A prize to reward excellence in urban liquid waste management in Ghana.

The Sanitation Challenge for Ghana (SC4Gh) Prize was launched on World Toilet Day, 19th November 2015 as a component of the Ideas to Impact global initiative to stimulate competition among Metropolitan, Municipal and District Assemblies (MMDAs) and to encourage inclusive partnership for the design and implementation of liquid waste management (LWM) strategies. 

In 2017, the Ministry of Sanitation and Water Resources launched the Prize for Private Sector and Non-State Actors alongside the SC4Gh to induce the private sector to partner with the competing MMDAs to improve LWM and to influence innovations, expertise and investments in the target localities.

The SC4Gh for MMDAs was funded by DFID-UK and the Prize for Private Sector and Non-State Actors by the Bill and Melinda Gates Foundation. The prize competition took place from November 2015 to July 2019 under the auspices of the Ministry of Sanitation and Water Resources with technical support from IRC Ghana, IMC Worldwide and Maple Consult.

The SC4Gh Prize for MMDAs was in two stages. The design of MMDA LWM strategies constituted the first stage and the implementation of the strategies the second stage. At the end of stage 1, on 30 April 2016, 48 of the 127 MMDAs who registered for the competition submitted their strategies for adjudication. 21 of the 48 MMDAs excelled and were duly recognised with honorary prizes with 3 winning a total of GBP 75,000 in monetary awards.

All 21 MMDA were invited to express interest to participate in the implementation of their winning strategies; and 17 of the 21 MMDAs met the minimum condition and were considered for stage 2. At this stage, the prize for private sector and non-state actors was also introduced. 

At the end of the stage 2 process on March 27, 2019, 15 of the 17 MMDAs and 14 of the over 60 registered private sector and non-state actors submitted their final implementation reports. These were screened and passed to an independent Verification Agent to verify the reports and subsequently to a panel of international and local judges for online and live judging to determine the deserving winners.

At the grand dignified city award on July 24, 2019 at the Marriott Hotel in Accra, 9 MMDAs and 6 private partners were announced and presented with a total prize value of GBP 1,285,000 and US$ 225,000 respectively - for excellence in the implementation of urban liquid waste management strategies and exploring inclusive partnership to influence innovations, expertise and investments in the target localities towards bringing transformational changes to city-wide sanitation service delivery.

The video below presents a snapshot of the SC4Gh events leading to the award and the Grand Dignified City Award ceremony, which took place on July 24, 2019 in Accra, Ghana.

Adapting to climate change and fostering a low carbon water and sanitation sector.

As the world grapples with COVID-19 pandemic, it has become increasingly clear that the provision of safe water, sanitation, and hygiene (WASH) is essential to protect human health during all infectious disease outbreaks. While, the focus is currently on fighting the pandemic, building momentum on an interconnected issue of climate change has to stay high on the agenda.  

The Sanitation and Water for All (SWA) global multi-stakeholder partnership exists to mobilise its partners to better work together to achieve the Sustainable Development Goals (SDGs). SWA partners can play a key role in supporting the bridging of SDG 6 (on water and sanitation) and SDG 13 (on climate action), while recognising that the ability to meet these SDGs directly affects and is affected by almost all of the other SDGs, including poverty, food, gender and inequality, as examples.  

A briefing note addressing the issue of climate change has been prepared that explores how Sanitation and Water for All (SWA) partners can address the risks and challenges presented by climate change through adaptation and mitigation measures. The SWA Framework offers concrete suggestions on how SWA partners can integrate climate change considerations into their planning and actions at global, regional and national levels. The briefing note can be downloaded from the SWA website.

This briefing note explores how Sanitation and Water for All (SWA) partners can address the risks and challenges presented by climate change through adaptation and mitigation measures. The SWA Framework offers concrete suggestions on how SWA partners can integrate climate change considerations into their planning and actions at global, regional and national levels.

This is part of The SWA Briefing Papers. These papers analyze key development issues that are relevant for the partnership, exploring how these issues can be better understood and proposing some concrete action that can be integrated into the collaborative work of SWA's partners.

See additional papers here 

The NDPC selected three districts in Ghana - Bongo, Wassa East and Asutifi North - to highlight successes and challenges in improving access to water and sanitation.

A new project SANIYA SO+ will be implemented in the 17 health centres of the commune of Banfora.

Development stakeholders are joining IRC in the support of the commune of Banfora in becoming a national reference for access to sustainable drinking water and sanitation services by 2030. The One Drop Foundation is financing a two-year project (March 2020 to April 2022) implemented by the Espace Culturel Gambidi (ECG). With a total cost of US$1 million, the project, "SANIYA SO+", complements the actions of the "SANIYA SO" project implemented by Catholic Relief Services (CSR). It will be implemented in the 17 health centres of the commune of Banfora.

SANIYA SO+

An evocative "plus" that announces and clarifies the ambitions of this project to contribute to the improvement of the health of the people of the district of Banfora, by promoting good hygiene and sanitation practices through social art for behaviour change. Indeed, a participatory assessment of the health centres, carried out by SANIYA SO+ and its partners in May 2020, revealed that there are significant risks in the control of infections linked to the transmission of pathogenic genes. These threats to the health of the population have multiple causes, including poor/non-practice of handwashing with soap by both health workers and patients, lack of handwashing facilities and attributes (soap and water), unavailability and lack of adequate maintenance of latrines that meet standards. Since health centres are vulnerable places, they could not be left out of this planning. This is the opinion of the project implementing manager, Mr. Amédée SININI, according to whom "health centres must be places of healing and not places where diseases are spread". Therefore, SANIYA SO+ is focusing its attention on making health centres clean because these places are meant to save lives.

The assessment led to the elaboration of an Implementation Plan (IP) for the said project, which plans to involve the different actors, both from the water and sanitation sector and from the health sector, to work in synergy for the success of the SANIYA SO+ project. Health actors will be at the heart of this project because, as the coordinator of the social art for behaviour change component of SANIYA SO+, Emmanuel Koama stated, "when the word is carried by the actors themselves, it is quickly taken on board".

The workshop

In order to inform the stakeholders of the IP, a workshop was organised on Monday 6th July 2020, in Banfora by the Espace Culturel Gambidi in collaboration with IRC and the commune of Banfora. Chaired by the mayor of the commune, Aboubakar HEMA, with his first deputy by his side, the workshop was attended by several actors from the water, hygiene, sanitation and health sectors. IRC, CRS, One Drop, Health District, Health Agents, MUNYU Association, Banfora municipality and its Directorate of Water, Sanitation and Public Hygiene, Espace Culturel Gambidi were the stakeholders at this meeting. During the workshop, the protocol was signed and exchanged between the municipality and Espace Culturel Gambidi in order to formalise the collaboration between the two parties.

Tasks are defined and precise

At the end of the meeting, the plan met with the approval of all participants and was therefore unanimously validated. After this act and subject to the consideration of the amendments made to the document by the participants, from now on, the tasks for the implementation of SANIYA SO+ are defined and precise. This is the actual start of the project and kick-off for the improvement of the drinking water, hygiene and sanitation services in the health centres of Banfora. All actors are aware of what is at stake. The mayor of the commune, Mr. Aboubakar HEMA said among other things: "We are all leaders for behaviour change in the water, hygiene and sanitation sector. This plan belongs to all of us and each of us must contribute their share to its implementation".

Un nouveau projet, "SANIYA SO+", interviendra au niveau des 17 centres de santé de la commune de Banfora.

Des acteurs de développement se mobilisent aux côtés de l'IRC, pour accompagner la commune de Banfora dans sa vision d’être une référence nationale en matière d’accès à des services durables d’eau potable et d’assainissement d’ici 2030. C’est le cas de la Fondation One Drop qui finance un projet d’une durée de deux ans (mars 2020 à avril 2022) et mis en œuvre par l’Espace Culturel Gambidi (ECG).  D’un coût global de 1 million de dollars US, le projet, "SANIYA SO+", vient compléter les actions du projet "SANIYA SO" mis en œuvre par Catholic Relief Services (CRS). Il interviendra au niveau des 17 centres de santé de la commune de Banfora.

SANIYA SO+

Un « plus » évocateur qui annonce et précise les ambitions de ce projet de contribuer à l’amélioration de la santé des populations de la commune de Banfora, par la promotion de bonnes pratiques en matière d’hygiène et d’assainissement à travers l’art social pour le changement de comportement. En effet un diagnostic participatif des Centres de santé, réalisé par SANIYA SO+ et ses partenaires en mai 2020, a révélé qu’il existe des risques importants lors du contrôle des infections liées à la transmission des gènes pathogènes. Ces menaces sur la santé des populations ont des causes multiples, notamment la mauvaise/non pratique du lavage des mains au savon aussi bien de la part des agents de santé que par des usagers, l’inexistence des lave-mains et du consommable (savon et eau) qui l’accompagne, l’indisponibilité et le manque d’entretien adéquats des latrines répondant aux normes. Les centres de santé étant donc des lieux à caractère vulnérable, ils ne pouvaient être laissés en marge de cette planification. Du reste, c’est l’avis du chargé de mise en œuvre du projet, Mr Amédée SININI,  selon qui « les centres de santés doivent des lieux de guérison et non de propagation de maladies ».  Ainsi, SANIYA SO+, dans la dynamique de rendre ces centres irréprochables en matière d’accès à l’eau et à l’assainissement, oriente son action dans une direction très sensible, car, bien plus que des hôpitaux, ces endroits permettent de sauver des vies.

Ce diagnostic a abouti à l’élaboration d’un Plan de Mise en Œuvre (PMO) dudit projet qui prévoit de mettre à contribution les différents acteurs aussi bien ceux du secteur eau et assainissement que ceux de la santé, œuvrant dans la commune et qui travailleront en synergie d’actions pour la réussite du projet SANIYA SO+. Les acteurs de la santé seront au cœur des actions car, comme l’a affirmé le coordonnateur du volet Art Social pour le changement de comportement au sein de SANIYA SO+, Emmanuel Koama, « lorsque la parole est portée par les acteurs eux-mêmes, elle est rapidement prise en compte ».

Atelier

C’est dans l’intention de soumettre le PMO à l’appréciation de ces acteurs qu’un atelier a été organisé, le lundi 6juillet 2020, à Banfora, par l’Espace Culturel Gambidi, en collaboration avec IRC et la municipalité de Banfora. Présidé par le maire de la commune, Aboubakar HEMA, qui avait à ses côtés son premier adjoint, ledit atelier a connu la présence effective de plusieurs acteurs des secteurs eau, hygiène, assainissement et santé. C’est ainsi que, IRC, CRS, One Drop, District Sanitaire, Agents de Santé, Association MUNYU, Mairie de Banfora et sa Direction de l’Eau, Assainissement et Hygiène Publique, Espace Culturel Gambidi, ont été les témoins oculaires et parties prenantes de cette rencontre. L’atelier, très à propos, a été mis à profit par ses organisateurs pour l’échange du protocole qui a été signé entre la Mairie et l’Espace Culturel Gambidi dans le but de formaliser la collaboration entre ces deux entités.

Des tâches précises

A l’issue des travaux de la rencontre, le plan a reçu l’assentiment de tous les participants et a donc été validé à l’unanimité. Après cet acte et sous réserve de la prise en compte des amendements apportés au document par les participants, désormais, les tâches pour la mise en œuvre de SANIYA SO+ sont définies et précises. Toute chose qui permettra le démarrage effectif du projet et donc l’amélioration du service d’eau potable, hygiène et assainissement dans les centres de santé de Banfora. Du reste, tous les acteurs, conscient de l’enjeu, devront tout un chacun veiller à la bonne marche de ce projet qui constitue un palier important de l’édifice commun qu’est le PSC-AEPA de la commune de Banfora. Le maire de la commune, Mr Aboubakar HEMA a si bien traduit cette synergie dans ses propos. Morceaux choisis : « Nous sommes tous leaders pour le changement de comportement dans le secteur de l’eau, l’hygiène et l’assainissement. Ce plan nous appartient à tous et chacun de nous doit apporter sa contribution, sa part pour sa mise en œuvre ».

Key concepts and case examples from pan-European countries were presented at the webinar ‘Don’t forget the small ones’.

Costing and financing of small-scale water and sanitation systems in the pan-European region is a challenge. During the webinar ‘Don’t forget the small ones’ a publication (available in English and Russian) was launched on this broad topic.

The webinar introduced the key concepts of the publication and presented case studies on the costing and financing of small-scale water and sanitation systems in Europe and included:

• Costing and financing of small-scale water and sanitation services – Stef Smits and Catarina Fonseca, IRC
• Findings on financing for rural water supply and sanitation services in the Danube region – Susanna Smets, World Bank
• Assisting small water supplies in southern Germany with calculating tariffs and costs - Steffen Krause and Christian Platschek, Universität der Bundeswehr München, Germany
• How to assess costs in small water systems in Portugal? - Alexandra Gonçalves da Cunha, Water and Waste Services Regulation Authority, Portugal
• Ways to improve financing in small water supply and sanitation systems in the Republic of Moldova - Corina Andronic, Skat Foundation, Republic of Moldova

Both the webinar and the publication were developed under the Protocol on Water and Health.

The publication can be accessed via the Resources below and all the presentations and discussions can be found in the downloads.

Link to the publication

The challenges of developing an 'Indian' protocol to monitor COVID-19 in sewage.

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. 

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)

Wastewater tracking

Traces of the coronavirus have been detected in sewage. As per a guidance document (23^rd 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.

Regular cleaning

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.

Formal and informal wastewater treatment set-ups

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.

Guidelines and protocols

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.

Opportunities for rethinking sanitation

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)

Proper medical waste management

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. 

Dealing with sharp waste

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:

• untrained and unprotected workers manually handle healthcare waste,
• waste workers rummage through unseparated waste at a dumpsite, or
• janitors operate faulty incinerators.

The waste workers cooperative of Pune (India)

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).

WASH-FIT

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

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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.

Public toilets in the market place

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

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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."

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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. 

Safe water a top priority

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.”

Strong progress has been made

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.”

Tackling open defecation

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.”

District Assembly takes responsibility

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.”

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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.

Common factors that drive success

• Political leadership from the District Assembly

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. 

• Motivated staff

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.

• Implementation partners

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.”

• Community level leadership

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.

• Supportive donors

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.

• Ambitious targets and innovative methods

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.

• Cost recovery

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.

• Sanitation and hygiene as well as water

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. 

Potential challenges

Success is a journey – all three districts are still addressing many challenges:

• Sanitation and hygiene

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 and the environment – the plastic bag nightmare

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.

• Keeping up payment systems for operation and maintenance

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.

• Longer term challenges of full pits and liquid waste

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.

• Water quality

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.

• Sustainability

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.

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Asutifi North district was one of the three selected districts where successes and challenges in the provision of water and sanitation services were collected.

Asutifi North is a district of about 65,750 people in Ahafo Region. The District Assembly committed itself to achieving Goal 6 of the SDGs by 2030 through a coordinated WASH master plan known as ANAM.

This ANAM Initiative brings together the district assembly, traditional leaders and development partners and has widespread community support. Safe water coverage rose from 4% in 2018 to 12% in 2019 and is set for another large rise from new infrastructure that came into use at the end of 2019. Schools and health facilities are especially benefiting from new services.

World Vision drilled 22 new boreholes in 2019 and rehabilitated a further 34 with the District Assembly. Safe Water Network and the District Assembly have delivered two small town networks with a third in an advanced stage of planning. Aquaya has provided kiosks and starter grants for water vendors to improve livelihoods and ensure payments will cover minor repairs. Water quality testing is being stepped up.

IRC Ghana provides a hub service to support the District Assembly with an office where partners work side by side. An ANAM website and monthly radio programme interact with the public and a WASH desk has been established in the District Assembly to handle feedback and complaints. ANAM is fully incorporated into the District Medium Term Development Plan.

Read the story Asutifi North: Collaboration makes water flow

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Bongo district was one of the three selected districts where successes and challenges in the provision of water and sanitation services were collected.

Bongo District in Upper East Region, is one of the driest areas of Ghana with a population of just over 103,000 people. More than 30 boreholes had to be taken out of use because of dangerously high levels of fluoride in some underground water, causing damage to the bones and teeth of the people who drink it. In 2015 Bongo District Assembly began to take urgent action with support from a number of donors including UNDP and UNICEF. Providing safe water has become a top priority.

Over the past five years WaterAid Ghana has worked with Bongo district on a WASH for Public Health (WASH4PH) project in 24 communities focusing on schools and community health care facilities. In 2019 the District Assembly doubled its own budget for WASH and committing itself to drilling and rehabilitating 15 boreholes a year and developing six small town schemes covering 20 communities. Water coverage is now 84% and the District Assembly expects to achieve full coverage by 2025. 

WASH4PH has also addressed sanitation. In 2015 when WaterAid Ghana began its project, more than eight out of ten people were practising open defecation in Bongo district. The District Assembly and WaterAid have been promoting Community-led Total Sanitation and providing hygienic toilets for schools, health facilities and markets. By the end of 2019, 19 of the 24 communities where WaterAid Ghana worked have become open defecation free. Overall in the district 38% of households have access at least to basic sanitation. The situation is improving.

Read the story Bongo works with partners to resolve fluoride legacy

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Wassa East was one of the three selected districts where successes and challenges in the provision of water and sanitation services were collected.

Wassa East in Western Region is an overwhelmingly rural area with a population of more than 105,000 people. The district was facing a water crisis in 2015. About six out of every ten water facilities were non-functional, and payment systems had largely broken down. The District Assembly launched a Sustainable WASH for All programme to improve both water coverage and sanitation and looked for partners to help them.

In 2015 the Assembly signed a Memorandum of Understanding (MoU) with Access Development, a limited liability company in Ghana established by the international NGO Water4. Access Development provides NUMA purified water in communities which sign an agreement for a 'pay-as-you-fetch' system. NUMA water has become a powerful selling point for a growing number of communities, showing that people will pay for water when it is convenient and safe.

Four years ago little over half of the population of Wassa East (56%) had access to safe water. Today the figure is 75.5% and the district is aiming for 90% coverage by the end of 2020. The District Assembly expects to cover the other 10% of communities through its own efforts by the end of 2023.

A Community-Led Total Sanitation (CTLS) programme was launched in 15 communities in conjunction with the Community Water and Sanitation Agency. By March 2020, 6 of the 15 communities had been declared open defecation free. But safe sanitation levels remain very low in the district.

Access Development and the District Assembly will in future also focus on schools, most of which lack water or sanitation facilities.

Read the story Wassa East: Communities show they will pay for clean, pure, water

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