Hand hygiene: our future is at hand

This article was initially published in the Zambia Daily Mail Newspaper on 15th October 2021 to commemorate the World Handwashing Day but its relevance hasn't diminished a single bit. 

The COVID-19 era, many public and private institutions had put up handwashing facilities at the entrance of their premises. Standing there to observe the number of people washing their hands as they enter or exit and that gave you a real picture of the battle around social and behaviour change relating to hand hygiene.   

If you took the trouble to check, you may find some of those buckets have not had water in a very long time. Neither is there soap. But for the sake of being seen to be compliant, the buckets still stand.

Handwashing is a simple yet powerful act of hygiene behaviour crucial for the prevention of diseases. Handwashing was important before COVID-19 arrived but has now taken on added importance in view of the pandemic.

According to the Joint Monitoring Programme (JMP, 2021), a UN mechanism that provides regular global reports on water, sanitation and hygiene (WASH) coverage, around 51 percent or over nine million Zambians lack access to any form of handwashing facilities at home.  

Another 82 per cent or over 15 million lack availability of a handwashing facility with soap and water at home. If this sounds farfetched, it may be because you are part of the 18 per cent that have access to a handwashing facility with clean water and soap.

The choice to have a handwashing facility is an investment decision by a household bordering on finance. Hence the reason majority making up the 82 per cent are found in rural areas and poor communities of urban areas.

For the first time in many years, Zambia did not record cholera cases this year. Though an inquiry is needed to establish this, we can argue that there has been a considerable improvement in hand hygiene necessitated by the COVID-19 pandemic. This has broken the fecal–oral route that causes cholera. However, cholera remains a risk unless the underlying WASH vulnerabilities - lack of access to safe drinking water and adequate sanitation - are addressed.

Whilst water and sanitation infrastructure provide the physical conditions for hygiene, it is the sustained good hygiene behaviours that help prevent the transmission of diseases. Handwashing with soap and clean water, together with other public health interventions, has proved key in reducing the transmission of COVID-19.

Caused by poor hygiene, including poor handwashing behaviours, diarrheal diseases are a leading cause of stunting among children under the age of five in Zambia. That is why it is important for all members of the household to ensure they have a clean environment and wash their hands at critical times such as after using the toilet, after changing baby nappies, before breastfeeding, after cleaning a toilet, before preparation and consumption of food, and after coughing, sneezing, or blowing their nose.

Improved hygiene behaviours reduce chances of transmitting diseases, thereby contributing to a disease-free community and the healthy growth of children.

Global Handwashing Day is a day commemorated annually on 15 October to raise public awareness on making handwashing with soap and clean water available globally, especially in public places. It also calls for institutions and individuals to improve hand hygiene efforts in the COVID-19 response that can outlast the pandemic and ensure continued access to clean water and soap.

In 2021, the theme was “Our Future is at Hand – Let’s Move Forward Together”

Since the creation of Global Handwashing Day in 2008, the Government of Zambia began implementing policies and programs that promote handwashing with soap. Handwashing stations have been integrated into the national Community-Led Total Sanitation (CLTS) program, an innovative methodology for mobilizing communities to take leadership in raising sanitation standards in their localities.

One of the organisations supporting the government’s WASH efforts is the Scaling Nutrition Technical Assistance (SUN TA) Project funded by the United States government. By working with District WASH committees in 13 districts (Mumbwa, Chibombo, Kabwe, Kapiri Mposhi, Ndola, Kitwe, Samfya, Nchelenge, Kaputa, Luwingu, Mbala and Kasama), the project has trained government staff and community volunteers to deliver key messages on improved sanitation and hygiene even before COVID-19 arrived.

In addition to providing handwashing facilities to the 390 health centres where it is working in, the project is also rehabilitating 700 and constructing 300 boreholes and 26 water schemes to increase access to clean and safe water, key to the attainment of improve sanitation and hygiene. Also, 390 Area Pump Menders have also been trained and given tools to support their continuous operation and maintenance of these water points.

That year’s commemoration of the Global Handwashing Day offered each one of us an opportunity to spread the word about handwashing and contribute to behaviour change on hand hygiene.

The private sector and donors should invest in national roadmaps, hygiene strategies, and research, as well as programs that are hygiene sensitive, promote sustainable behaviour change and drive hand hygiene habits. Businesses should contribute towards resilient hand hygiene systems through partnerships, financing, and innovative products and facilities and again promote hand hygiene within their workforce.

If there is anything COVID-19 taught us, it is the need for collective actions to address the historic neglect of hand hygiene investments, policies, and programs. Our future is at hand, let us move forward together.

Remember to wash your hands today and every day.  

Improving Sanitation By Placing Value On Toilets

The article below was published in November 2021 in the Zambia Daily Mail Newspaper to commemorate the World Toilet Day. It was relevant then and it is relevant now. 

On 9^th November students from the University of Zambia protested to bring to the attention of government the various challenges the school is facing one of which is the lack of proper sanitation as shown in a video where their Students Union President Gabriel Banda claimed that East Park Mall toilets have been their salvation. 2 days later, on 11^th November 2021, students from the Lusaka Business Technical College (LBTC) staged a protest alleging poor sanitation at the institution.

If situations can be this dire at higher learning institutions, how about the rural areas?

The Toilet Crisis

According to JMP (2021), only 3.2 in 10 Zambians have access to improved sanitation facilities which are not shared with other households. 1.1 in 10 Zambian disposes human faeces in open spaces as they lack any form of toilet. The true picture is that 1.94 million of rural Zambians have no toilet facility, as compared with 128,694 of urban. While toilet access is generally higher in urban areas as compared to rural, sanitary conditions in urban areas are aggravated by high-density living, inadequate septage and solid waste management, and poor drainage.

Poor sanitation undermines human dignity. Access to safe, hygienic, and private sanitation facilities is one of the strongest indicators of dignity. For many women across the country however, inadequate access is a source of shame, physical discomfort, and insecurity. Cultural norms strictly control behaviour in this area, in many cases requiring that women are not seen defecating – a requirement that forces them to leave home before dawn or after nightfall to maintain privacy. Delaying bodily functions is a major cause of liver infection and acute constipation. The loss of dignity associated with a lack of privacy in toilets helps to explain why women attach more importance than men to sanitary provision (UNDP 2006).

Poor sanitation hurt girls’ education. Young girls, particularly after puberty, are also less likely to attend classes if the school does not have proper toilets. UNICEF estimate that about half the girls in Sub – Saharan Africa who drop out of primary school do so because of poor water and sanitation facilities. That helps explain why improving school sanitation can increase the demand for education among girls. Conversely, inadequate provision can retard progress. Toilets at home, school and at work help women fulfil their potential and play their full role in society, especially during menstruation and pregnancy.

Poor sanitation causes child mortality. Of the 123,355 annual deaths in Zambia, 31,500 (26%) are children under the age of five (GBDx). Of these fatalities, 3,754 children won't survive to their 5^th birthday because of diarrhea. These sickness episodes represent the second largest cause of childhood death after acute respiratory tract infection. Globally, diarrhoea kills more people than tuberculosis or malaria – five times as many children die of diarrhoea as of HIV/AIDS. Most deaths from diarrhoea are caused by shigella, or bloody diarrhoea. Unlike other forms of diarrhoea, shigella cannot be treated effectively with simple oral rehydration therapies – it requires more costly antibiotics. Even for households that can afford treatment, shigella is a growing threat because it has rapidly developed resistance to antibiotics. The economic impact of poor WASH is also staggering as health is wealth. Despite all this background, less than 1.4% of 2022 Zambia's national budget will go towards Water, Sanitation and Hygiene.

Poor sanitation and undernutrition reinforce each other. When children are undernourished, their resistance to infection is lowered and they are more susceptible to diarrhetic disease and other infections. Where children regularly suffer from diarrhoea, they are also very likely to be malnourished as a result. For infants, particularly those under six months of age, diarrhoea can cause permanent damage to intestinal development, reducing a child's ability to absorb nutrients leading to stunting, both physical and cognitive. And children who are affected by stunting in their early years have lower test scores on cognitive assessments and activity level (Alderman, Hoddinott and Kinsey, 2006). Ultimately, adults who were stunted as children on average earn 22% less than those who weren’t (Anthony Lake, 2012).

Working with line ministries to contribute to stunting reduction in the Zambia, Scaling Up Nutrition Technical Assistance (SUN TA) is a project supported by USAID being implemented in 13 selected districts of Central, Copperbelt, Luapula, and Northern Provinces. To achieve this goal, SUN TA targets women of reproductive age with at least one child under 2 years of age, and/or a pregnant woman. The project’s sanitation demand creation and sustainable social behaviours change is promoted through Community Led Total Sanitation (CLTS) efforts. Given that recent evidence suggesting that poor sanitation is particularly threatening to early life health, efforts to improve sanitary conditions is therefore of urgent relevance.

2021 World Toilet Day

World Toilet Day - a day set worldwide to raise the awareness and inspire action to intensify the construction and use of toilets – falls on 19^th November every year. This year’s theme ‘Valuing Toilets” draws attention to the fact that toilets - and the sanitation systems that fund them – are often underfunded, poorly managed, or neglected. This has devastating consequences for health, economics, and the environment, particularly in our poorest and most marginalized communities. The use of toilets is a topic that is usually ignored and shrouded in taboos evidenced by the outrage UNICEF faced in 2018 for supporting the erecting of billboards proclaiming the eradication of open defecation in selected districts. It will take us to rightly focus such disgust and outrage at the man in the mirror for allowing our fellow Zambians to have the indignity of not having a toilet.

This World Toilet Day show us support that you care about toilets by joining the #WorldToiletDay conversation on all social media platforms.

Solving the water and sanitation crisis

SINCE 1993, World Water Day has been commemorated every year on 22 March to raise awareness and inspire action to tackle the water and sanitation crisis.  It enjoins stakeholders to take action to tackle the global water crisis that has seen over 2 billion people living without access to safe water. 

The theme for this year’s commemoration is ‘Accelerating Change in the Zambian Water Sector through Partnerships and Cooperation.’

With the world having committed to ‘clean and safe water for all by 2030’ under Sustainable Development Goal (SDG) 6, this year’s theme is a clarion call to action,  to identify the strengths and resources of the WASH sector partners and determine how these can be used to support the shared goal. This collaboration can create synergy, which can lead to more effective and efficient results of delivering clean and safe water to all.

According to the 2018 Zambia Demographic and Health Survey (ZDHS), 72% of households in the country have access to an improved source of drinking water. Urban households (92%) are more likely to have access to an improved source than rural households (58%).

More than half of households (54%) in Zambia use an improved sanitation facility, including facilities shared with other households. Urban households are twice as likely as rural households to use improved sanitation facilities (78% versus 37%).

While some of these statistics (like 92% access) may seem impressive, the reality is different. In both rural and urban areas, the distances people cover to what they consider their nearest source of water are long and greatly compromise access. Some households do not have a toilets and practice open defecation, thus increasing the risk of waterborne diseases such as cholera.

The paradox for rural communities is that despite some of them residing near huge water bodies such as rivers and lakes, they do not have access to clean and safe water, underscoring the difference between availability and access. The reasons for this crisis are complex and multifaceted, but they include rapid population growth, climate change, and poor water management practices.

To address these challenges, the Zambian government has been working with various partners and stakeholders to accelerate change in the water sector. These partnerships and collaborations are critical in achieving sustainable water management and ensuring access to safe water for all.

One of the key partnerships in the Zambian water sector is between the government and civil society organizations. Civil society organizations play a critical role in promoting community engagement and participation in water management. They work with communities to raise awareness about the importance of water conservation and help build community capacity for sustainable water management.

Despite the progress made through these partnerships, challenges remain in the Zambian water sector. One of the biggest challenges is the lack of funding for water infrastructure development and maintenance. The government and its partners must work together to find innovative financing solutions to address this challenge.

The vagaries of climate change have also complicated water access, with traditional sources of water for some communities such as streams and protected wells drying up completely or much earlier than anticipated each year.

In both the Vision 2030 and the Eight National Development Plan (8NDP), the government has outlined plans on improving access to safe and clean water, and improved sanitation. Water is inextricably linked to the pillars of sustainable development, and it integrates social, cultural, economic and political values.

“Key programmes to be implemented include climate resilient water supply infrastructure development and maintenance, water quality monitoring and protection of aquifers and protected water sources,” according to the 8NDP.

In the Vision 2030, the government seeks to achieve universal (100%) access to clean water supply to all by 2030. This is a tall order given the current situation and will require massive investment in the water and sanitation sector if the country is to come close to meeting national and global targets.

 The Zambia Water Investment Programme launched by President Hakainde Hichilema on the sidelines of the African Union Mid-Year Coordination Summit in July 2022 requires $5.75 billion to improve water security and sanitation investments and create approximately 200,000 formal jobs by 2030.

 While government has the overall national mandate of providing clean and safe water to communities and ensuring improved sanitation, the scale of the challenge only suggests that government alone cannot overcome it. Hence, the need for households, non-state actors and other entities to step in and supplement efforts of central government.

Across the country, several organisations are contributing to solving the water and sanitation crisis through a variety of projects and programmes. Among them is the USAID Scaling Up Nutrition Technical Assistance (USAID SUN TA) Project that is operating in 13 districts across four provinces, namely Central, Copperbelt, Northern and Luapula.

The project, whose objective is to contribute to a reduction in malnutrition, is working with various government ministries to, among other activities, deliver clean and safe water and improve sanitation in communities. 

Clean and safe water and sanitation are crucial to reducing diarrheal diseases which are a leading cause of malnutrition in children under two years.

In 2022, the project delivered clean and safe water to around 118,000 people in the four provinces through the construction and rehabilitation of 239 boreholes.

In 2023, the project has an ambitious target of rehabilitating 260 waterpoints and constructing 150 new ones across the 13 districts to boost provision of clean and safe water to more communities and households.

Sanitation goes hand in glove with increased access to water. By working with civic and traditional leaders and trained community volunteers, the USAID SUN TA project has over the last four years mobilised communities to take action to improve community and household sanitation through an approach called community-led total sanitation (CLTS).

Among the achievements include households constructing toilets and handwashing stations to eliminate open defecation and improve hygiene. For instance, Kaputa District was in 2021 declared an open defecation free (ODF) district.

By supplementing government efforts through strong partnerships and cooperation, the USAID SUN TA Project is contributing to the national goal of addressing the water complex challenges and ensuring access to clean and safe water and sanitation for all