Memorandum submitted by NGO Forum for
Drinking Water Supply and Sanitation
IMPROVING HEALTH
AND HYGIENE
THROUGH WATER
AND SANITATION
INTERVENTIONS: THE
IMPACT OF
COMMUNITY-MANAGED
APPROACH
EXECUTIVE SUMMARY
Bangladesh has been progressing optimistically
towards a satisfactory WatSan scenario in the recent times despite
many problems. The moves from the govt. and relevant agencies
and stakeholders addressing the problems and focusing on effective
progress have been showing promises for a desirable WatSan future.
Following the declaration of the World Summit on Sustainable Development
in 2002 in Johannesburg, South Africa "To halve, by the year
2015, the proportion of people who do not have access to basic
sanitation" and the Millennium Development Goals (MDGs) of
halving the proportion of people without sustainable access to
safe drinking water, the GoB has declared intensive sanitation
movement `Sanitation for All by 2010'. However the complementing
role played by NGOs and different other stakeholders alongside
the govt. initiatives has added dimensions to the WatSan drives
in the country.
— NGO Forum realizes that there is
still much to do in this sector. Breaking through people's mind-set
and traditional practices is yet considered a laborious job while
unsanitary practice and open defecation still prevail as threats
to public health. Children are the most vulnerable victims of
diarrhoea. Despite many positive developments preventing child
mortality rate, 110,000 U5 children die annually in Bangladesh.
— The water supply situation of the
country from the apparent high success of about 97.5% has come
down to around 74% and a lot more needs to be done on the drinking
water supply area. The alarming facts like identification of arsenic
in tubewell water above permissible limit in 322 upazilas of 61
districts among 376 tested upazilas, 36 million people being at
risk of arsenic contamination, identification of 38,118 arsenic
patients through upazila-based survey, etc make the arsenic mitigation
a top priority area in the sector.
— Hygiene, being still in a vulnerable
condition in our country demands much attention in promoting hygiene
education. However, in Bangladesh, alongside the GoB, NGOs, donor
community, different agencies and stakeholders, NGO Forum considers
hygiene high among its agenda. In relation to this, NGO Forum
has been mobilizing different community groups including men,
women, school students & teachers, religious leaders, local
allies and so on under its Community-managed WatSan Programme.
While these groups are being mobilized, water supply, sanitation,
hygiene issues in perfect balance are being discussed and emphasized
as the pre-requisite to sound health.
INTRODUCTION
1. At the back drop of grim scenario around
the globe in the area of water supply and sanitation resulting
in dangerously high incidences of mortality and morbidity, the
United Nations General Assembly launched the International Drinking
Water Supply and Sanitation Decade (IDWSSD) for the period 1981-90.
The Decade was observed with the mission to help reduce mortality
and morbidity caused by water-borne diseases at the grassroots
through appropriate low-cost interventions by formulating demand-driven,
effective, efficient and uniform implementation strategy nation-wide.
And to implement the Decade programme in Bangladesh, NGO Forum
for Drinking Water Supply & Sanitation launched its journey
in 1982 as the brain-child of the United Nations Steering Committee
of the IDWSSD. In course of time NGO Forum has emerged as the
apex networking and service delivery agency of NGOs, CBOs and
private sector operators who implement safe water supply, environmental
sanitation and hygiene promotion programmes at the unserved and
disadvantaged poor communities in Bangladesh.
2. Unlike other development agencies NGO
Forum follows the community-managed approach in its programme
implementation while a village is targeted for a 2-year period
for 100% WatSan coverage. Because NGO Forum realizes that, the
spontaneous participation of the respective community at every
step is a prerequisite for the successful implementation of any
development programme. All classes and sectors of the community
should be organized and their active participation should be ensured.
This is why community approach instead of target group approach
is proved more effective in successful implementation of WatSan
programme.
3. In the Community-managed WatSan Programme
of NGO Forum a Village Development Committee (VDC), formed with
the participation of the respective community, works in the focal
point for ensuring the successful implementation and sustainability
of WatSan services. For involving the entire community into the
development initiatives and making coordinated efforts in attacking
these mounting problems, the villagers form a VDC for ensuring
sustainable rural development with special focus on WatSan activities.
The VDC is formed with 15 members. This is a working group that
represent a cross section of villagers ranging from rural opinion-leaders
to commoners including the women.
4. Awareness building and social mobilization
process of NGO Forum has substantially strengthened the issue
of community participation in the Community-managed WatSan Programme.
After selection of the villages different tools and techniques
of participatory planning are used to assess the needs of the
villages. This process ensures the effective implementation of
the WatSan programme in a community-managed approach.
5. Participation of various community groups
mobilizes the villagers to feel demand for safe WatSan facilities.
Through effective participation people realize implication of
using unsafe water and unhygienic latrine. The programme is implemented
mainly by the Village Development Committees, which ensures the
participation of both male and female members of the community.
The synergistic efforts of the villagers also create the sense
of self-monitoring system to sustain the achieved success of WatSan
coverage and practices on way to ensuring improved public health.
6. NGO Forum implements the programme in
line with the National WatSan Policy objectives of sustainable
WatSan promotion and hygiene practices. The community-managed
water and sanitation programme is designed for making the community
active through different strategies and techniques that help make
them aware and enable them to understand the reality through experiences.
The community participation creates a sense of ownership among
the community people over the programme success as it covers all
aspects from decision-making to cost-sharing by the respective
community. As a result the programme success finally sustains
as the achievement of the respective community.
WATSAN
AND HEALTH
7. In Bangladesh, it is an accepted fact
that in spite of impressive achievements in water supply and sanitation
coverage, expected health impacts have not yet been realized.
Infant mortality and morbidity are still high; with about 110
deaths per 1000 live births. The transmission of water and excreta-borne
germs causes the vast majority of diseases prevalent among the
poor. Diarrhoeal diseases account for a significant part of this
morbidity. Each year diarrhoeal illnesses cause the death of over
110,000 children under five years old. Diarrhoeal diseases contribute
to school absenteeism and loss of production and income. As a
result of this apparent lag in impact on health, there is increased
emphasis on health and hygiene promotion in many WatSan programme
and projects in Bangladesh.
8. Water and sanitation are intimately linked
to health in several ways. It is important to address the increasing
need for adequate and safe water, sanitation and hygiene facilities
to protect both people and the planet. Millions of people including
children die each year of diarrhoeal diseases linked to inadequate
safe water supply, hygienic sanitation and proper hygiene habit.
30 million suffer from chronic fluorisis, and 1.5 million are
infected with hepatitis A. These diseases can be reduced by improving
water quality, sanitation and personal hygiene.
Catalyzing the Community Mobilized:
Wise Heads on Young Shoulders. They
are small and playful. They are just about to enter into their
teens. But the general hype on health, water and sanitation awareness
that have taken a stronghold in Natuapara have also touched their
young lives as they are virtually bombarded with regular tips
on these issues both at home and school. In the process, they
have become wiser and are able to make informed choices about
these.
Md. Abdus Salam and Md. Bachhu Miah are both
Class-VI students of Abdul Gafur Memorial Secondary School in
Natuapara, Jessore. Stating that both of them use sanitary latrines
at home, they confirm that they never drink water from unknown
sources "as those are unclean and not safe for the human
health." They admit that the elders at home and school told
them that the water from unknown sources is unsafe. Both, however,
vow that they `always' abide by the instructions given to them
by the teachers at school.
As far as their sanitation practices are concerned,
they inform that they wash their hands with soap thoroughly after
using the toilets. Asked if they do it regularly, a visibly offended
Bachhu Miah says: "We have made it a regular habit. So, we
don't have to lie about it." He believes that all his friends
also follow the same health tips". Both of them, however,
admit that such awareness on water, sanitation and hygiene issues
have left them in a good physical health and they have not suffered
once from dysentery or any other stomach related ailments in the
last six months.
Asked if they pass on these information and
advices to those younger than them in the family and in the community,
Bachhu Miah, Mosammat Rita Khatun and Mosammat Ayesha Khatun of
the same class and the same school proudly assert: "We always
tell them about the things we learn and try our best to make sure
that they follow the advices". Both the girls say they have
not suffered from any stomach-related ailments in the recent years.
The girls also inform that the need for saline have diminished
greatly as people hardly have dysentery or any other stomach ailments
due to regular consumption of safe drinking water and leading
hygienic lives.
9. To generate awareness and mobilize the
community people, the NGO Forum has undertaken many promotional
activities, which have been implemented at the field level. These
activities include Formation of VDC, Orientation of VDC, holding
of a Review Meeting every month, mobilizing the general masses
through holding Courtyard Meeting and Community Meetings for the
women and men respectively of the village. These activities help
to motivate people to use safe water for every household purpose,
particularly for drinking and cooking, use of sanitary latrines
and to maintain sound environment for personal health and hygiene.
This helps to reduce the incidence of diseases.
10. Software Services have been provided
to mobilize awareness among the villagers through posters, leaflets,
stickers, flip-charts, rallies and mikes. As religious leaders
play a crucial role in moulding the sentiment of the people in
a predominantly religious rural society, it also has used the
services of the Imams in the social mobilization campaign. Besides
as children of today are the custodians of their future environment,
School WatSan Programmes have been offered to enlighten the younger
generation on healthy water and sanitation practices.
11. NGO Forum has also imparted training
to its partner NGO staff and officials working with the programme
on arsenic awareness and mitigation, conduction of promotional
activities and orientation on community-managed approach. It is
basically through these means that the NGO Forum has provided
hardware and software mixed support to the VDC and the PNGOs.
12. With the implementation of NGO Forum's
Community-managed WatSan Programme the community participation
has substantially strengthened social mobilization, has made the
participatory need assessment process of the respective villages
easier, has helped to create demand for WatSan technologies among
community people. It has also generated realization about serious
health problems due to lack of proper hygiene practices. The participation
has created self-confidence and self-monitoring system of WatSan
programme, which has helped to achieve higher coverage of water
& sanitation in the community.
13. Lack of awareness, low level of literacy,
inadequate access to information and insufficient hygiene knowledge
are major factors for higher levels of morbidity and mortality
particularly in the poor communities. Knowledge on the primary
health care and hygiene promotion, better information flow, successful
hygiene education can be effective to improve the health situation.
The community people have realised that for their survival they
need to protect themselves at least from water-borne diseases.
Now, the prevention of water-borne diseases has become easier,
through using of sanitary latrine and safe water in almost all
domestic purposes.
Burying Bad Bygone Habits
Unlike many aged people who tend to live out
life as practiced over the years, China Bala, an illiterate octogenarian
of Natuapara, Jessore, has embraced new water and sanitation habits
with an open mind. Although she does not attend the periodic Courtyard
Meetings conducted by the women of the village, she is thoroughly
convinced that they hold the meetings with a strong sense of purpose.
She rules out the slightest possibility that the women of the
village gather round the courtyards for idle time-pass or gossiping.Refusing
to be cynical, she says: "Though I don't attend these meetings,
I believe they talk good sense." Being asked why she should
allow a few young people to change her long-practiced way of life,
she expresses her strong conviction saying, "I don't mind.
Because they are talking no-nonsense". Then, she goes on
to declare that she only drinks water from the local Arsenic-iron
Removal Plant. "I don't like the taste of water from other
sources," she bluntly argues.
Though China Bala feels that the women in
her community is doing a great job through creating awareness
regarding safe water, sanitation and hygiene practices, she believes
that unless their words were backed up by actions and positive
changes, no one would have paid heed to their words, herself included.
She, however, held her age and failing health
condition responsible for not attending the Courtyard Meetings.
The happily transformed China Bala concludes with an almost philosophical
utterance: "I'm an old woman. They are young. So, they should
sort out their problems while there is still time."
WOMEN EMPOWERMENT
14. For both men and women it is important
to have access to the safe water and sanitation facilities. It
is crucial especially for women because they are the principal
managers of domestic water needs and family health care. To meet
the health objectives the government has changed its policy towards
an integrated approach which combines provision of safe water
and sanitary latrine with health education. However, health education
has been considered necessary because continued practice of indiscriminate
defecation and use of contaminated surface water for non-drinking
purposes including bathing, washing utensils, etc have serious
effects on health. The approach also emphasises on the health
education to put greater attention on women because women have
the control over family hygiene practices. NGO Forum has been
implementing the WatSan programme following the National WatSan
Policy adopting an integrated community-managed approach of water
and sanitation programme giving special focus on ensuring the
participation of women.
15. Women participation is quite good in
some areas, under NGO Forum-facilitated WatSan programme. Women
are involved in different activities. The water technologies have
been taken care of and maintained mainly by women. Alongside,
women are also taking decisions about the installation of sanitary
latrine and water point in their houses. This has only been achieved
through the participation of people, especially the women, in
the water and sanitation programme of NGO Forum.
ASSESSING THE
WATSAN
COVERAGE
16. In relation to achievement of the 6-year
programme implementation from 2000-05 it has been consolidated
that a significant number of households/peoples have been ensured
with safe WatSan and hygiene facilities in 800 target villages
following the community-managed approach. A total of 238,400 households
and 237,600 households have been covered with safe and affordable
water supply facilities and hygienic latrine facilities respectively
out of around 240,000 households in the intervened villages.
17. Around 1,231,750 people have been mobilized
on safe hygiene behaviour out of around 1,250,000 population in
the target villages. The services have been ensured in a community
approach while the poor people have especially been considered
and addressed under the facilities. More than 18% hard core poor
households have been benefited with the services in the intervened
villages.
IMPROVEMENT OF
PUBLIC HEALTH
SITUATION
18. The health education and awareness-raising
programme have an impact on the knowledge base and attitudes towards
the water and sanitation in WatSan coverage villages. The community
people are involved in the water and sanitation programme which
has played a substantial role in improving their health condition.
The frequency of the incidence of diseases in the programme intervened
villages has decreased. The improvement of health condition is
indicated as "Sale of oral saline has decreased at programme
villages", stated by some village doctors. The villagers
in some area have stated that before two years a significant percentage
of people used to drink pond or, river water and were affected
by various water-borne diseases like diarrhoea & dysentery.
At present the cases of diarrhoea and dysentery have almost removed.
However, before the WatSan programme intervention, people, particularly
children were dying every year due to diarrhoea. Because of the
campaign and motivational activities, many people have given up
the habits of open defecation, which has also helped to a great
extent in reducing the incidences of diseases, health hazard and
deaths in the villages.
19. A resulted effect on decrease of water-borne
diseases as well as improvement of the general health status of
the people is significant. However, still few people have belief
on traditional fake treatment and medicine. Though achievement
is tremendous but a few number of people become affected by dysentery
and other water-borne diseases like fever and skin diseases. In
some regions many people especially the children and old men take
bath in pond, ditch or river water due to unavailability of safe
water in the dry months. But a few people still take bath because
of their habit.
A New Lease of Life
Life was never an easy journey for Sunil Kumar
Majumder. With chronic forms of stomach ailments following him
like a curse, his life was a long-drawn battle with diseases.
As the 47-year-old carpenter points out: "I suffered from
chronic diseases of the digestive system like dysentery and diarrhoea
almost throughout the year. Besides, I also had acute skin diseases
during the winter seasons."
However, he has left those dark days behind
him. "Ever since I started to drink arsenic-free water from
the Arsenic-iron Removal Plant (AIRP), these two ailments have
surprisingly left me," says a rejuvenated Sunil Kumar Majumder.
Needless to mention, such recurrent ailments
not only eroded Sunil's health, but it created additional financial
pressures on him. He always had to keep a good inventory of medicines
and oral saline at home. "It used to drain a lot of money
out of me. On an average, I had to spend at least Taka 150 to
Taka 200 per month on medicines," he recalls. "But ever
since I started to consume water from the AIRP, it worked like
magic on me, making the use of oral saline and other medicines
redundant," he confirms.
It is true that because he did not have to
spend on medicines any longer, his ability to spend on other things
has increased. "Had it not been for my improved health, I
could not have installed a sanitary latrine at my house incurring
a cost of around Taka 1200. Besides, I have done some renovation
to my existing house and can now afford the cost of education
of my two daughters and a son," he says pointing out the
changing fortune of his life.
20. The people from most of the villages
have mentioned that though incidences of water-borne diseases
have decreased, but still there are some exceptions. The community
participation is enhancing the promotion of health & hygiene
education among mass people, because through participation the
community people have gained knowledge about health-care that
has an impact in reducing infant mortality rate. With the change
of knowledge and attitude the culture related to some specific
diseases have also been changed. Now almost all the people have
knowledge about diarrhoea that it is not anything other than germs
of the specific disease. Rehana Akter, a housewife says, "The
improvement of the health status in the village has occurred as
a result of strong and massive participation of the community
people. No individual or any specific group of people can do such
activities, it needs united efforts". However, united and
uniform effort of NGO Forum, PNGOs and the villagers has made
this success in WatSan and health improvement.
RECOMMENDATION ON
THE ROLE
OF THE
DIFFERENT ACTORS
ROLE OF THE DIFFERENT ACTORS
|
| International Level | Government and international bodies must acknowledge the community-managed WatSan approach as potential to contribute in the improved public health situation.
Donors must continue its funding in an increased manner to implement the programme effectively.
The global fund should be increased to fight arsenic problem on way to save million of lives.
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|
| National Level | Government should set a mechanism while the WatSan programme can be facilitated in coordination with the health and other relevant departments.
Appropriate training should be provided for govt. and NGO staff.
More promotional activities through visual media are required to disseminate the comprehensive idea about health hazards and necessary preventive measures to achieve the goal of WatSan programme.
Women must be considered as the mainstream interest group in the field of water and sanitation, rather than a special interest group.
Frequent information & documentation sharing and public debate on health & WatSan should be ensured.
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| Community Level | Community people should participate actively in WatSan programme.
Should be involved in scaling up the good practices.
Be involved and united to ensure the sustainability of the WatSan set-ups.
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REFERENCES
1. Sector Development Programme (SDP), Unit for Policy
Implementation (UPI), LGD, MoLGRD & Cooperatives, December
2005.
2. Propelling Participation, NGO Forum for Drinking Water
Supply and Sanitation, December 2000.
3. World Water Day Seminar Report "Safe Water for
Sound Health, April 2001.
4. A Silent Social Awakening, NGO Forum for Drinking
Water Supply and Sanitation, December 2002.
October 2006
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