Chronic under funding still plagues Uganda’s water and sanitation sector - Kampala

(Saturday, September 19 2009) By: Ronald Musoke

This sewage treatment facility at Bugolobi only caters for 10 per cent of Kampala City's residents

Why government continues to give ‘lip-service’ to the country’s water and sanitation sector remains a mystery to many stakeholders.

According to the World Bank, Uganda’s national budget allocation for the sector between 2004/05 and 2008/09 has significantly reduced from just under five per cent then, to the current 1.8 per cent.

Yet the water and sanitation sector is a crucial aspect to people’s well-being and health not only in Uganda but also around the world.

In addition to the already well known health benefits of improved water and sanitation, there are many other associated benefits at household level, said Mr. John Bosco Isunju, a lecturer at Makerere University School of Public Health (now college) at a recent Uganda Health Communication Alliance (UHCA) workshop.

Notable dividends, he said, include; increased comfort, privacy, safety for women especially at night and for children, improvement in social status, cleanliness, prevention of smell and flies, less embarrassment before visitors, reduced accidents, reduced conflict with neighbours, increased property value and increased rental income.

Conversely, poor water and sanitation drain the economy in terms of meeting treatment costs.

This over burdens the already constrained health facilities, not to mention the individual families which spend their hard earned incomes (and work-time) on treatment and nursing the sick, said Isunju.

Communities that have given the sector the due attention it deserves have reaped numerous dividends, among which include the banishment of water borne diseases such as diarrhoea, cholera, dysentery and Hepatitis A and E.

Yet investment in the sector is still perceived as a cost by many governments although research has proven otherwise.

The World Health Organization (WHO) says every US dollar invested in water supply and sanitation gives an economic return of US $4-12 back to the community.

But even with such merits of investing in the sector, most sub-Saharan countries including Uganda have achieved little, largely because of inadequate investments.

Should we then be surprised that a big proportion of Ugandans continue being afflicted by water-borne ailments?

In early September, a Uganda Health Communication Alliance (UHCA) workshop brought together key speakers to answer one question: Clean water, can Uganda meet the challenge?

One conclusion was drawn from the discussion: under funding of the sector is still a major problem.

And there is so much incontrovertible evidence.

Although 88 per cent or 25 million Ugandans are rural-based, rural areas receive only about 27 per cent of the overall water budget yet this is one constituency where more should be invested, said Mr. Ezra Natumanya, a lecturer at Makerere University’s Institute of Environment and Natural Resources.

Currently, of the 25 million people in rural Uganda, 57 per cent have access to safe water and 54 per cent have access to basic sanitation facilities.

“Still the above figures mask considerable disparity between and within districts and hardly consider the functionality of water sources,” said Natumanya.

Mr. Paddy Twesigye, the Projects Manager at National Water and Sewerage Corporation (NWSC) whose parastatal has a mandate of improving the water and sanitation sector in urban Uganda noted that the profile for sanitation in the country is still low.

He has a point. Although NSWC has performed excellently in providing safe water to urban Ugandans over the past couple of decades, the sanitation sector has been left way back.

According the water parastatal’s figures; only 10 per cent of Kampala, Uganda’s capital city, is connected to the sewerage system. The rest of the city population has on-site sanitation facilities such as latrines which often discharge effluent into the environment untreated.

Mr. Samuel Mutono, a World Bank country co-ordinator for the Africa Water and Sanitation Project enumerated several challenges that are affecting progress in countries like Uganda.

Mutono said despite several decades of massive investments in the water and sanitation sector across Africa, only 56 per cent of about 753 million Africans use improved water and sanitation facilities.

Still on this same continent, at least 37 per cent of the population access adequate sanitation and out of that number, 53 per cent are urban-based and 28 per cent rural. And according to World Bank statistics, a third of the people in Africa engage in open defecation- a very risky practice.

Little wonder then that a 2005 MDG survey noted that Sub-Saharan Africa remains the most off-track sub-region in meeting the seventh MDG target.

Only the five North African countries remain on track of realizing the 2015 target of halving the number of people without sustainable access to safe water and basic sanitation.

That survey concluded that at the current rate, targets for water and sanitation and MDGs in Africa will only be achieved in 2040 and 2076 respectively. But even then, the World Bank says, 400 million Africans will still lack access to safe water and sanitation facilities.

According to the World Health Organization (WHO), the burden of disease costs the world US$4.1 trillion each year and lack of safe sanitation is the world’s biggest cause of infection.

Yet one tenth of the global disease burden could be prevented by improving water supply, sanitation, hygiene and proper management of water sources.

WHO says a global reduction in diarrhoeal episodes of only 10 per cent can lead to an annual health related cost reduction of US$7.3 billion. 

Are the interventions all that costly? 
Not so according to the World Bank. For instance, of the different Water Sanitation Hygiene (WASH) interventions, hand washing (with soap) has been noted to be the most effective in the reduction in diarrhoeal morbidity as opposed to hygiene promotion, water quality, water availability and sanitation.

“Washing hands with soap may sound simple but it is a proven method of fighting water borne diseases,” said Mutono.

Research shows that hand washing with soap could lead to a 47 percent reduction in diarrhoeal diseases.

That particular intervention could easily reduce Uganda’s disease burden considering that a 2004 second health sector strategic plan noted that over 75 per cent of Uganda’s disease burden is considered preventable as it is primarily caused by poor personal and domestic hygiene and inadequate sanitation facilities and practices.

Mutono noted that households with improved WASH services suffer less morbidity and mortality from water and sanitation-related diseases.

Further, WASH services close to home lead to significant time saving while WASH at home and schools could contribute to more educational opportunities for women and girls in terms of attendance.

Mutono noted that factors behind the water and sanitation sector gains made by countries such as Tunisia, Morocco, Libya, Egypt and Algeria include; realistic and robust planning; having clear MDG road maps and approaches; developing and implementing support to large-scale programmes, having clear-targets for financing and service delivery, establishing institutional leadership, decentralization with strong involvement of consumers as well as involving NGOs/CBOs and local private sector participation in the sanitation and hygiene programme.

And for those nations still struggling like Uganda, there are large gaps in capacity to scale-up, insufficient focus on sanitation, low sustainability of services, and variable pace in developing/implementing national policies.

Mutono noted that there is also weak stakeholder involvement, and due to weak human resource capacity, the institutions are not prepared for up-scaling.

The situation is even dire given the poor monitoring and evaluation systems, weak decentralization and inadequate attention to sustainable financing.

There is indeed evidence for low funding and lack of prioritization of sanitation and hygiene in Uganda.

World Bank says only four per cent of the Districts’ Water & Sanitation Conditional Grant in the Ministry of Water and Environment goes into sanitation and hygiene activities. And two percent of the Primary Health Care Non- Wage Conditional Grant in the Ministry of Health curative health is utilized for sanitation and hygienic activities.

The World Bank further notes that approximately 0.001 per cent of the Local Development Grant (LDG) is used for sanitation and hygienic activities.

What must be done?
Stakeholders must now vigorously invest in some cost effective approaches such as the school sanitation and hygiene promotion or engage in total sanitation approaches such as shifting focus from toilet construction for individual households to collective behaviour change, finance village mobilization and initiate awards for positive out comes such as open defecation-free villages, said Mutono.

Mutono noted that besides initiating community health clubs, there is also need for sanitation marketing using commercial marketing ideas to develop and disseminate themes/messages that generate demand for services and lead to behaviour change.

He said there is need for a re-awakening momentum for sanitation where behaviour change needs to be matched by stimulating local market solutions, adding that the diversification of sanitation status requires different approaches.

For instance, there should be zero tolerance for open defecation. This should be closely followed by upgrading of traditional latrines to improved systems as well as investing in community/public facilities and sustainable sewerage development.

Mutono added that the water and sanitation sector can significantly improve if the sector is decentralized; a more participatory approach adopted and, voices of the poor and under privileged brought to the fore.

There is also need to empower people (especially the rural-based citizenry) to take responsibility, respect traditions and culture, recognize the key role women play and mobilize public and private resources.

As far as sanitation improvement is concerned, Mutono said, behaviour change is key, good leadership matters and can induce change.

The financing gaps in all sub-sectors; rural, urban, water for production, and water resources management must also be taken seriously to meet the desired targets or objectives.

Mutono also noted that financing of water resources management needs special attention given the challenges of monitoring water catchment bases and enforcement of regulations to prevent continued degradation of the resources.

Natumanya added that government needs to address the rapid loss of rural water catchment areas such as wetlands, mountains and forests.

Climate change and climate variability and the need to improve preparedness for disasters such as floods and droughts and expansion of NWSC supply areas outside the gazetted city and municipal/town council boundaries need to be given more focus.

The Kasese Pupu Crisis | Red Pepper Online: News,Gossip

The Kasese Pupu Crisis

NWSC's Charles Mushabe Shows the Police what Pupu can Do to the environment

*Bishop, Residents Grab Land @ Sewerage Disposable Site
*Group Uses Feaces To Make Bricks To Build Permanent Houses
*Kilembe, Mubuku, Margerita Land Taken As Dysentery Grows

By Tony Kizito.

Kasese municipality is in a pupu-scare after some residents refused to vacate the town’s sewerage disposable site located at Kikonjo-Railway in Kasese town.

Business Link visited the site and discovered that the group that includes a bishop called Nzerebende under his organisation Fiphai-Uganda, have grabbed the 0.725acre land that is supposed to hold lagoons for managing the town’s sewerage system. They have set-up and are building more permanent structures.

NWSC and the municipal authorities are battling the over 57 homes that have grabbed the said land and have divided it into 31 plots amongst themselves. They now want the municipal authorities to dish them between Shs5m – Shs6m as re-compensation to leave the land that they grabbed.

The group has also started using the decayed feaces in the old sewerage lagoons to make bricks. They use the water in the current disposable site to build and do other activities.

Due to some pressure from NWSC officials and district authorities, the group has increased the rate at which they are setting up those structures by day and night.

It is buying time to continue more encroachment on the sewerage site land and building more structures by taking the municipal authorities and NWSC to court after loosing assistance from the Uganda Human Rights Commission (UHRC).

UHRC had advised them to vacate the area. UHRC told them to try the courts of law to solve their land grabbing problem if they were not satisfied by its decision.

The place has been invaded by flies and managing the area is hard for NWSC officials because of the rowdy residents.

When we told the Kikonjo – railway LC chairperson, Bwambale Kikoma about the situation of his residents eating feaces, he said: “They are not eating feaces, they are just fighting for survival.”

Kikoma added that the town authorities gave people the land in question way back in 1996 and that they had proper documentation to have right to it. He added that they had been paying premium to the authorities for the said land.

“All we want is for these people to be compensated. They are ready to leave”, said Bwambale.

Pupu Crisis
The Kasese Town Council health inspector, Louis Muhwezi recently revealed that the lack of a proper sewerage system in town has caused residents to suffer from water-borne diseases like dysentery and cholera.
He said in 2007, National Water and Sewerage Corporation (NWSC)
did a feasibility study in the town but had no funds to set up the system.

He revealed that after a feasibility study, NWSC promised to lobby
for funds for the project but up to now, they were failing to fulfill their promise due to unavoidable circumstances like the matter of land grabbing hitting the area.

The Kasese District LC5 chairman, Rev. Canon Julius Kithaghenda then, said the lives of the people of Kasese town were at a risk due to lack of a sewerage system.
During rainy seasons Kasese town is hit by floods due to its location
at the foot of the Rwenzori Mountains.

Last year, between March and June, Kasese was hit by cholera,
which left six people dead and over 300 hospitalised and this included Bp Nzerebende (Fiphai Uganda) who is still up to now refusing to leave the set sewerage site despite his God-sent survival.

Land Grabbing
As land grabbing becomes the order of the day with the recent one being Lubigi, Kasese is one of the most affected areas where people grab any land they wish to have without any rule of law or intervention. In most cases, the land in question has always ended up being taken over by the grabbers either from service providers or particular individuals.

Kasese Minicipal Deputy Town Clerk, Mukobi Seleverio described the Kasese land system as a ‘Grab, Share and Sell’ system.

He said that residents just grab land the way they want and are ready to die fighting to save the land that they have grabbed from either way.

Mukobi said: “If start talking about the land problem, you may either be burnt or chopped into pieces. They may way-lay you. One time we tried to demolish structures that those people at the NWSC site were putting up. On an afternoon, as the council was doing its duties, we recognised over 200 people, sneeking in with sticks and pangas towards our offices. We went to the armoury got guns positioned ourselves. We warned to shoot any of them if they moved ahead. We were going to die “

“People here have grabbed Kilembe mines land, Mubuku scheme land has been taken, Margerita hills land is gone, our over 400acres industrial land has also been taken but now we are fighting to save the NWSC land because it concerns all of us, both the land grabbers and the other legal people. Its a health factor. We pray the environment minister intervenes”, said Mukobi.

NWSC Speaks
Kasese Town water supplies Manager, Charles Mushabe said that the problem has persisted for long and is a hinderance to great service delivery.

He said: “We want the Minister for Water and Environment Hon. Maria Mutagamba and the Lands Ministry to help us on this matter. We just want to do our job. If people die because of improper sewerage disposal, we may be the target.”

Mushabe said that lagoons are natural and if set up, will have trees surrounding the area with a proper road to the place as a good lagoon bed would be.
He added that his staff are leaving in fear because of those residents. “They are threatening our lives and families. Kasese is a difficult place especially with issues related with land but we have to deliver”, said Mushabe.

We (this writer) went to the site guarded by police but we recognised that four of the pits had already been re-filled with soil.

The Benefits of These Interventions Are Greater Than the Health Benefits Alone

Environmentally caused mortality and malnutrition have substantial economic costs. In Ghana and Pakistan, for example, the indirect effect on child mortality of environmental risk factors mediated by malnutrition adds more than 40% to the cost of directly caused child mortality (Figure 4) [22]. If one takes into account the effect of such malnutrition on impaired school performance and delayed entry into the labour market, the cost doubles to 9% of gross domestic product (GDP). With the possible exceptions of malaria and HIV/AIDS in Africa, it is hard to think of another health problem so prejudicial to household and national economic development.

Figure 4. The cost to two national economies of inadequate HSW.

The “direct” effect is mortality attributable to these environmental risk factors, “indirect” effect includes mortality mediated by environmentally caused malnutrition, and “education” includes the effects of that malnutrition on (i) grade attainment; (ii) school achievement (learning productivity) in terms of grade equivalents; (iii) delayed primary school enrolment; and (iv) grade repetition. The latter two effects result in delayed labour force entry. Source: [22].

doi:10.1371/journal.pmed.1000367.g004

Lack of sanitation also leads to intestinal helminth infections, which cause stunting, late entry to school, and impaired cognitive function [23],[24]. Furthermore, inadequate sanitation and water supply are associated with much loss of time spent on water collection or seeking a place to defecate. An analysis of survey data from 39 African countries showed that for 160 million people (many of them women), collection of each container of water took substantially more than 30 minutes [4],[25]. A World Bank study [26] found that, even ignoring the effect of water supplies on health, the value of time saved from water collection alone was sufficient to justify investments in rural water supply in most settings. Finally, a WHO report suggests that the time lost in collecting water and seeking somewhere to defecate could be valued at US$63 billion annually [27].

When all these benefits are accounted for, many HSW investments yield a net benefit in the range US$3–46 per dollar invested [19],[27], and some additional benefits remain unquantified. For example, there are suggestions that sanitation and water supply boost school attendance and reduce dropout rates—presumably in part by reducing the demand on children's time to collect water. Well-run sanitation facilities in schools might also help to prevent girls from dropping out after menarche [28]. Overcoming such constraints to education can yield real benefits. Thus, at the beginning of the 20^thcentury, 40% of schoolchildren in the southern US were infected with hookworm. When the disease was eradicated early in the century, school enrolment, attendance, and literacy increased, and there was a long-term gain in incomes [29].

These benefits are substantive at macroeconomic as well as household levels, as shown by the World Bank study cited above [22], and by a study for the Commission on Sustainable Development. This second study found that the per capita GDP growth of poor countries with improved access to water and sanitation was much higher than that of equally poor countries without improved access (3.7% and 0.1%, respectively) [30].

This Disease Burden Is Largely Preventable with Proven, Cost-Effective Interventions

Figure 2 shows the average reductions in diarrhoea incidence found to be associated with HSW interventions in several literature reviews. The impact of “real world” interventions varies widely in response to local factors such as which pathogens are contributing to disease and the relative contribution of different transmission routes.

Figure 2. Results of reviews of the effect on diarrhoea of HSW interventions.

Results of the previous reviews are for the better quality studies. The reduction for household drinking water connections is in addition to reductions for water quality and availability of public sources. Previous reviews: (a), (c)–(f) [8]; (b) [11]). Fewtrell et al. [57].

doi:10.1371/journal.pmed.1000367.g002

A balanced interpretation of the available evidence suggests that a reasonably well-implemented intervention in one or more of hygiene, sanitation, water supply or water quality, where preexisting conditions are poor, is likely to reduce diarrhoeal disease prevalence by up to a third. Still greater reductions (up to 63%) are associated with water piped to one or more taps on a property [8]. Such a major impact merits far more attention from health professionals and health systems than has been common in recent decades.

We are still learning about the role of HSW in disease control. For example, Ascaris and other intestinal worms are known to be associated with poor sanitation, but a recent review [9] found evidence that hand washing with soap can also help to prevent transmission of ascariasis. We know that trachoma is prevented by facial hygiene and hand washing, but recent research has also highlighted the role of latrines in controlling the Musca sorbens flies that carry the Chlamydia pathogen between children's faces [10]. Even regarding the effect of hygiene on diarrhoea among young children in poor communities, we still have much to learn. There is good evidence to justify promotion of hand washing with soap [11], but for other aspects of hygiene behaviour, such as proper disposal of children's stools[12], the epidemiological evidence is from observational studies, which are subject to confounding.

The most effective means of promoting behaviour change is also a fruitful research field. It has only recently become clear to health professionals that emotional levers (“Clean hands feel good”) change people's health behaviours more effectively than cognitive statements (“Dirty hands cause disease”). Advertising agencies have known this for years. They also know the importance of investing in formative research, testing, and evaluation, to tailor the messages to local people's beliefs and aspirations [13]. If health workers can divest themselves of the unsubstantiated belief that health considerations motivate behaviour, they can become a more effective force for hygiene behaviour change.

There are alternative ways to tackle some of the HSW-associated disease burden. The widespread introduction of oral rehydration therapy (ORT) in the 1980s, for example, contributed much to reducing mortality from diarrhoeal disease [14]. However, such interventions focus on mortality rather than morbidity and on secondary rather than primary prevention. Moreover, ORT does not address the problems of persistent diarrhoea and dysentery.

It is sometimes claimed that the lack of an overall decline in diarrhoea morbidity rates despite increasing coverage with water and sanitation shows that the health benefits of HSW are illusory. However, there are other possible explanations for the apparent contradiction. First, coverage has not advanced as rapidly as one would wish, or as some official figures suggest. Second, the diarrhoea morbidity data are subject to a variety of interpretations; for example, reviews have found that apparent geographical variations could be explained by differences in study design [15]. Third, if challenge by diarrhoea pathogens can cause tropical enteropathy [16] without diarrhoea, a reduction in that challenge could reduce mortality risk without necessarily reducing diarrhoea morbidity.

In fact, the benefits to health of improving HSW are far greater than implied by disease-specific statistics. In the early 1900s, sanitary engineers in the US and Germany identified the “Mills-Reincke phenomenon.” Their studies showed that for every death from typhoid fever averted by water supply improvements, two to three deaths from other causes, including tuberculosis, pneumonia, and other causes of child mortality, were also avoided [17].

We now know that frequent bouts of diarrhoea and intestinal parasitosis are important causes of malnutrition, which renders children more susceptible to other diseases. For example, when malnourished children are recovering from an episode of diarrhoea, they are unusually susceptible to pneumonia; this diarrhoea-induced susceptibility may be associated with as much as 26% of all childhood pneumonia episodes [18]. Similarly, while 7% of the HSW-associated disease burden is directly associated with malnutrition, reductions in diarrhoea also reduce the incidence of diseases that are the consequence of malnutrition and that account for 29% of the disease burden (Figure 1).

The disease burden weighs heavily on both households and health systems. It has been estimated that the health costs alone amount to some US$340 million for households lacking water supply and sanitation and US$7 billion for national health systems [19]. The household burden weighs most heavily upon the poor, but well-conceived sanitation and water programmes can weaken the link between poverty and disease [20] (Figure 3) and so contribute to health equity.

Figure 3. Determinants of diarrhoea in Salvador, Brazil, 1997–2004: Results of a hierarchical effect decomposition analysis.

The width of each vertical bar shows the proportion of diarrhoea risk attributable to socioeconomic status and mediated by the intermediate variables shown. The two figures show conditions respectively (A) before and (B) after implementation of a major sanitation project. The project was associated with a 21% reduction in diarrhoea citywide, and 42% in the high incidence areas. Socioeconomic status accounted for 23% of the variance in diarrhoea rates before the project, but afterwards the strength of that link had been halved, to 11%. The proportion of that association mediated by intermediate variables, particularly sanitation, was also greatly diminished. Source: [20].

doi:10.1371/journal.pmed.1000367.g003

The World Bank/WHO Disease Control Priorities Project judged most interventions in HSW in developing countries to be highly cost-effective health interventions (Table 2). Indeed, hygiene promotion was the most cost-effective of all major disease control interventions at US$5 per DALY averted, with sanitation promotion also in the top ten at just over US$10 per DALY [21]. Although these figures do not consider the construction costs of water and sanitation facilities (which would lower cost-effectiveness if included) or the indirect costs of malnutrition (which would increase cost-effectiveness if included), Table 2 clearly shows that the HSW interventions most appropriate for the health sector are among the most cost-effective interventions it can make. Furthermore, most investments in water and sanitation infrastructure are made from other sources and for reasons other than health.

Table 2. Cost-effectiveness of HSW compared with other public health interventions.

doi:10.1371/journal.pmed.1000367.t002

A Massive Disease Burden Is Associated with Deficient Hygiene, Sanitation, and Water Supply Top

While rarely discussed alongside the big three” attention-seekers of the international public health community—HIV/AIDS, tuberculosis, and malaria—one disease alone kills more young children each year than all three combined. It is diarrhoea [2], and the key to its control is hygiene, sanitation, and water (HSW).

Figure 1 breaks down the preventable HSW-associated disease burden. It is dominated by mortality from infectious diarrhoea, nearly 90% of which is borne by children under five years old and 73% of which occurs in only 15 developing countries [1]. Moreover, mortality from diarrhoea is only part of the disease burden. Even using the most conservative scenarios, the long-term sequelae due to diarrhoea in early childhood contribute more DALYs than do the deaths [3].

Figure 1. Contributions in DALYs of individual diseases to the total burden of ill-health preventable by improvements in HSW.

PEM, protein-energy malnutrition. Source: [1].

doi:10.1371/journal.pmed.1000367.g001

Regrettably, it is no surprise that much ill health is attributable to a lack of HSW. Globally, nearly one in five people (1.1 billion individuals) habitually defecates in the open. Conversely, 61% of the world's population (4.1 billion people) has some form of improved sanitation at home—a basic hygienic latrine or a flush toilet. Between these two extremes, many households rely on dirty, unsafe latrines or shared toilet facilities [4]. Not only can it prevent endemic diarrhoea, adequate sanitation can help to prevent intestinal helminthiases, giardiasis, schistosomiasis, trachoma, and numerous other globally important infections (Table 1).

Table 1. Environmental classification of water- and excreta-related infections.

doi:10.1371/journal.pmed.1000367.t001

The situation for drinking water appears better than that for sanitation. Although around 13% of the world's population (884 million people) lives in households where water is collected from distant, unprotected sources, 54% (3.6 billion) receives piped water at home. However, many piped water systems in developing and middle income countries work for only a few hours per day and/or are unsafe. In larger Asian cities, for example, more than one in five water supplies fails to meet national water quality standards [5]. Reliable safe water at home prevents not only diarrhoea but guinea worm, waterborne arsenicosis, and waterborne outbreaks of diseases such as typhoid, cholera, and cryptosporidiosis.

Much of the impact of water supply on health is mediated through increased use of water in hygiene. For example, hand washing with soap reduces the risk of endemic diarrhoea, and of respiratory and skin infections, while face washing prevents trachoma and other eye infections. A recent systematic review of the literature [6] confirmed that hygiene, particularly hand washing at delivery and postpartum, also helps to reduce neonatal mortality. It might be argued that water supplies also make flush toilets feasible, but this does not necessarily add to their health benefits, as we have seen no credible evidence that the health benefits of sanitation cannot be achieved by dry latrines, if they are properly built and maintained [7]