Prioritising Water, Sanitation and Hygiene in Ebola Recovery: For health, life and dignity | Sanitation

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The benefits of water, sanitation and hygiene (WASH) are clear and well understood. Improved WASH provision has direct impacts on health, education, dignity and gender equality and therefore on long-term development and prosperity. But the reality is that the Ebola-affected countries in West Africa have some of the worst WASH coverage in the world. And this has had fatal impacts: poor WASH provision has limited the prevention and control of infection and exacerbated the impact and reach of the Ebola outbreak. This briefing describes how the Ebola recovery process needs to strengthen public health services, including WASH improvements in schools, slum areas and more broadly to make WASH provision sustainable in communities. 
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  Page 1 of 6 Prioritising Water, Sanitation and Hygiene in Ebola Recovery: For health, life and dignity   ‘ No other issue suffers such disparity between its human importance and its political priority. ’   Kofi Annan, former Secretary-General of the United Nations Freetown Wash Consortium Key messages The benefits of water, sanitation and hygiene (WASH) are clear and well understood; improved WASH has direct impacts on health, education, dignity and gender equality, and therefore has impacts on long-term development and prosperity. Yet the reality is that the Ebola-affected countries have some of the worst WASH coverage in the world. And this has had fatal impacts: poor WASH has limited infection prevention and control and exacerbated the impact and reach of the Ebola outbreak. The recovery process needs to radically strengthen public health services, and WASH must be a crucial part of that. This clearly requires a focus on WASH in health centres. WASH improvements are also needed in schools, slums and more broadly in communities. Improvements must go beyond WASH hardware into clear plans for effective community-led engagement, involvement them in managing services and so ensuring sustainability. Communities must be equipped to hold WASH providers accountable for service provision This paper provides specific recommendations for the Ebola Recovery Pledging Conference, July 2015.  Page 2 of 6 The importance of WASH The benefits of WASH are clear and well understood: Return on investment:  every $1 invested in WASH in sub-Saharan Africa has an estimated return of $2.5. 1  Preventing the spread of Ebola: WASH, particularly hand-washing with soap, forms an important additional barrier to the spread of Ebola. 2   Wider health: 88 per cent of diarrhoeal diseases are attributable to poor WASH. 3   Child health and education: Nematode infections inhibit the intellectual and physical growth of children; they are wholly attributable to poor WASH. 4   Gender equity: The lack of WASH in schools has more impact on girls and women and 50 per cent of girls who drop out of schools do so due to poor WASH. 5  Protection for women: Women who have to walk long distances to fetch water or who are forced to defecate away from their homes can be vulnerable to physical attack.  Yet Ebola-affected countries have some of the worst WASH coverage in the world. Despite the unambiguous benefits, WASH is often not prioritised by governments or donors. For example in 2012  – 13, only 1.2 per cent of the Liberian national budget was invested in WASH and in the planned budget for 2013  – 14, WASH was only 0.4 per cent. 6  The results are clear: In Sierra Leone,  only 13 per cent of the population has access to improved sanitation and 34 per cent of the rural population practices open defecation; 63 per cent of the population has access to improved water supplies (48 per cent rural, 85 per cent urban). In Liberia,  only 17 per cent of the population has access to improved sanitation and 68 per cent of the rural population practices open defecation; 76 per cent of the population has access to improved water supplies. In Guinea , only 20 per cent of the population has access to improved sanitation and 77 per cent has access to improved water supplies. 7   Poor WASH was an important factor in the Ebola outbreak ‘   Pervasive unhygienic conditions and use of unsafe water have been identified as a key underlying factor in thousands of deaths prior to and during the Ebola outbreak …In the medium to long  -term, lack of development in the WASH sector is a constant  burden to the three countries’ recovery and development  . ’  8  Getting to zero, staying there and ensuring Ebola preparedness for any future outbreak requires major investment in WASH. Effective infection prevention and control (IPC) relies on safe water. The fact that this was not available for households, in communities and even in some health clinics, limited what could be done. In Sierra Leone  for example, only 32.3 per cent of basic emergency obstetric and new-born care centres are compliant with the Ministry of Health and Sanitation WASH standards. 9   WASH is crucial for public health and must be prioritised in the recovery process  Investing in WASH not only increases the protection of communities against the spread of Ebola, but also against the spread of other infectious diseases. Eighty-eight per cent of diarrhoeal diseases are wholly attributable to poor WASH, 10  and yet the simple practice of hand washing with soap can reduce diarrhoea morbidity by nearly 40 per cent and has been found to be the most cost-effective health intervention available. 11  Hygiene knowledge and behaviour is crucial to this process.   Page 3 of 6 In Liberia,  improvements to the water supply could reduce illness due to diarrhoea by 21 per cent, while improved sanitation facilities could reduce diarrhoea morbidity by 37.5 per cent. 12  Cholera outbreaks in all three countries are a risk, especially in the rainy season when there is increased flooding and the risk of drinking contaminated water. In Sierra Leone  the last major cholera outbreak was in 2012, affecting around 23,000 people and causing 300 deaths. There are currently 28 hotspots in the country that have been identified as particularly vulnerable to WASH-related diseases. In Guinea,  the 2012 cholera outbreak saw 7,351 cases and 138 deaths. 13   Investing in WASH: a matter of gender equality and dignity ‘  Some of our friends are raped when they go far to get water, some are drowned in the streams. ’    Boy aged 7  – 10, Kailahun 14   As well as its health benefits, access to safe, hygienic and private sanitation facilities is a matter of dignity. Women and girls perform most of the unpaid labour associated with water and sanitation, leaving them less time for education, economic activities and leisure. For millions of women across the world, inadequate access to basic household facilities is a source of shame and physical discomfort. Millions of women living in rural areas are only able to defecate late at night, often at the edges of their communities, where they are vulnerable to physical attack and sexual abuse. In urban areas of Sierra Leone, communities have told Oxfam that limited access to water means that women are routinely subjected to sexual abuse in exchange for provision of water.  A recent study on the impacts of the Ebola outbreak on children found that sexual violence was observed to have increased during the outbreak and the risk of rape was highest when girls went to collect water, travelled long distances to trade in other villages, or when using the bush to go to the toilet. 15   Key areas for investment WASH in schools: WASH in schools is a fundamental necessity for children ’s  health and development. A recent study on the impacts on children of the Ebola outbreak found that about half the children interviewed were afraid of returning to school, and one key concern was whether schools had sufficient WASH facilities. It confirmed that lack of WASH in schools affects girls disproportionately. ‘ Adolescent girls reported concerns about the lack of sanitation facilities at schools. Some girls reported that in the past they had missed school if they were menstruating; there were inadequate facilities for them at the school  . ’   16   In Liberia, a 2013 study found that 55 per cent of primary schools lacked access to water and 33 per cent did not have latrines. The Liberian government has mounted a campaign to raise $60.3m to provide WASH in schools; this effort should be supported by donors at the Pledging Conference. WASH in health centres: It is obvious that   having   sufficient WASH facilities in health centres is crucial for health. In Guinea,  a 2014 government study found that 39 per cent of healthcare units had no water point. 17  This situation needs to dramatically improve if countries are going to be able to deal effectively with Ebola and other illnesses. Sanitation in urban slums:  Appropriate disposal of waste is a key challenge, particularly in urban slums, which proved to be persistent hot spots for the spread of Ebola. Faecal sludge  Page 4 of 6 management services in Freetown, Sierra Leone , are ineffective, with an estimated 90 per cent of Freetown’s faecal sludge being discharged to the open environment without treatment. This has a significant impact on the health of the Freetown population, and particularly the most vulnerable people who live in Freetown’s low -lying informal settlements, through which a majority of the city’s faecal sludge flows.  WASH in communities: However keen people are to wash hands and ensure effective sanitation, they cannot do so without appropriate services. In rural areas of Sierra Leone , 55 per cent of villages surveyed had no drinking water point. 18   ‘  Here the whole community has only one hand-pump for drinking water. There is not a single toilet. Our people go to the bush for long coals. The type of soil here makes latrines very expensive to build. Only rich people can build latrines. Only government can help us build latrines. ’    Community leader in Port Loko, Sierra Leone, May 2015 Strengthening community management of WASH facilities: Prior to the Ebola crisis, lack of maintenance of WASH facilities was a long-term challenge in all three affected countries. It is crucial that investments in WASH include a strong focus on working with communities at the grassroots level. This is the only way to ensure sustainability and effective functioning of facilities. Example: Community-led total sanitation (CLTS) This programme, active in Sierra Leone and Liberia  mobilises communities to eliminate open defecation and increase sanitation access to help build healthier, more disease- resistant communities. CLTS triggers communities’ desire for change, propels them into action and encourages innovation, mutual support and appropriate local solutions. It therefore leads to greater ownership and sustainability and does so without external subsidies for latrine construction. CLTS achieved major results in reducing the pre-Ebola rate of open defecation in Sierra Leone. CLTS was used as the basis for stimulating community-level behaviour change by several organisations in Sierra Leone, with communities triggered to make and keep agreements which protected their communities from Ebola. However, recent studies have identified some challenges related to the sustainability of toilet use and hand washing practices. Future work needs to enhance the quality of latrines through the marketing of affordable and durable sanitation products, and incorporate behaviour-change programming targeting a broader range of hygiene and health-related behaviours. This work also needs to be integrated further into other sector initiatives, such as nutrition and livelihoods, as well as stimulating community preparedness for emergencies. Accountability: Communities need to be strengthened in their ability to hold health service providers to account. In the long term it is communities, supported by civil society and other organisations, who are best placed to hold governments and other service providers to account. To achieve this, they need to understand their healthcare rights, develop advocacy skills and build capacity to monitor programmes and network to represent their needs. There needs to be greater transparency in the allocation of funds and programme planning for healthcare at the district level. This will enable communities and other organisations to have access to the information they need to advocate for improved services.
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