Limited access to WASH & health facilities

Though awareness of the importance of clean drinking water is high among the population, many farmers (have to) use water from defective and contaminated groundwater sources in the region (Table 42).

In the project region, access to clean drinking water is severely restricted due to poor water infrastructure, poor maintenance of water sources and widespread poverty (Table 43). The limited access to and low availability of (drinking) water worsens during the dry season. Communities and individuals use different instruments and techniques to purify water such as aquatabs⁵⁶, chlorine, filtering and purification with ground moringa seeds.

Table 42: Different sources of water

Water sources and usage

Borehole⁵⁷ Water from boreholes is the cleanest source of household water and almost exclusively used for drinking. However, it is fairly expensive (around 25 CFA per bowl) and can be unaffordable for poor households.

Well Water from wells is used for cooking, washing, hygiene and drinking.

While well water is for free, it can be contaminated by dirt, insects, worms, algae and bacteria, posing a serious health risk.

Rain and river water

In many small villages, residents must travel long distances to reach the nearest boreholes. As a result, they frequently turn to rivers and runoff for water despite high risk of contamination. The use of rain and river water for drinking is directly linked to disease.

Source: Own data.

56 Individuals stated to have concerns about their health using aquatabs.

57 Many boreholes are constructed by both international donors (e.g. European Union, UNDP and smaller local organisations.

Table 43: Limited access to drinking water

Barriers in access and availability of drinking water Economic

barriers

As many households face economic constraints to access clean drinking water, they consume water from open wells, rivers, or rainwater despite the risk of contamination.

Water

infrastructure

Villages often do not have access to water, and women, who are responsible for fetching water, need to walk far to collect it. y Carrying water over long distances not only consumes women’s precious time but are also physically exhausting, especially for elderly or pregnant women.

Maintenance Poor well maintenance often results in inaccessibility or contamination of water sources. In many places, there are no functioning water committees to maintain the sources.

Source: Own data.

Disease and health expenditures

Almost all villagers said that they suffer from either constant or reoccurring malaria in combination with fever, diarrhoea and fatigue. Pregnant women and children under age 5 are especially at risk of malaria due to their weaker immune systems (Global Fund, 2018). Sickness affects people’s ability to work in agricultural production and generate income. Women said illness kept them at home for 15–30 days a year, depending on the severity. For treatment, many individuals use medicinal herbs first (e.g. papaya leaves, baobab fruit, hog plum and spondias mombin / anacardiaceae spp.) and go to health centres only when traditional treatments have failed.

Nutrition-related diseases, such as anaemia, diarrhoea and intestinal pose big difficulties to women. Women in all villages complained about high rates of diarrhoea. Breastfeeding mothers are more likely to transfer diarrhoea to their babies when general hygiene conditions are inadequate. Some women attributed incidences of diarrhoea to pesticides but argued that the use of pesticides was necessary due to declining soil quality.

In reducing diarrhoea, a multi-sectoral approach is needed. Women in a beneficiary village gave the following reasons for a reduced incidence of diarrhoea: (1) interventions such as handwashing promoted by ProSecAl; (2) improved availability of clean drinking water; (3) the construction of boreholes in two

neighbouring villages; and (4) the introduction of government training programmes for traditional healers.

Inadequate access to WASH- and health facilities

The access to sanitation- and health facilities in the region is limited. Due to inadequate healthcare and hygiene practices, the target group’s health-related expenses are high: health is the number one expense among all surveyed households (before education and additional food) and often makes up 50% of expenditures. Some women said that they “forget about buying food because we have to spend money on health issues.” Moreover, they explained, the need for quick cash to cover medical treatment forces them to sell agricultural products at unfavourable prices.

The majority of villages do not have a health station, infrastructure is poor and transport options are few (especially during rainy season). The few health facilities that exist are inadequate (no electricity nor running water) and lack medical equipment to diagnose stunting (i.e. scales, growth charts) (Box 29). The lack of adequate local health facilities means that residents incur extra expenses for transport at night, no form of transport is available.

Sanitation facilities, toilet usage and handwashing

Most villages have only few hygiene sanitation facilities such as latrines or handwashing facilities. Open defecation next to houses or in nearby bushes or fields is not uncommon. In some villages, residents cover faeces with palm strands and ash. No governmental hygiene programme is in place to promote sanitation and hygiene. The poor management, and the lack of sanitation facilities contribute to the spread of diseases.

The construction of latrines is too expensive for most villages (EcoSan toilets cost 40,000 XOF and pit toilets cost 4500 XOF; Box 30) Villagers asked for toilets and landfills located away from their homes. They said they were willing to maintain public latrines; in their view, a steering committee could be responsible for running the facilities.

Box 29: Identification of stunting and access to health facilities.

Identification of stunting

Some health workers (HW) had difficulties to identify stunting and to relate the causes and symptoms of undernutrition. Many health centres lack growth charts, scales and measuring devices. In one beneficiary village, nurses identified stunting and related it to “small children eating too little and too few vitamins.”

ProSecAl recommends interventions and nutritional education for mothers. For mothers, stunting was difficult to grasp, and they related it mainly to protein malnutrition because images of a child suffering from kwashiorkor have been shown to them at the health centre.

Access to health facilities

In Avégodé, the next hospital is more than six kilometres away. People walk or take a motorbike taxi to reach the facility. Frequently, women give birth while on the way to the hospital. Men believe that this is a reason why women get sick.

Women stressed that if people feel sick, they walk even further to the next bigger hospital.

Source: Own data.

Box 30: Composting toilets

Composting toilets/Ecosan toilets

An expert from the German Red Cross stated that people first disliked the Ecosan toilets, but, having experienced positive effects on health, hygiene and agricultural output, eventually approved the composting toilets. Now, the benefits are well known. To ensure sustainable practices, the German Red Cross installed field schools near the roads to inform farmers about the agricultural benefits. The organisation highlighted the importance of building toilets in cooperation with local villagers. UNICEF is also very active in the construction of latrines. At schools, pupils build and maintain latrines.

Source: Own data.

Awareness about the importance of handwashing is rare, and only a minority has access to handwashing facilities (such as tippy tap bottles). Households reported that they learned from ProSecAl that handwashing would help eliminate microbes.

A major challenge is availability: tippy tap bottles are placed in open spaces and are often broken or stolen.

Childcare at health facilities

The number of pre- and postnatal care visits of women is often limited by a lack of knowledge, a lack of financial resources, a lack of decision-making power and lack of access. Free initial consultations for pregnant women provide basic information about living with pregnancy, malaria treatments and preventative mosquito nets.

Paid services include medication, dietary supplements, ultrasounds, consultation programmes, blood tests, and checks for parasites. Special consultations are provided to women with physical conditions that could complicate pregnancy, including undernourishment, stunted growth (under 1.5 meters) and obesity.

Fees for giving birth are high and unaffordable for many women. Prices range from 2,000 to 10,000 CFA (for caesarean sections). Fees of health centres and private hospitals do not differ much, but women prefer to deliver in private clinics due to the availability of credit payments for prenatal consultations. Home births are commonplace due to the high cost of prenatal care. Women who opt for home birth often visit a care centre the following day for a check-up.

Experts, community leaders and individuals reported a high risk of maternal deaths in home births. Following experts, the high risk of maternal death was due to the limited use of health services attributable to the lack of awareness, lack of money, lack of access to facilities with pre- and postnatal treatment and to a high workload of the mother.

Box 31: Postnatal treatment

Health workers in the project region described the ideal postnatal treatment to prevent stunting as follows: Immediately after delivery, a baby receives a vitamin K1 supplement to prevent blood clots. After drying the baby, the midwife measures parameters such as weight and height, head circumference, MUAC and malformation using standard reference values from WHO (<2500gramms = underweight, >50cm normal height). Infants receive vitamin A with 9 months and the vitamin complex ADEK for the first year.

Source: Own data.

During postnatal care visits (usually two visits in the first four months; Box 31), new-borns receive vaccinations and are checked for stunting. Health workers

instruct women to breastfeed their infants exclusively for the first six months and teach them on a nutritious, iron- and folic acid-rich diet including the leaves of cassava, amaranth and moringa. Undernourished children with symptoms of stunting and wasting may be transferred to another hospital.