence yet to suggest that the SARS–CoV-2 virus transmitted through treated or untreated wastewater is infectious. Tracking sewage for traces of the virus, however, can be one of the proxy indicators to identify where the infection is prevalent. “Routine wastewater surveillance could be used as a non-invasive early-warning tool to alert communities to new COVID-19 infections.”
In light of a high percentage of asymptomatic or undiagnosed cases, Wastewater-Based Epidemiology in the absence of adequate clinical surveillance can provide the critical information required for the management of the public health crisis. Faecal matter may in fact be a more reliable test of infection than respiratory samples. According to Dr. M.R. Seetharam, tracking sewage cannot only be useful when studying the behaviour of the virus but can also help in identifying the geographical area and the asymptomatic carriers and decode subsequent outbreaks, as has been done in the case of cholera in the past.
Participants webinar on Addressing stakeholder concerns around testing sewage for COVID-19. Photo Credit: IRC
On 22 May, the India chapter of the Sustainable Sanitation Alliance (SuSanA), WaterAid India, IRC and the India Sanitation Coalition jointly organised a webinar on Addressing stakeholder concerns around testing sewage for COVID-19. With speakers, Malini Reddy (Administrative Staff College of India), M.R. Seetharam (SVYM), Sharada Prasad (Azim Premji University), S, Vishwanath (BIOME), chaired by Sunetra Lala (SNV), the discussion was attended by 350 participants. The speakers at the webinar discussed the significance of testing sewage and the infrastructural, administrative and social implications.
The discussants shared that while most cities in India are yet to adopt wastewater tracking, it is important to be vigilant in terms of management and handling of waste. Safe management of liquid waste, faecal waste, and bio-medical waste is essential to prevent the spread of the SARS–CoV-2 virus. Therefore sewage treatment plants (STPs), community and public toilets, and faecal sludge treatment plants need to be regularly cleaned.
Further, workers at all levels should be wearing Personal Protection Equipment (PPE). A circular issued by the Central Public Health and Environmental Engineering Organisation of the Government of India, to water and wastewater utilities and pollution control boards, recommends that wastewater treatment should be followed by chlorination. Further, it suggests PPE for sanitation workers and following certain health protocols - such as testing the workers for symptoms and hygiene and disinfection of contact surfaces of the STPs.
While important, these recommendations address only the formal wastewater treatment set-up. Meeting the recommendations will require changes in the design parameters for STPs that currently do not include chlorination as a means of disinfecting sewage.
Sewage or wastewater testing though important has inherent challenges. Tracking sewage or wastewater is complicated, especially in the context of India, where most wastewater is a cocktail of black water, grey water, bio-medical waste and industrial effluents. Wastewater-based surveillance is focused on sewered areas. Slums and rural areas, thereby, remain untested largely because most people use onsite sanitation systems. These are not amenable to mass testing of the kind being proposed. The wastewater catchment area is huge, comprising of formal and informal set-ups. For example, in the city of Bangalore, there are 28 sewage treatment plants under the Bangalore Water Supply Sewerage Board, which cater for around 10 million people. Then there are more than 3500 decentralised STPs mandated for apartments and gated communities, and there are the community toilets run by the municipalities. This is further compounded by the fact that there are more than 500,000 onsite systems, comprising of pit toilets, community septic tanks, and temporary toilets. And, there are more than 500 honey-suckers, who collect waste from onsite systems and take it to either the STPs, or dump it in agricultural fields or stormwater drains.
It is also important to take into consideration the movement of wastewater. In most cities, wastewater flows through a vast hinterland. In the case of Bangalore, for example, treated wastewater from the formal STPs flows up to 90 kms from the city, filling up lakes and recharging aquifers in the process. Farmers then tap into this wastewater through shallow open wells for agriculture.
In terms of the informal set-up, only half of the wastewater gets collected and treated. The rest flows through stormwater drains and enters river systems. Farmers tap into the untreated wastewater – comprising of a cocktail of chemicals - for agricultural purposes. It is important to mention here that there are no standards for groundwater recharge using wastewater in India.
Competing priorities often tend to overshadow wastewater testing. And, in the absence of clarity on testing protocols, guidelines and regulations, Urban Local Bodies (ULBs) are hesitant to adopt sample testing. They realise if test results are positive, it can lead to scaremongering.
Handling of waste renders sanitation workers particularly susceptible. In India, the unique sanitation infrastructure implies that sanitation work comprises of a spectrum of activities – including manual scavenging, stormwater drain cleaning, collection and segregation of solid waste, construction work, and more. Informality in sanitation work is widespread which in turn increases the risk factor associated with such work. Formalising the entire spectrum of sanitation work is not feasible. And, mechanisation does not address the entire gamut of work involved. Likewise, the available PPE is not suitable for the range of activities associated with sanitation work. There are persisting issues related to practicality and comfort, which hinder, rather than aide work.
The implications of sewage testing as a reliable tool to inform on the spread of the infection is significant. Regular monitoring of sewage is important in the context of COVID-19 as well as for any future public health emergency. The benefits of testing far outweigh the costs involved in the same. The willingness of ULBs, however, is an area requiring work. Additionally, it is important to have standard protocols and guidelines from the national government, and Central Pollution Control Boards in the states need to regulate STPs on the same, in order to mitigate any public health risk. Developing a risk matrix based on wastewater flows, at present, may prove useful as a starting point.
Further, in addressing the pandemic, there is also a need to shift focus from development infrastructure to social infrastructure. Ensuring health and safety of sanitation workers is crucial. Sanitation workers work and live in close proximity to other citizens. Thereby, having the right mechanisms in place is crucial from the public health outbreak point of view as well. Thus, COVID-19 presents an opportune moment to rethink sanitation and think about systemic changes towards building a sustainable public health infrastructure in India.
Watch a video recording of the webinar below.
Under Resources you will find a synthesis document of on online discussion held in conjunction with the webinar on "Testing sewage for early warnings about COVID-19".
Is hazardous medical waste sufficiently managed?
This article was written with Kim Worsham, founder of FLUSH
During the COVID-19 pandemic, the world became aware of the importance of improving WASH for communities (and that for many, the first line of defense against COVID-19 is out of reach). It also became obvious how vital it is for healthcare facilities to have proper access to WASH so that patients and medical professionals have a fighting chance to recover from illness and prevent the spread of infectious disease. And, let us not forget the striking risks of exposure for essential workers like janitors and waste handlers and their need for appropriate personal protective equipment (PPE).
One in five healthcare facilities in the world lacks access to essential WASH services, which has hurt a lot of the Global South’s ability to recover from COVID-19 and reduce spreading. In Niger, where IRC is working with the Conrad N. Hilton Foundation on a WASH in healthcare facilities programme, baseline data from two communes is shocking: most healthcare facilities do not have access to WASH facilities.
Baseline information of access to WASH and waste services in Niger, based on 2019 Public Water Service of Municipalities Report. (Adapted from a presentation by I. Krukkert)
With the surge of concern and need for healthcare, however, the world urgently needs to start addressing how we can make sure medical waste is not contaminating our environment and increasing the spread of other diseases in the future. With the COVID-19 pandemic, the volume of medical waste has quickly risen, as have questions of proper disposal and waste labourers’ working conditions.
Globally, one in four healthcare facilities lacks basic waste management services (WASH in Healthcare facilities, 2019 baseline report), meaning that healthcare staff safely segregate waste into at least three bins and hazardous waste is treated and disposed of safely. The three bins are for general waste, infectious waste, and sharps. Where does this medical waste go if it’s not managed? The odds are pretty high that they end up in the environment.
Fortunately, about 85% of healthcare facility waste is non-hazardous, and facilities can dispose of it along with general solid waste, which means it will likely end up at the local dumpsite. However, this doesn’t mean that healthcare facilities actually manage their solid waste properly or at this basic level. An evaluation of WASH and Environmental Conditions in 40 healthcare facilities in a rural district (Kabarole) in Western Uganda found that the facilities did not commonly practice proper bin use or waste segregation.
The remaining 15% of healthcare waste is hazardous - namely those that are infectious, chemically hazardous, radioactive, or sharp. When hazardous waste is treated, the common methods in healthcare facilities in the Global South are autoclaving and incineration. Autoclaving uses steam to sterilise medical waste, which is then often landfilled. Incineration of hazardous medical waste aims for controlled burning. Both practices can be part of a good waste management system; however, they can also pose health risks indirectly. Poor incineration practices can cause severe environmental pollution, including the release of highly toxic carcinogens like dioxins and furans, which is harmful for surrounding communities (2004 WHO Policy Brief). Disposing of untreated healthcare wastes can contaminate waterways, especially when landfills are not properly engineered and managed.
When practising landfill dumping, healthcare facilities must appropriately manage this waste to prevent dangerous exposure. Used needles are generally the most hazardous of healthcare waste because they can easily cause stabbing injuries and subsequent infections. Sharp waste is also highly infectious - needle-stick injuries have a 30% Hepatitis B transmission rate. When hazardous waste is poorly segregated from nonhazardous waste, general waste has a high risk of getting contaminated (2018 Africa Waste Management Outlook).
Exposure to hazardous medical waste is especially worrying for janitors and waste workers. The opportunities for skin contact with medical waste are ample, especially when:
The COVID pandemic has brought to our attention the hazardous conditions in which untrained and unprotected healthcare workers work. These vulnerable (and often overlooked) workers are essential and also deserve PPE and training to do their jobs effectively, with their health protected and risks minimised and/or controlled. In Pune, India, the waste workers cooperative (SWACH) is working hard to protect their #CoronaWarriors with PPE and food rations, educate the public on how to support the waste workers, and advocate with the city to amend waste disposal protocols. The efforts are commendable, as seen in the picture below. More places need to protect waste workers better, especially with the influx of hazardous medical waste being disposed of.
The adjusted waste pickup schedule in Pune issued by the municipality with instructions for households. Households can dispose of medical waste including sanitary napkins and diapers daily so long as it is labelled with a red dot – a simple but effective mechanism alerting waste workers not to open these packages (Times of India, 25 May 2020)
For healthcare facilities that opt for incineration in resource-scarce settings, simpler single-chamber incinerators are all too common; these technologies don’t reach high enough temperatures or control the emitting gases. Curiously, given that single-chamber technology may be the best available option for the area, it meets the requirements for basic waste management service at a healthcare facility, assuming it is a transitional measure (as described in a 2019 WHO report on treatment technologies of hazardous medical waste).
In Addis Ababa, Ethiopia, a study of hospital incinerators paints a very stark reality. Nearly all of the incinerators (93%) were single-chamber brick incinerators, none of the chimneys were of appropriate lengths and none of the hospitals’ incinerator operators (janitors) were trained. Only a few of the “modern” incinerators were functioning and properly used! Inadequate incineration of hazardous healthcare waste is a serious environmental and public health concern (2017 Hospital incineration study in Ethiopia).
WHO and UNICEF developed a methodology to improve WASH and waste management in healthcare facilities, called WASH-FIT. Essentially, the approach includes assembling a team that completes a hazard and risk assessment for the healthcare facility, develops an improvement plan for waste management, and monitors implementation. The approach promotes the use of bins required for basic waste management.
There are lots of improvements to be made around the management of healthcare waste worldwide, especially if we’re trying to reduce pandemic-prone diseases and climate change at the same time. The WASH-FIT methodology is a first step to thinking beyond the boundaries of the facility and where healthcare wastes (and also faecal waste) end up and if they are properly disposed of and treated.
Special thanks to Aditi Dikey (SWACH Cooperative) for insights into the cooperative and Tettje van Daalen (IRC) for editing.
Some of the cleanest and smartest toilets in the whole Bongo district are found at Foe Community Health and Planning Services (CHPS). This community health post serves more than 2,280 people in four communities across an area stretching up to the border with Burkina Faso.
Material prepared by a team from the Ghana National Development Planning Commission and IRC Ghana
Isaac Adita Principal Enrolled Nurse at Foe CHPS – now one of the most popular centres in the district for women to give birth
Isaac Adita has been Principal Enrolled Nurse since 2016 - a time when the CHPS centre had neither running water nor effective sanitation. Mothers had to fetch water themselves or get relatives to deliver to them. Instruments could not be washed easily and mothers and nurses had nowhere to clean themselves up after delivery.
WaterAid Ghana – with funding from Canada and support from Bongo District Assembly – brought clean piped water to the health centre in 2017 through a mechanised borehole. In 2019 they added a toilet block and a brick kiln for burning sharps and some waste. The whole system is connected underground to a biogas unit that will eventually supply cooking gas to the staff quarters for cooking.
Isaac Adita says that this is one of the most popular CHPS in for women to deliver. Patients have a shower and toilet next to the delivery room. They can wash themselves and their clothes before returning home with their babies. “I am very, very, very happy,” he said. “We used to have water shortages and staff walked to fetch water before they came to work.”
Infection control is a major objective and it is now easy to sterilise instruments and keep the centre clean. For the patients, liquid soap and toilet rolls are provided. “Cleanliness is next to godliness,” says Isaac Adita. “Health workers have to ensure that the structure is clean enough to reduce infection so we also educate the community on how to use the toilet facilities any time they visit.
Facilities at Foe Community Health and Planning Services
Bongo district is increasing its reliance on small town water systems to provide safe water in areas where the population is more concentrated. Deep boreholes provide water to storage tanks and standpipes across the area – with the potential also to make household connections.
Material prepared by a team from the Ghana National Development Planning Commission and IRC Ghana
In the town of Bongo Soe three mechanised boreholes pump water to a single overhead tank which distributes the water to eight standpipes, currently used by about 6,000 people. They pay small amounts 10-20 pesewas (US$ 0.17-0.35) depending on bucket size to collect from the standpipes.
So far only 15 households are directly connected but the Water and Sanitation Management Team has a target to increase household connections to at least 100 with a second overhead tank to meet demand. Households buy the parts (pipes and meter) they need for connection costing from 300-500 GHS (US$ 52-88) – but do not pay a connection fee. They are billed monthly for water they use.
In the heart of Bongo Soe is a market site which is currently being redeveloped. There is already a tap in the market square. When traders return they will also find an immaculate suite of toilets.
Cynthia Azure has a cloth stall at the market and is also the water vendor. She will look after the toilet block and collect a small fee from everyone who uses it. There can hardly be a market place anywhere with nicer toilets than these! Looking proudly around the new facility, she says: "The way they have done it is nice. That is what we want. We should not be defecating outside."
Daniel Canyase, Bongo Assembly District Co-ordinating Director, agrees. "A toilet is very important for every public space and more especially for a market where we have so many people coming from outside the community and we are still battling with household toilets. Otherwise what is going to happen is they will free themselves in any case and where will they do that? They will end up polluting our markets and our communities."
Cynthia Azure water vendor and market trader will look after the toilet block designed to keep the market defecation free
Asaloko is a small community in the Bongo district where lives have been transformed through the introduction of safe water and effective sanitation. Householders no longer carry water long distances, children are better able to learn and the whole environment has been cleaned up.
Material prepared by a team from the Ghana National Development Planning Commission and IRC Ghana
Just 360 people live in this settlement of 24 wide spread compounds, where a primary school also meets the needs of 201 children from Asaloko and the neighbouring community of Amanga.
Asaloko was included as one of the WASH for Public Health (WASH4PH) project communities where WaterAid installed a solar powered mechanised water system piping water to the school and the community and helped local inhabitants to tackle pollution and hygiene issues through community-led total sanitation (CTLS).
The impact is visible. Three tall structures with overhead Polytanks supply clean, safe water. Almost every household compound has added a toilet and many also have made tippy-taps for hand-washing. It is one of a relatively few communities not disfigured by plastic bags drifting across the landscape. The water system serves Asaloko Primary School and the local community through three tap stands. To reduce cost, the solar powered system operates without batteries and pumps water during the day.
When mechanic Atanga Adongo arrives first thing in the morning to open the pipeline, the system pumps water to the overhead tanks at about 100 litres per minute. The tanks supply enough storage for the community to be access water 24 hours a day, seven days a week.
Jennifer Nyaaba (see picture below), advocacy team secretary for the community water and sanitation management team (WSMT), says the WASH4 Public Health project has also brought significant changes in sanitation. “Before 2016 you would come to the community and the whole place smelled. People thought that maybe in defecating in the open they were adding manure or something like that to their land – ignorantly. But true awareness came to them."
She points out the tree where people used to go to defecate. “If it happens that you are all ladies or men then you are able to manage but if it happens that it is a lady and man you don’t feel comfortable. And if the pigs are around they are there crying to get you to get up faster so they can come and eat the faeces. Meanwhile we cook the meat of that pig and eat it. So we are causing harm to our bodies, our systems and a lot of diseases.”
After a big community effort Asaloko was declared open defecation free in July 2019 and proudly maintains its status. “You can see around there is no rubbish – we don’t litter, we don’t defecate openly. If you go to a far place and you feel like defecating and don’t see a toilet, you will be in a hurry to get home.”
Margaret Awoo a teacher at Asaloko School is happy that Asaloko was one of the communities selected by WaterAid Ghana. “They came here to train us how to clean and how to end open defecation. So through that every household has to build a toilet.” The community selected leaders to check that everyone was following the new ways. “We have days that they go round to see – they enter the toilet and see whether it is clean. And we charge you. If we find your toilets unclean or your surroundings with rubbish you pay. And if we catch you defecating outside not in a toilet you pay. Because of that the community is clean."
Head teacher, George Apikia says that children at Asaloko Primary School are happier and more focused now there is water close by. In former times the children aged 4 to 13 would walk more than 25 minutes to fetch water and lessons would be delayed. Now they fill water bottles from the Polytank or use cups provided by the school and water outside the classroom. They also have a toilet onsite and wash their hands using a Veronica bucket and soap. The children put on WASH education performances at the school for parents and encourage them to make tippy-taps so they can wash their hands.
Jerry Nyaaba, secretary of the Asaloko WSMT, says the project has improved the children’s education. “Any time they come to school in the morning there is enough water stored in the polytank for their usage and when they go to the toilet there is water for them to wash their hands. It has improved their health conditions and made life and learning easier for them."
It is not only the children who appreciate the change. Rosa Nsobilia, pregnant with her second child, had been advised not to let her first child drink from the old borehole. “But this one, I think it is quality. If you give the child this water I think the child will be healthier. I am happy, simply because there are some people in cities that don’t have quality water. We are in a village but we have quality water to drink."
Bongo district in the Upper East Region of Ghana became known throughout Ghana for the quality of its water –for the wrong reason. The district is a global hotspot for fluoride concentration and water from some wells was damaging the health of its population.
Material prepared by a team from the Ghana National Development Planning Commission and IRC Ghana
Bongo district in the Upper East Region of Ghana became known throughout Ghana for the quality of its water – for the wrong reason. The district is a global hotspot for fluoride concentration and water from some wells was damaging the health of its population.
While many countries add low levels of fluoride to drinking water to prevent tooth decay, high concentrations do just the opposite – damaging teeth and bones and implicated in other health problems.
Ebenezer Asomaning, Bongo District Engineer and WASH Focal Point, says the effects are visible in the community. “You can see the dental fluorosis in our children and some other groups. We are also aware that it affects the bones with constant pain to aged groups, so the effects are very serious.” Good practices to combat this have now been implemented throughout the district including communities in Bongo town, Asaloko, Foe and Soe.
When the local government, Bongo District Assembly, set out to address this issue they first had to take a step back. More than 30 boreholes that had been dug to replace surface water sources had to be capped after they were found to be severely affected. There was an urgent need to replace them with safe clean sources.
Daniel Canyase, Co-ordinating Director of Bongo District Assembly, says the district had to appeal for help. “Community members and leadership cried out to Government and other development partners to come to assist them. All the opinion leaders and the stakeholders coordinated their efforts to get people to appreciate their plight." And partners did respond – including the World Bank, UNDP and UNICEF. Most recently, WaterAid Ghana has been working on a WASH for Public Health (WASH4PH) project in 24 Bongo communities, focusing on schools and community health care facilities (CHPS).
The district itself also responded, more than doubling the District Assembly WASH budget for 2019/20 and committing itself to drilling and rehabilitating at least 15 boreholes a year and increasing the number of small-town schemes.
The Co-ordinating Director says that water has become a top priority for the Assembly. “Even though the District Assembly is doing other things including education and health, we see water as a major concern because of the vital role it plays in our lives.”
Bongo district has made strong progress. Water coverage is up from 70% in 2017 to 84% in 2020. However, only 24% of people receive safe water through mechanised boreholes. By next year (2021) the district plans to raise mechanised coverage to 40% with six small town schemes covering 20 communities, based on deep boreholes.
Both WaterAid and the District Assembly install mechanised systems powered by the latest solar technology so that communities do not face electricity charges for running their systems. More emphasis is being paid to ensuring that community Water and Sanitation Teams collect money to sustain the systems, while the District Assembly WASH team provides technical advice and training.
The most efficient means of collecting money is through ‘pay as you fetch’. However Daniel Canyase, District Co-ordinating Director says that it is important that payment systems have community support and some prefer monthly collections. “We do not force them to adopt a certain system of collection. We rather build their capacity on what they already know and how to do it. If you push them and support them a little they will be able to collect the money.”
Ebenezer Asomaning, Bongo District Engineer and WASH focal point, is optimistic that they will achieve SDG Target 6 ahead of schedule. “We are on course by 2030, even before that time. Looking at our investment and what we have now, we will be able to achieve 100% coverage by 2025.”
The focus is not only on water. Sanitation is equally significant. In 2015 when WaterAid began its WASH4PH project, more than eight out of ten people were practising open defecation in Bongo district. So when WaterAid installed solar powered mechanised water systems to pipe water across communities, it also helped them to tackle pollution and hygiene issues by introducing community-led total sanitation (CLTS) and training community members to promote good hygiene.
District Environmental Health Officer, Mumuni Abdulai and Jennifer Nyaaba, advocacy team secretary for the community water and sanitation management team
The District Environmental Health Officer, Mumuni Abdulai, describes how the district and partners trigger the CLTS process leading people on “a walk of shame” through the community, noting where people defecate and then drawing a community map on the ground, marking all the houses, schools and water points. People soon agree that when the rain comes the faeces will pollute the water supply. “They will tell you - the faeces will all flow to the water sources. In effect, if you go and drink, what are you doing? You are taking in your own faeces. That is where the triggering starts. People start to think that the situation where we find ourselves is not the best and they think about how to change it.”
Today the district reports that 38% of households have access at least to basic sanitation and the number of communities that have been declared open defecation free is increasing.
George Kwabena York, WaterAid Ghana Head of Policy, Advocacy and Campaigns, says good sanitation and hygiene practises are the hardest targets to achieve. With enough resources and commitment, safe boreholes can be dug and water provided. “The sanitation component is very difficult to change because it is really about attitude and behaviour, so it takes a little bit of time."
Over the course of its five year project, completed at the end of December 2019, WaterAid helped 19 of the 24 communities where it worked to become open defecation free, and it hopes in the future to expand this record.
“We still have a long way to go and a lot of activity with ODF. We are hoping that when we go there in a year or two, they will not have gone back to their old way of doing things.” WaterAid is looking for ways to ensure that progress is sustained and expanded to more of the 99 communities in Bongo district. “We are developing case stories and ensuring that we share them with the District Assembly and throughout the country for others to also buy into that, so that together we can really help the country to achieve our SDG target by 2030.”
Bongo has benefited from the support of partners, but the District Assembly takes responsibility for the overall plan and coordination, developing its Medium Term Development Plan with other stakeholders and preparing a District Water and Sanitation Plan, within guidelines set in the National Medium Term Policy Framework (NMTPF).
Daniel Canyase says: “The Assembly coordinates all the partners in such a way that everybody is put on their toes to play the role they committed to. We don't leave anybody out of the equation. Everybody is brought on board and is supported to do what he is expected to do.”
Thomas Kugoriba, District Assembly Planning Officer, says that the district has created an enabling environment for development partners and it also ensures that communities are in favour. “Community entry is very important so before we start any project through development partners, we get in touch with the traditional authorities, interact with them and ensure they buy into the idea. We ensure that they are part of it so that they can take ownership of the project. It all boils down to good leadership.”
Effective WASH services are a source of resilience for communities under threat from COVID-19.
Interview in progress, Peter McIntyre talking to Dr Kodjo Mensah-Abrampa, Director General of the NDPC Ghana
Ghana's development aspirations are aligned with the 2030 Agenda for Sustainable Development and the Sustainable Development Goals (SDGs). Goal 6, which ensures the availability and sustainable management of water and sanitation for all, is a challenge since in 2017 19% of the population did not yet have access to at least a basic level of water services and only 36% were using safely managed water accessible on the premises. Almost one in five (18%) of the population was still practising open defecation. Service sustainability has been further challenged by the large number of non-functional water systems.
In February and early March 2020, a small team from the Ghana National Development Planning Commission and IRC Ghana visited three districts of the country where innovative work is being done towards meeting the Sustainable Development Goal 6. The aim was to collect and document case studies within the WASH sector, share best practices and lessons learned to contribute further to evidence-based innovative development approaches in Ghana. The districts were Wassa East in Western Region, Bongo District in Upper East Region and Asutifi North in Ahafo Region.
The visits took place between February 17 and March 5 2020, meeting leaders of WASH services at district level, representatives of NGOs and development partners, conducting community visits and interviews, and conducting some interviews at national level. The visits were concluded as concern over COVID-19 was developing but before the first cases were found in Ghana. Predictions for future coverage and progress may be affected, depending on the course of the virus in Ghana. However, it should also be noted that effective WASH services are a source of resilience for communities under threat from the virus. COVID-19 highlights the importance of WASH – especially hygiene – as essential protection for communities.
Some common factors can be drawn from these districts, illustrated in the reports that can be found on this website.
Raising the priority of WASH issues was a political imperative in each district. In Wassa East the decision to bring in a more entrepreneurial partner was part of a change in strategic direction. In Bongo district, there was a decision to appeal for outside support to deal with fluoride in groundwater. In Asutifi North, the ANAM process was a decision to become the testing ground for a new approach.
Districts have many partners but the central coordinating, monitoring and oversight role belongs to the District Assembly. There are critical roles at the level of coordinating director, development planning officer, environmental health officer and senior members of the district WASH team who must translate the medium term development into an effective WASH plan and communicate effectively at community level. The three districts had proactive and motivated teams to lead the day to day work.
District Assemblies cannot transform WASH services alone. Each district had at least one specialist implementation partner currently playing a central role in developing services working to the district WASH plan. These partners become familiar brand names in communities. In Wassa East people talked about NUMA water, in Bongo communities progress was linked to “when WaterAid came” and in Asutifi North, one chief had a slogan “where World Vision goes, water flows.”
The example set by influential people within the community is critical in promoting safe water, sanitation and hygiene. If the sub chief is first to build a household latrine, others follow. In one community in Bongo, members of the community water and sanitation management team (WSMT) had the right to inspect latrines and to fine people who defecated in the open. WaterAid Ghana has trained community members to be more active in upholding their rights to water and sanitation. In Wassa East, one Queen Mother is campaigning for household water connections. In Asutifi North, traditional leaders were actively engaged in the development of the Master Plan. Civil society groups play an active role in educating communities to take responsibility for maintaining services.
District Assemblies’ budgets are stretched over a range of services. Financial support is required to implement WASH plans. Donors not only provide funds, they also provide encouragement and support. In Wassa East, capital and central staff costs for Access Development are supported by Water4 which in turn is supported for work in Ghana by the Netherlands’ Enterprise Agency (RVO). The Conrad N. Hilton Foundation provided funds to subsidise the cost of household connections and provided training in marketing. In Bongo, WaterAid Ghana provided funding for health care facilities and schools and for its work in communities. It is looking for further finance to continue work in the district. In Asutifi North, the Conrad N. Hilton Foundation has not only provided finance towards the ANAM process, but brought its grantees together and encouraged them to work collaboratively.
These districts all faced low rates of access to water and sanitation but set ambitious targets for a high level of service delivery. Schools and Community Health Planning and Services (CHPS) centres have been a particular target for improved facilities for the most vulnerable. Mechanised provision is more common, aiming to provide water 24/7, through a combination of solar power and larger water tanks, to remove the need for costly electricity or even solar batteries. One innovation being trialled is to use mobile money to activate water points using a smart card.
Payment systems for water in rural communities often fail to cover the costs of minor repairs, leaving the community without water when there is a breakdown. All three districts are making determined efforts to improve cost recovery levels to cover the costs of minor maintenance. The sums charged are small – 10 pesewas (US$ 0.017) for 20 litres of water, but vital to sustainability. In Wassa East, communities sign an agreement with Access Water to practise ‘pay-as-you-fetch’, with monthly bills for those who have household connections. New systems introduced in Asutifi North are all on the basis of ‘pay-as-you-fetch’ and vendors are trained to ensure that the money is collected and banked. In Bongo, the District Assembly does not give directives about how money is collected but encourages communities to make their payment systems work.
Poor sanitation puts water sources under threat, while good hygiene and handwashing is vital during the threat from COVD-19. In Bongo district, WaterAid Ghana links the provision of water to sanitation and hygiene and has provided some schools and health premises with modern flush toilets. The district is promoting Community-Led Total Sanitation (CLTS), helping communities to see how open defecation threatens their water supply. In Asutifi North, World Vision and the District Assembly are telling communities: “no sanitation, no water.” In Wassa East, the District Assembly is working with Community Water and Sanitation Agency to introduce CLTS in 15 communities with support from the World Bank.
Success is a journey – all three districts are still addressing many challenges:
Although Ghana has adopted Community-led Total Sanitation as official policy, sanitation coverage in all three districts lags far behind water coverage. Promotion of sanitation is still not strong enough to eradicate open defecation and ensure that every household has its own latrine. Hygiene, especially handwashing with soap, is essential in this era of COVID-19 but is impossible to practise in the absence of facilities.
Solid waste is a major concern in all three districts. Traditional methods of dealing with waste have been largely abandoned while there is no effective collection system outside urban areas. Many communities live in a sea of floating plastic which blocks drains and blights community life. The national contract for dealing with solid waste is felt to be unsatisfactory.
Where effective cost recovery is missing, facilities are at risk. In one community which introduced a monthly household fee, some people refused to pay, preferring to use former polluted sources. As a result the payment system collapsed. “Free water” is still promoted by some politicians, when it is not free to collect, clean and deliver. Water and Sanitation Management Teams are becoming better at collecting and banking payments but this needs to become standard practice in every community.
In very rural areas where pits are now being dug, the threat from full pits may seem remote. But as open defecation is eradicated and populations in peri-urban and urban areas grow, the need for a strategy to deal with the contents of pits will become pressing. Transforming faecal waste into safe fertiliser is an aspiration, but the technology and safe practice for doing so have not yet been developed. This longer term threat needs national attention.
Asutifi North is seeking ways to monitor water quality at lower cost. Currently, the cost of testing water points at six monthly intervals is prohibitive.
As social and commercial enterprises become more common in rural WASH, it is essential that new enterprises do not lower standards to cut prices. It has been suggested that national guidelines should be developed to ensure a level playing field and to prevent competition on pricing damaging water quality.