Urban Health Updates

Health emergencies: Research points to practical financial solutions for India’s urban poor | Source: May 9, 2013, RAHIL RANGWALA |

How do Indian families living in urban poverty approach health care? To answer this question and better understand how to structure a customized emergency health loan product for India’s urban poor, the foundation recently commissioned a study of families in five Mumbai slums. 

The research, conducted between December 20, 2012 and February 8, 2013, surveyed members of 545 low-income households located close to hospitals.

The families surveyed all had monthly incomes ranging between INR 7,500 to 20,000 (US $139 to $370.) When the results were collated, we learned that:

• 82 households had a major health issue in the last two years. Reported ailments included cardiac issues, broken bones, accidents, malaria, dengue fever and others.
• The average cost to treat heart-related illnesses, which topped the list of major illnesses, was INR 82,000 (US $1,515.)
• Around 50 percent of participating households had taken out loans at interest rates of over 60 percent per annum to meet their health financing needs.
• Local private clinics (usually unlicensed medical practitioners) were typically the first point of contact for respondents seeking care. As such, these clinics play an important role in influencing behavior for both minor and major ailments.
• Respondents were skeptical or wary of private hospitals, because they worried about either being overcharged or being treated poorly.
• Participants had a positive perception of government-run hospitals, where they felt they would be well treated at an affordable cost.
• Participants responded positively to the concept of an emergency health loan at an interest rate of roughly 20 percent per annum.
• Private hospitals offer differential pricing based on ability to pay.

Clear needs among India’s urban poor; no clear solutions

One important caveat to note is that the results of this survey were self-reported and not verified. Several major implications are nonetheless clear.

• There’s an enormous gap between the health costs impoverished urban families face and the income they earn.
• There’s a huge need for a financial product that helps families deal with emergency health issues.
• There’s a market opportunity for a health credit product that can positively impact the lives of the urban poor.
• There are several potential barriers to success that must be overcome for any market-based solution to gain enough traction to benefit the intended recipients. These include:
• Insufficient awareness and adoption among intended customers: Market-based health-loans will depend on ensuring awareness among the right set of influencers and intermediaries (e.g., community based organizations)
• Risk of abuse by health care providers: Any emergency health loan product would need to be offered at the right kind of hospitals, since purely commercial operators might charge more if they realize that poor patients have access to financing mechanisms.

Overcoming the adoption challenge starts with understanding the real-world behaviors of India’s urban poor

How do we address the gap between need and adoption? Microinsurance, if appropriately designed, priced, and distributed, would be an ideal financial intervention, but to date, microinsurance has had limited success. (A recent review of more than 30 studies, described in an April blog post from CGAP, offers an analysis of the reasons global customers don’t buy microinsurance. Topping the list are “trust, liquidity constraints, the quality of the client value proposition and behavioral constraints.”)

Sharing insights

Given the right insights, Indian entrepreneurs and established financial service providers have an immense opportunity to tap this underserved market and design a product that would have a positive impact on the lives of the urban poor in India. We’re making the details of our study available in the hopes that it can spur needed innovation in the field. Share it far and wide. We look forward to the next generation of innovation designed to address the specific health care needs, motivations and concerns of India’s urban poor.

The findings, a joint product of the foundation, Delphi Research Services Private Limited and a start-up company, can be read here. They include more detail on the kinds of ailments, decision-making behavior of the urban poor, the role of local NGOs and hospitals as well as government run health insurance schemes in Mumbai.

Cholera Toolkit 2013. UNICEF.

• Toolkit website

The UNICEF Cholera Toolkit aims to provide UNICEF Offices, counterparts and partners with one source of information for prevention (or risk reduction) and control of cholera outbreaks, preparedness, response and recovery – including integration with regular/development programmes. 

The Toolkit provides guidance primarily for the Health and WASH sectors; nevertheless guidelines are presented in an integrated manner, to avoid the continuation of ‘silo’ approaches for cholera prevention, preparedness and response. In addition, the Toolkit includes specific content linked to Education, Nutrition, C4D, Child Protection and other relevant sectors.

The Toolkit comprises this ‘Main Document’, a series of ‘Annexes’ (templates, checklists, spread sheets and more detailed reference information available only in electronic copy) and a selection of ‘Additional Resources’ (an electronic library including published papers, IEC materials, cholera guidelines, training packages, examples of mapping and a range of other practical information, available in the companion USB). Links to web-based resources are included throughout the electronic version of the Main Document.

India – For better health | Source: Deccan Herald, May 11, 2013 |

The Union cabinet’s approval for the launch of a national urban health mission (NUHM) is welcome for its aim of providing basic health services to the poor and disadvantaged sections in cities and towns.

The Rs 22,500 crore programme plans to cover 7.75 crore people living in 779 urban clusters and is mainly targeted at the poor people living in slums. The national rural health mission (NRHM) was launched in 2005 and it has taken about eight years to design a similar programme for city-dwellers.

Both missions will be part of the bigger national health mission. The launch of a populist programme intended to benefit large numbers of people months before elections may have a political angle. But that should not detract from the value of the programme if it is implemented efficiently.

Provision of public health facilities to the poor and needy is the responsibility of the state. All the health indicators in the country are much below par. The poor cannot afford even meagre expenses on health and so the government has to provide the infrastructure and personnel to them.

The scheme at present intends to provide one health centre for 10,000 people and nursing midwives and health activists for specified numbers of people and households. Seventy-five per cent of the funding will be met by the Centre in most states. As different from the NRHM, the programme seeks to involve non-government bodies also in the NURM as these are active in many urban areas. A decentralised system of implementation involving state, district and ward level bodies is envisaged so that the programme can reach the lowest levels.

The aims, design and methods of the programme may be good but its success will depend on how well it is administered. The NRHM has suffered in many places from corrupt practices like leakage and misutilisation of funds and failure to create necessary health infrastructure and to reach out to the needy people. The lessons should guide the implementation of the NURM.

However the strategies will have to be different for rural and urban areas. In the NURM there is a proposal to reimburse private practitioners for their services at government rates. The accent should be on providing necessary infrastructure and services by the government. It will also have to be supported by schemes for sanitation, clean drinking water and other basic conditions for good health.

Cabinet approves launch of National Urban Health Mission | Source: Big News Network, May 1, 2013 |

The Union Cabinet on Wednesday approved the launch of National Urban Health Mission (NUHM) to reduce rates of infant mortality, maternal mortality and for universal access to reproductive health care.

The scheme, which will focus on the primary health care needs of the urban poor, will be implemented in 779 cities and in towns that have a population of over 50,000. It will cover about 7.75 crore people.

The estimated cost of NUHM for a five year period is Rs.22,507 crore, with the Central Government’s share of Rs.16,955 crore.

The Centre-State funding pattern of the scheme will be seventy five is to twenty five.

However for North Eastern states and other special category states like Jammu and Kashmir, Himachal Pradesh and Uttarakhand, the funding pattern between Centre and State governments will be ninety is to ten.

Recognizing the seriousness of the problem, urban health will be taken up as a thrust area for the Eleventh Five Year Plan.

The NUHM will be launched with focus on slums and other urban poor. At the state level, besides the state health mission and state health society and directorate, there would be a state urban health programme committee.

At the district level, similarly there would be a district urban health committee and at the city level, a health and sanitation planning committee.

At the ward slum level, there will be a slum cluster health and water and sanitation committee.

For promoting public health and cleanliness in urban slums, the Eleventh Five Year Plan will also encompass experiences of civil society organizations (CSO) working in urban slum clusters.

It will seek to build a bridge of NGO-GO partnership and develop community level monitoring of resources and their rightful use.

Goli S, Doshi R, Perianayagam A (2013) Pathways of Economic Inequalities in Maternal and Child Health in Urban India: A Decomposition Analysis. PLoS ONE 8(3): e58573. doi:10.1371/journal.pone.0058573.

• Full-text

Background/Objective – Children and women comprise vulnerable populations in terms of health and are gravely affected by the impact of economic inequalities through multi-dimensional channels. Urban areas are believed to have better socioeconomic and maternal and child health indicators than rural areas. This perception leads to the implementation of health policies ignorant of intra-urban health inequalities. Therefore, the objective of this study is to explain the pathways of economic inequalities in maternal and child health indicators among the urban population of India.

Methods – Using data from the third wave of the National Family Health Survey (NFHS, 2005–06), this study calculated relative contribution of socioeconomic factors to inequalities in key maternal and child health indicators such as antenatal check-ups (ANCs), institutional deliveries, proportion of children with complete immunization, proportion of underweight children, and Infant Mortality Rate (IMR). Along with regular CI estimates, this study applied widely used regression-based Inequality Decomposition model proposed by Wagstaff and colleagues.

Results – The CI estimates show considerable economic inequalities in women with less than 3 ANCs (CI = −0.3501), institutional delivery (CI = −0.3214), children without fully immunization (CI = −0.18340), underweight children (CI = −0.19420), and infant deaths (CI = −0.15596). Results of the decomposition model reveal that illiteracy among women and her partner, poor economic status, and mass media exposure are the critical factors contributing to economic inequalities in maternal and child health indicators. The residuals in all the decomposition models are very less; this implies that the above mentioned factors explained maximum inequalities in maternal and child health of urban population in India.

Conclusion – Findings suggest that illiteracy among women and her partner, poor economic status, and mass media exposure are the critical pathways through which economic factors operate on inequalities in maternal and child health outcomes in urban India.

Solid waste management in African cities: Sorting the facts from the fads in Accra, Ghana. Habitat International, Volume 39, July 2013, Pages 96–104.

• Abstract/Author email

Martin Oteng-Ababio, et al.

Municipal solid waste management continues to be an environmental health burden in many African cities. Overwhelmed with the magnitude of the problem, city authorities tend to seek out ‘environmentally friendly’ but costly “win–win” technologies via public-private partnerships with firms often from the North, yet these technologies may be inappropriate for the local conditions. While the authorities’ intentions may be laudable, the approach may be born out from an empirical vacuum. Using case studies from Accra, we illustrate how investments in new solid waste management technologies may well be ill-fated if the requisite waste stream composition data does not exist to justify such investments.

We also highlight the importance of recognizing the innovations of “informal” waste pickers and legitimizing them with the formal system. Until the evidence – along with appropriate institutional and financial instruments – show favorable conditions for investing in advanced waste management technologies, authorities in African cities would do well to consider integrating proven innovations taking place in their own “backyard.”

Alvarado-Esquivel C (2013) Toxocariasis in Waste Pickers: A Case Control Seroprevalence Study. PLoS ONE 8(1): e54897. doi:10.1371/journal.pone.0054897.

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Background – The epidemiology of Toxocara infection in humans in Mexico has been poorly explored. There is a lack of information about Toxocara infection in waste pickers.

Aims – Determine the seroepidemiology of Toxocara infection in waste pickers.

Methods – Through a case control study design, the presence of anti-Toxocara IgG antibodies was determined in 90 waste pickers and 90 age- and gender-matched controls using an enzyme-linked immunoassay. Associations of Toxocara exposure with socio-demographic, work, clinical, and behavioral data of the waste pickers were also evaluated.

Results – The seroprevalence of anti-Toxocara IgG antibodies was significantly higher in waste pickers (12/90: 13%) than in control subjects (1/90: 1%) (OR = 14; 95% CI: 2–288). The seroprevalence was not influenced by socio-demographic or work characteristics. In contrast, increased seroprevalence was found in waste pickers suffering from gastritis, and reflex and visual impairments. Multivariate analysis showed that Toxocara exposure was associated with a low frequency of eating out of home (OR = 26; 95% CI: 2–363) and negatively associated with consumption of chicken meat (OR = 0.03; 95% CI: 0.003–0.59). Other behavioral characteristics such as animal contacts or exposure to soil were not associated with Toxocara seropositivity.

Conclusions – 1) Waste pickers are a risk group for Toxocara infection. 2) Toxocara is impacting the health of waste pickers. This is the first report of Toxocara exposure in waste pickers and of associations of gastritis and reflex impairment with Toxocara seropositivity. Results warrant for further research.

BMJ Open. 2013 Apr 3;3(4). pii: e002251. doi: 10.1136/bmjopen-2012-002251.

The high cost of diarrhoeal illness for urban slum households-a cost-recovery approach: a cohort study.

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Patel RB, Stoklosa H, Shitole S, Shitole T, Sawant K, Nanarkar M, Subbaraman R, Ridpath A, Patil-Deshmuk A.
Departments of Emergency Medicine, Brigham and Women’s Hospital and Massachusetts General Hospital, Boston, Massachusetts, USA.
Abstract

OBJECTIVES: Rapid urbanisation has often meant that public infrastructure has not kept pace with growth leading to urban slums with poor access to water and sanitation and high rates of diarrhoea with greater household costs due to illness. This study sought to determine the monetary cost of diarrhoea to urban slum households in Kaula Bandar slum in Mumbai, India. The study also tested the hypotheses that the cost of water and sanitation infrastructure may be surpassed by the cumulative costs of diarrhoea for households in an urban slum community.

DESIGN: A cohort study using a baseline survey of a random sample followed by a systematic longitudinal household survey. The baseline survey was administered to a random sample of households. The systematic longitudinal survey was administered to every available household in the community with a case of diarrhoea for a period of 5 weeks.

PARTICIPANTS: Every household in Kaula Bandar was approached for the longitudinal survey and all available and consenting adults were included.

RESULTS: The direct cost of medical care for having at least one person in the household with diarrhoea was 205 rupees. Other direct costs brought total expenses to 291 rupees. Adding an average loss of 55 rupees per household from lost wages and monetising lost productivity from homemakers gave a total loss of 409 rupees per household. During the 5-week study period, this community lost an estimated 163 600 rupees or 3635 US dollars due to diarrhoeal illness.

CONCLUSIONS: The lack of basic water and sanitation infrastructure is expensive for urban slum households in this community. Financing approaches that transfer that cost to infrastructure development to prevent illness may be feasible. These findings along with the myriad of unmeasured benefits of preventing diarrhoeal illness add to pressing arguments for investment in basic water and sanitation infrastructure.

Understanding the nature and scale of urban risk in low- and middle-income countries and its implications for humanitarian preparedness, planning and response, 2013.

• Full text, pdf

David Dodman, et al.

More than half of the world’s population now lives in urban centres. Most of the world’s urban population and its largest cities lie outside the most prosperous nations and almost all future growth in the world’s urban population is projected to be in low- and middle-income countries. Within these urban centres it is common for up to 50 per cent of the population to live in informal settlements. These are often located on land that is exposed to hazards, with poor-quality provision for water, sanitation, drainage, infrastructure, healthcare and emergency services. The residents of these low-income and informal settlements are therefore highly vulnerable to a range of risks, many of which are specific to urban settings.

Yet despite this, many humanitarian agencies have little experience of working in urban areas, or of negotiating the complex political economies that exist in towns and cities. This working paper has two main purposes: (1) to review the quality of the evidence base
and to outline knowledge gaps about the nature and scale of urban risk in low- and middleincome countries; and (2) to assess the policy implications for humanitarian preparedness, planning and response. It does so by analysing a wide range of academic and policy
literature and drawing on a number of interviews with key informants in the field. It particularly focuses on evidence from Africa and Asia, but also draws on case studies from Latin America, because many examples of good practice come from this region. The paper
aims to help ensure that humanitarian and development actors are able to promote urban resilience and disaster risk reduction and to respond effectively to the humanitarian emergencies that are likely to occur in cities.

Bad Air, Ill Health: Air Pollution in Urban Slums | Source: By Thaddaeus Egondi and Diana Warira, African Population & Health Research Center, March 1, 2013 |

Although there is a wealth of information on the health consequences of air pollution, little information exists on the level of air pollution in LMICs (Lower-middle-income countries), in general, and in urban areas, in particular. In Nairobi, Kenya’s capital city, for example, the few studies that have assessed air pollution levels have been conducted along roads and provide a limited picture of exposure levels in residential areas.

Yet we know that air pollution – obviously present in poor urban areas– has been linked to respiratory infections, heart problems, lung cancer and undesirable pregnancy outcomes, such as low birth weight and still births. The World Health Organization (WHO) estimates that air pollution leads to 3.1 million premature deaths worldwide every year. More than half of the global burden of disease stemming from air pollution occurs in LMICs.

Research indicates that young children, expectant mothers, old people, and those with chronic health problems, such as asthma, heart and lung disease, suffer more when exposed to air pollution. The extent to which an individual is harmed by air pollution usually depends on thetotal exposure to pollutants, a measure of the duration of exposure and the concentration of the pollutants.

Slums are a pervasive feature of many cities in LMICs. The level of air pollutants in slum settlements is likely to be higher than in non-slum settings due to close proximity to industries, dust from unpaved roads, poor waste disposal, burning of trash and heavy use of solids fuels such as charcoal and wood. Nairobi as one of the rapidly growing cities is not exceptional from these environmental concerns. Research we have done at the African Population and Health Research Center (APHRC) on the main fuel type for household energy needs in two slums (Korogocho and Viwandani) indicates that 84% of households use kerosene/paraffin, 14% charcoal and 2% use other fuels such as firewood, animal waste and gas. Outdoor air pollution in slum setting contributes to the level of indoor air pollution because of infiltration of air pollutants into poorly ventilated structures.

It’s Time to Monitor Air Quality

Establishing air pollution levels and associated health impacts is critical for programmatic and policy action to reduce air pollution levels. Quantifying the health impact of air pollution is a challenge faced by LMICs due to the lack of health outcome registries and air monitoring data.

In response to this gap, APHRC has recently initiated a study on air pollution in two urban slums in Nairobi (Korogocho and Viwandani). This study, which is nested in the Nairobi Urban Health and Demographic Surveillance System (NUHDSS), aims to understand community perceptions on air pollution, and assess the level of air pollution and related health effects. In addressing these objectives, the Center will start monitoring indoor and outdoor air pollution levels in the two slums.

The study provides an important first step in providing community-level air pollution information to policy makers. In addition, it is envisaged that sharing the findings from the study with community residents will create awareness on exposure risk and encourage urban slum residents to take measures to reduce pollution levels in their community.  In the long run, this vital information about urban environments may not only decrease the health burden associated with pollution, but also serve to decrease emissions and mitigate the effects of global warming.

Asian Water Development Outlook 2013: Measuring Water Security in Asia and the Pacific, 2013.

• Full text, pdf

This second edition of the Asian Water Development Outlook (AWDO) provides a quantitative and comprehensive view of water security in the countries of Asia and the Pacific. By focusing on critical water issues, AWDO 2013 provides finance and planning leaders with recommendations on policy actions to improve water governance and guidance on investments to increase their country’s water security. AWDO 2013 is presented in three parts.

Part I introduces the five key dimensions of water security and presents the combination of indicators for assessment of national water security. The assessments for individual countries are aggregated to provide regional snapshots, with overviews of what the findings mean, identifying regional issues and hot spots where urgent action is required to improve water security.

Part II applies the indicators to demonstrate how countries in Asia and the Pacific measure up against the AWDO vision of water security, discusses what is at stake, and introduces policy levers that may be used to increase security in each key dimension.

Kenya’s waste management challenge | Source: IRIN Africa, March 13, 2013 |

NAIROBI, 13 March 2013 (IRIN) – As the urban population in Nairobi and elsewhere in East Africa grows, so does the solid waste management burden – a situation worsened by poor funding for urban sanitation departments and a lack of enforcement of sanitation regulations.

At least 100 million people in East Africa lack access to improved sanitation,according to UN sources.

“Due to budgetary deficiencies, town authorities find it difficult to address solid waste management in a sustainable manner. In addition, insufficient public awareness and enforcement of legislation is also a hindrance,” Andre Dzikus, coordinator of the urban basic services section of the UN Human Settlements Programme (UN-Habitat), told IRIN.  

In Nairobi, a large percentage of solid waste is managed by the private sector and NGOs due to public-private partnerships, says Dzikus.

The city council’s solid waste department, like those in Kampala and Dar es Salaam, is not well equipped, with transport vehicles few and often poorly serviced, despite increasing waste quantities due to rapid urbanization, he added.

Understaffing and a lack of skilled staff in waste management is also a challenge.

Without proper controls, solid waste is often dumped in abandoned quarries or similar sites. In Nairobi, for example, municipal waste is taken to the Dandora dumping site, a former quarry some 15km east.

Dandora slum residents who live close to the dumpsite are therefore exposed to environmental and disease risks, said Dzikus.

“Burning plastic produces very toxic fumes, such as furans and dioxins, which are very harmful to human beings and the environment. Most of the uncontrolled dumpsites are some of the major sources of greenhouse gases contributing to global climate change,” he added.

Although Nairobi has a sanitation policy, the Environmental Sanitation and Hygiene Policy 2007, which recognizes the role of NGOs, community-based organizations (CBOs) and the Kenya Water and Sanitation Network (KEWASNET), often there is little collaboration in service delivery, according to a February report, Comparing urban sanitation and solid waste management in East African metropolises: The role of civil society organizations.

“Sanitation service delivery for the urban poor is a disconnected pluralism between government and NGOs/CBOs institutions,” it states.

Living with waste

More often than not, the urban poor have to make do with living amid waste despite the health risks; child mortality in the slums is 2.5 times higher than in other areas of Nairobi, according to the UN World Health Organization (WHO).

In the Mathare slums, for example, the sight of children playing among plastic bags full of human excrement, referred to as “flying toilets”, is common.

“We use plastic bags to relieve ourselves because the few toilets that are there are too expensive,” Mama Annah, a resident of Mathare, told IRIN.

“If I have to choose between paying for the toilet and buying food, the choice is easily made.”

The improper disposal of faecal matter within settled areas is a major public health problem. “We throw the plastic bags in the streets because there is no other alternative. Our children have no [other] place to play,” added Mama Annah.

Insecurity and a lack of hygiene awareness are other problems.

“I have built toilets and bathrooms several times, but every time it rains, or there is a conflict, they are destroyed. Because of the instability, I take my time before I build a new one,” Simon Macharia, a slum property owner, told IRIN.

“We also have to work together, because every time some of us try to keep clean, someone defecates in front of your door.”

Health risk

According to WHO, open defecation was the only sanitation practice available to 33 percent of the population in East Africa in 2006. Lack of access to proper sanitation, including clean water, is a major cause of diarrhoea, the second biggest killer of children in developing countries, according to the UN Children’s Fund (UNICEF).

Many slum dwellers in East African cities pay five to seven times more per litre of water than the average North American, notes WHO.

And it is children and women who suffer the most due to poor sanitation, according to Akiba Mashinani Trust, an NGO focusing on the rights of slum dwellers in Nairobi.

“One of the health risks women have is [with] reproductive health because they use public toilets that are not properly maintained. Some of them have suffered from urinary [tract] infections,” Edith Kalela, a communication officer at Akiba Mashinani Trust, told IRIN.

The biggest challenge to waste management in the slums is the lack of disposal space, added Kalela. “Since these people live in informal settlements, the government has failed to manage their solid waste.”

Lack of land tenure

Slum residents often do not own the land they live on, risking eviction.

In the Huruma slum area, also in Nairobi, Akiba Mashinani Trust has helped residents obtain some land by negotiation with the government and the city council, for which a communal title deed was issued. “If you have land, you have more prospects to do developments,” said Kalela.

“We help these people build houses that are self-contained. Even if we build toilets, there are over 200,000 households, so how many toilets will we build for public use? A sustainable solution is to help them build a house that is self-contained.”

In the past, the government has attempted to improve living conditions in the slum areas under the Kenya Slum Upgrading Programme (KENSUP), but without much success. KENSUP has recently completed a sanitation project in the Kibera slum, handing over seven water sanitation facilities to community groups there, but there are concerns over the project’s sustainability.

State of the World’s Cities 2012/2013: Prosperity of Cities, 2012.

• Download file (5.5MB, pdf)

UN HABITAT

The State of the World’s Cities Report 2012 presents some of the underlying factors behind the financial, economic, environmental, social and political crises that have strongly impacted on cities. Chapter 2.2 ‘Urban Infrastructure: Bedrock of Prosperity’ addresses the issue of ‘Water Supply: When Good Governance Changes the Equation’.

The gist of this Report is the need for transformative change towards people-centred, sustainable urban development, and this is what a revised notion of prosperity can provide. This focus on prosperity comes as institutional and policy backgrounds are in a state of flux around the world. Prosperity may appear to be a misplaced concern in the midst of multiple crises –financial, economic,environmental, social or political – that afflict the world today. It may appear as a luxury in the current economic predicament. However, what this Report shows with compelling evidence is that the current understandingof prosperity needs to be revised, and with it the policiesand actions deployed by public authorities. UN-Habitat suggests a fresh approach to prosperity, one that reaches beyond the sole economic dimension to take in other vitaldimensions such as quality of life, infrastructures, equity and environmental sustainability. The Report introduces a new statistical instrument, the City Prosperity Index, measuring the prosperity factors at work in an individual city, together with a general matrix, the Wheel of Urban Prosperity, which suggests areas for policy intervention.

Waste pickers protest against unsafe disposal of sanitary napkins | Source: Indian Express, March 9, 2013 |

Sanitary napkin companies have engaged in aggressive campaign to spread awareness about the use of sanitary napkins in schools and colleges in rural areas and the urban cities but they have ignored the requests of waste-pickers to provide a disposable bag along with the product, or make suitable amends for appropriate disposable techniques.

“You roll it and chuck it, sparing little thought to what happens to the sanitary pads after they are disposed. Sanitary pads are not bio-degradable but can we make their disposal less degrading?” This is the question that the campaign titled ‘Chuck de, the right way!’ by SWaCH NGO has raised. When waste-pickers sort the wet and dry garbage, they are exposed to the unhygenic used sanitary napkin. While recognising and separating these non-biodegradable napkins, waste workers are infected with eye problems, respiratory ailments, gastrointestinal ailments, skin infections and allergies. These workers often belong to the lower income groups and are often undernourished which makes them more prone to diseases.

Members of SWaCH NGO have come up with a disposable paper bag that cost Re1 to pack the used sanitary napkin before chucking it into the dustbin. These bags have a bright yellow sticker with the details of usage, which makes it recognisable by waste pickers to separate it. “There has never been a uniform way of chucking sanitary napkins. Some wrap it in paper, some put it in plastic bags and some just throw it away. If everyone used an uniform way of disposing the bag, it would be easier for waste pickers to separate it without being exposed to the harmful effects,” says Baby Mohite, a SWaCH member and waste picker.

After sending numerous written requests to companies that manufacture sanitary napkins and diapers and getting no response, the SWaCH members decided to collect used sanitary napkins and send it to the companies as a gift on Women’s Day. “We have been writing to these companies to discuss sustainable ways by which their products can be disposed. Since they have shown no interest whatsoever, we have organised a campaign called ‘Send it back’. We will be sending back used towels and diapers to make them realise what waste pickers to go through while sorting such waste,” says Malati Gadgil, CEO, SWaCH.

Building a scalable business in Ghana: because every family deserves a toilet, by Andy Narracott, WSUP. | Source: Skoll World Forum, Feb 2013 |

ARTICLE HIGHLIGHTS:

• Through collaboration, Unilever and Water and Sanitation for the Urban Poor are building a scalable solution to an enormous problem.
• Clean Team Ghana is a social business that is in high demand by urban consumers in Ghana.
• Each toilet installed helps creates jobs and revenues that help expand the business, taking us one step closer to a safer and more hygienic environment for the benefit of the entire community.

It’s often hard to believe that a small company can face a global problem head on and try to solve it.

At Clean Team, we are driven by that very belief and think we have found an answer to the global sanitation issue.  We’re putting this it into practice as we begin rolling out a new service which is already delivering massive benefits to individuals and families.  While we’re poised to tackle the issue at a local level, we’re preparing to scale our business way beyond our initial base in Kumasi, Ghana. 

The concept has been some time in the making, but solutions to incredibly complex issues don’t just happen overnight.  I’m an urban water and sanitation professional and social-minded entrepreneur. I began working for my father’s UK toilet business while at school and university and would often ponder why my father was able to make a good living in the UK from providing ‘conveniences’ for outdoor events while businesses around the world were failing to serve billions with no toilet at all.

Convenient sanitation is a basic human need and it seemed logical that someone would develop a viable business model to serve this enormous market.  Years later, I joined Water and Sanitation for the Urban Poor (WSUP) in Bangalore, India to support their slum sanitation programme, seeking to demonstrate viable models for government investment.  Spending day after day in the slums, I saw mothers, fathers, grandparents and children nonchalantly walking over to some nearby waste land to defecate, being stripped of their dignity on a daily basis.  Their needs were so obvious and again, I thought, why isn’t someone offering a convenient toilet that people would be willing to pay for, instead of their inconvenient visit each morning that costs them so much in health and economic terms?  Fast forward to today, and I’m now part of a team that is answering that very same question.

The numbers associated with lack of sanitation access are breath-taking;  2.4 billion people worldwide don’t have adequate access to sanitation, meaning people resort to open defecation, polluting the environment and water sources.   The impact on health is huge, 2 million people die every year from diarrheal diseases, and most of them are children under the age of 5.  The estimated cost of poor sanitation in Ghana is $290 million, this sum is the equivalent of US$ 12 per person in Ghana per year or 1.6% of the national GDP.

The are many constraints in Ghana preventing wide deployment of good sanitation; lack of funding, education, water, proper planning, unwillingness of rural and urban communities to incur cost, (with the children being denied access to facilities) and  lack of funds to pay for user systems are all contributory factors which have led to the  continued spread of water borne diseases, such as  bilharzia, schistosmomiasis, guinea worm, yaws and high incidence of diarrhoea affecting mainly children.  Lack of home sanitation incurs further time costs for accessing sites of open defecation: valued at 30% of the Gross Domestic Product per capita for adults and for children over 5 years of age, at 15% of the GDP per capita² (i.e. half that of adults). This is not only a costly situation but especially harmful to women, children, the elderly and disabled, who risk their safety visiting public facilities at night. 4.8 million Ghanaians (approximately 1 in 5) have no latrine at all and defecate in the open, and that the poorest quintile is 22 times more likely to practice open defection than the richest.

This extreme situation may now be resolved to some degree by Clean Team Ghana, a collaborative project with its origins in the collective vision of the partners committed to the project; Unilever, WSUP and IDEO.org.  The seed of the Clean Team concept was first planted by Neal Matheson, then Chief Technology Officer at Unilever, who commissioned a study out of which arose the idea of putting portable toilets into people’s homes.  The next step was to find a partner with an understanding of the challenges of urban sanitation in the developing world, cue Water and Sanitation for the Urban Poor (WSUP) joining the partnership.  IDEO.org, the nonprofit organization focused solely on social innovation to make a positive impact on global poverty through Human-Centered Design projects, joined the partnership with a brief to create a toilet designed from start to finish with the end users in mind – the urban poor.

Ghana was chosen as the home for Clean Team because Unilever has a significant presence there and WSUP was already operating in Kumasi, the second city of Ghana.  More importantly, the habit of paying for sanitation, by using public conveniences, was long established among its inhabitants. In addition, the urban sprawl meant a burgeoning low income population was desperately in need of an alternative to their current, unsatisfactory, sanitation facilities.

As the collaboration developed, the team constructed a new business model to overcome the lack of sanitation infrastructure and solve the issue of waste removal: the concept of a service-based system.  The next phase was to understand the lack of demand, why there are people in Africa with two mobile phones, but not their own toilet. Using Unilever’s extensive analytic and marketing expertise, paired with IDEO.org to develop insight and then a solution, we transformed sanitation from the functional into the aspirational, and created a branded service.

In November 2010, the team visited Kumasi to gain a better understanding of the sanitation market and refine the business model, with incredibly encouraging results out of which the IDEO.org team came up with the “high touch service toilet” concept which was then piloted successfully in Kumasi households.

Clean Team, is working in partnership with the Waste Management Department of Kumasi to deploy an affordable and sustainable in-home urban sanitation service.  It is a registered, profitable business in Ghana that provides families with a toilet in their home at a cost comparable with inconvenient public toilet options.

By the end of 2012, Clean Team had over 100 households as customers and 2,000 new Clean Team toilets in production. This January, the first container load of nearly 400 toilets arrived in Kumasi, extending our reach enormously.  We aim to service 2,000 households, serving 25,000 people in 2013, increasing to 10,000 households in 2014.  People of all ages who are using our service are experiencing a wide range of instantly tangible benefits which are improving their everyday lives.

“With the Clean Team service, I can go to the toilet at anytime. I used to use a plastic bag for fear of stepping out at night. Anything could be out there; people say you can be raped or robbed on your way to the toilet. Clean Team is hygienic, ensures privacy, safe and has provided me something to be boastful about as these days it is the only predictable and dependable service I get.”  Said Kumasi resident and customer, Henrita Piramang Agyeman, 32 years.

It’s not just the product that is based around human centred design; the business model takes into account the circumstances of our customer in their locale.  We know that many people are unable to save up enough money to build a toilet in their home, and even if they could, landlords would not permit them and there is no sewer network to connect to. For a monthly charge, we give our customers an attractive WC-style portable toilet which we return to empty and clean 2, 3 or 4 times a week.  It’s a simple solution with no plumbing or upfront cost and our customers actually like the fragrance the toilet brings to their home and the relationship they build up with the company.  Waste cartridges from the toilets are removed from homes by our uniformed service personnel who build a good rapport with the customers.  They transfer the sealed waste cartridges to a local holding tank which then gets removed by vacuum truck once it builds up in volume. It’s currently taken to the municipal treatment site, but we’re working out ways to recover this valuable resource for use as a fertiliser or an energy source, adding an additional revenue stream to the business.

With the generous support of our benefactors, we’re creating a new market for sanitation that will add millions of dollars to national GDPs and bring dignity to millions of households. While governments figure out how to mobilise the billions of dollars of investment needed for public sanitation infrastructure, we believe our business model offers a viable solution that can serve hundreds of millions of people today. No more queuing at 4am for smelly toilets, we give somewhere fun for kids to go when they need to go, and we’re a business that can be up and running in a new city and serving thousands in next to no time.  A business that my father would be proud to run.

Slum upgrading – improving health and wellbeing?

This guest blog was written by Dr Ruhi Saith, a Research Fellow based in New Delhi and an author of a systematic review examining the effects of slum upgrades on health and socio economic outcomes.

Globally over one billion slum dwellers reside in informal housing and according to UN predications this figure will increase to 1.4 billion by 2020. Whilst progress towards the UN millennium goals, which aim to improve the lives of slum dwellers, is being made, slum improvements have failed to keep pace with the growing ranks of the urban poor.

To overcome the poor standards of living which can be rife within slum areas, the past 15 years has seen consistent political commitment to large-scale slum upgrading programmes. Strategies have sought to improve, formalise and incorporate informal urban areas into cities and also improve the health and livelihoods of people living and working in these areas.

Understanding what works

So, while valuable resources continue to be invested in slum upgrading strategies, how can these resources be invested in the most effective and efficient way? How can policy makers and implementers know what interventions will work to improve the health and wellbeing of those living in slum areas?

Until recently, the evidence on the effectiveness of strategies to reduce the ill effects of urban slums had not been examined systematically. Our review was the first comprehensive review of slum upgrading programmes, collating all relevant research and providing a broad picture of the effectiveness of strategies across different settings, interventions and outcomes. At the same time the review considered the reliability and validity of results and measures within each study.

There are many types of slum upgrading programmes, all which have the potential to effect various and interwoven health and socio-economic outcomes. Our review looked specifically at interventions involving physical environments and infrastructure changes. For instance, we looked at interventions that might improve water and sanitation, energy infrastructure, electricity, transport infrastructure, mitigation of environmental hazards, waste management or housing improvements. But we also wanted to know if these interventions had been combined with other interventions to improve health, education or social services.

We then wanted to understand how these strategies might impact on health and quality of life of slum dwellers in these areas. Such changes to health were determined by changes to mortality and morbidity and where associated to levels of communicable and non-communicable diseases and quality of life measures. In addition, the review examined whether upgrades could affect socio-economic status. We asked whether upgrades could result in changes to financial poverty, employment and occupation or crime and violence, education or social capital.

Here’s what we found:

Following a comprehensive search of the literature, we found that five main studies had used suitable methods for examining the effect of slum upgrading on health, quality of life and social wellbeing. We also identified a further nine supporting studies which could indicate associations between interventions and outcomes. However, due to the methods used in these supporting studies, we could not assess whether the interventions in these studies actually caused the reported effect.

After we had looked at the reliability and validity of the results and measures in all of the studies, we found

• Limited but consistent evidence to suggest that slum upgrading may reduce diarrhoea in slum dwellers and that slum dweller’s water related expenses may also be reduced
• Mixed results for whether slum upgrading can reduce parasitic infections, educational outcomes, financial poverty and unemployment outcomes
• Very little information on other health or social outcomes, or which types of interventions were most beneficial
• Some of the studies we included in the review, asked slum dwellers for their views and their experiences of slum upgrading interventions and these studies suggested a number of reasons why facilities were not used as intended and the factors which may have reduced the benefits of the upgrade

What next?

So, what does this review actually tell us? Whilst our review demonstrates that slum upgrading strategies can improve aspects of health and economic social wellbeing, the review also demonstrates that there are a number of evidence gaps around their effectiveness. We still do not understand what effects physical slum upgrades can have on other aspects of health and wellbeing. Research is needed to examine the effects of slum upgrades on non-communicable diseases, quality of life, employment, education, social capital, injuries and crime.

To close these evidence gaps further, research is required using more rigorous methods. Until evaluation study designs are improved, we will not be able to draw firm conclusions on the impact of slum upgrading strategies.

In the future it is vital that those involved in slum upgrades undertake independent and high quality evaluations of upgrade interventions, including a comparison of different interventions and approaches of implementation. If we are to continue to progress towards the Millennium Development goals, these evaluations will be essential to help determine how valuable resources can be invested to improve the conditions of existing slums and to offer the most benefit to the health, quality of life and social wellbeing of slum dwellers.

• Turley  R, Saith  R, Bhan  N, Rehfuess  E, Carter  B. Slum upgrading strategies involving physical environment and infrastructure interventions and their effects on health and socio-economic outcomes. Cochrane Database of Systematic Reviews  2013, Issue 1. Art. No.: CD010067. DOI: 10.1002/14651858.CD010067.pub2
• Click here to listen to a podcast about the review.
• This article originally appeared on the Evidently Cochrane blog: http://evidentlycochrane.wordpress.com/

Dealing with land tenure and tenancy challenges in water and sanitation services delivery, 2013.

• Full text

Water & Sanitation for the Urban Poor.

WSUP’s work in providing water and sanitation services to the urban poor takes place in contexts with complex formal and informal land ownership arrangements. How can these challenges be overcome?

Drawing on WSUP’s experience in the African Cities for the Future (ACF) programme, this Topic Brief gives an overview of this area, and discusses solutions that have been developed within the ACF programme. The Topic Brief also offers practical guidance on this issue for programme managers.

Is urban ecological sanitation possible? Lessons from Erdos, China. | Source: News from Stockholm Environment Institute, Jan 2013 |

For a large share of the 750 million urban people worldwide who lack adequate sanitation, flush toilets connected to municipal sewers are not a viable option due to poverty, water shortages, groundwater contamination risks and other issues. The research and development project at the China–Sweden Erdos [Ordos] Eco-Town Project was the first major urban project of its kind and was designed to test, at full scale, alternative sanitation in the form of eco-toilets in an arid area of the world.

The project encountered many challenges and uncovered many truths, and was a valuable learning experience that will make future urban ecological sanitation projects more effective.

Apartments at Erdos Eco-City which all had UDD toilets. Photo credit: Sustainable sanitation/Flickr

The project was a collaboration between the Dongsheng district government in Ordos and our organisation, the Stockholm Environment Institute, and aimed to save water and provide sanitation services in this drought-stricken and rapidly urbanising area of northern China.

Before the start of the project in 2003, the 250,000 residents of Dongsheng suffered water-rationing and used mainly public toilets, which were largely unfinished, concrete-slab squatting pit latrines that had no lighting or heating, and no running water for washing. The harsh winters, during which temperatures can drop as low as minus 30° Celsius, made the existing pit latrines even tougher to use, and during the hours of darkness they became more or less open defecation zones in the city.

The birth of eco-toilets
The challenge for the project was to work with local builders, officials and residents to improve conditions and develop a dry sanitation system with urine diversion in multi-storey apartments. Although the technology for these systems is not standard, it has been successfully carried out in Sweden and Germany as well as other locations at a smaller scale. The “Gebers” project in southern Stockholm has been running well since 1997. The Ordos project was an upscaling effort, involving 832 apartments and about 3,000 inhabitants.

As the project got under way, the value of coal in China was rapidly increasing and Dongsheng saw a mammoth building boom. The standard of living skyrocketed to levels similar to Hong Kong and Shanghai. Also, a 100-kilometre pipeline was built from the Yellow River to Dongsheng to increase freshwater supply, and fossil groundwater reserves were further developed. As a result, the bases for the project – extreme water shortage and poverty – quickly disappeared, and the eco-toilet project was overshadowed by the rapid development. In fact, an entire new city, Kangbashi, was built adjacent to Dongsheng during the period of the project.

The rapid urbanisation became a major burden and the project lacked skilled labour. The buildings were put up very quickly and the plumbing done by dozens of firms with varying levels of competence. There was a serious lack of building inspection and apartments were put on the market before the eco-toilet and ventilation equipment was properly installed. Much of the poor workmanship came from not following the blueprints carefully, resulting in leaky or wrong-sized pipes, and these faults were not discovered until walls were dismantled in 2008, two years after the buildings were completed. The building company was not interested in repairing its poor work and the city government was not in a position to apply pressure. The necessary investments to complete the project were not going to be made, mainly because there was no dedicated owner.

Air-pressure differences caused by high winds, open bathroom windows and kitchen fans also created ventilation problems. Some top-floor apartments experienced odour problems more often, due to design limits and improper construction. During the project, design improvements to the basement ventilation installations were implemented at full scale by SEI. However, the building company did not play its role in repairing the pipe work, which was in fact poorly constructed from the outset.

Furthermore, a lack of pipe insulation in the attics and above the roof – an item not covered in China’s building codes – was mainly to blame for the frozen ventilation pipes which caused havoc during the extremely cold winters of 2007 and 2008.

Eco-toilet technology not only needs care in its construction, but also in use and maintenance. Many residents used the eco-toilets as receptacles for solid waste, blocking the ventilation system. Those who put bags of food waste into their eco-toilets often saw flies during the summer, and the faeces containers in the basements needed to be sprayed. Residents who used and maintained their toilets properly did not suffer the same problems.

It should also be noted that neither residents nor workers reported health effects of any kind during the entire period of the project. The project had a 24-hour hotline where residents could file observations and complaints, and they received immediate service from the maintenance team. Most complaints dealing with odour could be solved on the spot.

The residents who were worried about the dry toilets reducing the value of their apartments actually found out that their properties had increased in value by three to four times during the project. In fact these apartments were and remain very popular because of the green spaces and parking which were insisted on by the architects involved in the project from Sweden.

During the final stages of the project, a new kind of dry toilet from Separett AB was tested. Each eco-toilet contained its own small evacuation fan, meaning odours could be eliminated even if the external vent pipes had been improperly built. The ideal eco-toilet is therefore something that works even if there are building and plumbing faults. These new eco-toilets were successfully run for an additional year up to the end of 2010, however the decision to install flush toilets had already been made by the local government.

Besides rapid regional economic development, the main reason the dry toilet project ran into problems was the lack of a dedicated owner. Other decisive factors were:

1. Water shortage was – at least temporarily – no longer a problem due to the Yellow River pipeline and deeper groundwater extraction.
2. The odour problems during the extreme winter of 2007 acted as a negative tipping point for the project.
3. It was not possible to take a stakeholder approach among tenants to help choose the most appropriate sanitation system, since the tenants arrived on the scene as buyers after the apartments were built.
4. The household committee stated to the local government that it was not capable of taking on the costs of continuing the scheme, and the district governor responded by investing in flush toilets.
5. The standard of living in the Ordos area rose dramatically during the project period. Dry toilets were considered by some residents as something backward in a modern urban setting.

Ecological sanitation is progressing well around the world. Ten years ago it was a fringe activity, but is now reaching mainstream status within the UN system, and some governments have far-reaching plans for expansion. About five million people are using these systems and the numbers are growing.

Closing the loop on water and nutrients is a necessity in order to feed an increasing (mostly urban) world population, expected to reach 9 billion by 2050. Dry urine-diverting toilets are just one approach and others are being developed. The dialogue on this development around the world continues on the Sustainable Sanitation Alliance discussion forum.

Nat Rev Gastroenterol Hepatol. 2012 Dec 11. doi: 10.1038/nrgastro.2012.239.

The impoverished gut-a triple burden of diarrhoea, stunting and chronic disease.

Guerrant RL, Deboer MD, Moore SR, Scharf RJ, Lima AA.
Center for Global Health, Division of Infectious Diseases and International Health, University of Virginia School of Medicine, 1400 West Main Street, Charlottesville, VA 22908, USA.

More than one-fifth of the world’s population live in extreme poverty, where a lack of safe water and adequate sanitation enables high rates of enteric infections and diarrhoea to continue unabated. Although oral rehydration therapy has greatly reduced diarrhoea-associated mortality, enteric infections still persist, disrupting intestinal absorptive and barrier functions and resulting in up to 43% of stunted growth, affecting one-fifth of children worldwide and one-third of children in developing countries.

Diarrhoea in children from impoverished areas during their first 2 years might cause, on average, an 8 cm growth shortfall and 10 IQ point decrement by the time they are 7-9 years old. A child’s height at their second birthday is therefore the best predictor of cognitive development or ‘human capital’. To this ‘double burden’ of diarrhoea and malnutrition, data now suggest that children with stunted growth and repeated gut infections are also at increased risk of developing obesity and its associated comorbidities, resulting in a ‘triple burden’ of the impoverished gut.

Here, we Review the growing evidence for this triple burden and potential mechanisms and interventions that must be understood and applied to prevent the loss of human potential and unaffordable societal costs caused by these vicious cycles of poverty.