WATERKEYN, OKOT and KWAME
31st WEDC International Conference, Kampala, Uganda, 2005
MAXIMIZING THE BENEFITS FROM WATER AND ENVIRONMENTAL SANITATION
Rapid sanitation uptake in the internally displaced people camps of
Northern Uganda through community health clubs
J Waterkeyn, P Okot, V Kwame, Uganda
One of the worst humanitarian disasters in the world is currently taking place in Northern Uganda where 89% of the
population in Gulu District now live in 33 Internally Displaced Peoples (IDP) Camps, with low levels of home hygiene
and only 5% sanitation coverage. A local NGO, Health Integrated Development Organization (HIDO), has started 116
Community Health Clubs in 15 IDPs camps, with 15,522 regular members who meet weekly for hygiene sessions. Within
4 months, health club members have constructed 8,504 latrines, 6,020 bath shelters, 3,372 drying racks, and 1,552 hand
washing facilities, with an estimated 100,000 direct beneciaries. The strategy has been based on the A.H.E.A.D Com-
munity Health Club Approach using participatory PHAST training tools, and may provide a cost-effective model for future
IDP emergency sanitation programs.
Background in other countries in terms of building community cohe-
For the last 18 years, Northern Uganda has suffered from a sion and demand led sanitation (Waterkeyn 2001, 2003, &
violent rebel insurgency forcing 1.6 million people to leave Cairncross 2005).
their homes and seek protection in Internally Displaced By using Community Health Clubs of between 70-150
Peoples Camps (IDP) organized by the Government in people, it is possible to effect a rapid transfer of information
vicinity of the main towns where they are guarded by the and improve home hygiene practices, using peer pressure
army. In Gulu District, this displacement accounts for 89% and the development of a Culture of Health (Waterkeyn,
of the population in 33 IDP camps all of which have between 1999). The design also incorporated local approaches to health
15,000 people, and the largest at Pabbo having 68,000. These promotion, adapting the standard Participatory Hygiene and
temporary settlements are badly congested, and with scarcity Sanitation Transformation (PHAST) methodology, which
of basic sanitary facilities, shortage of water, poor drainage had been used in Uganda during the 1990s. This is the
and poor hygiene have led to a exceptionally poor health rst time in Uganda, that the PHAST participatory training
conditions in the IDP camps, with high levels of malaria methodology has been combined within the structure of a
and diarrhoea. This was demonstrated last year when there health club, providing regular reinforcement and targets.
was an outbreak of cholera in Pabbo, where it was found
that all the boreholes and samples of drinking water from Implementation
homes were contaminated. In the past four months HIDO has formed 116 CHCs having
Health Integrated Development Organization (HIDO) is a total enrolment of 15,522 members, which accounts for
an indigenous organization recently started in Gulu District, 42% of the 36,138 households within the programme area,
formed by a group of dedicated graduate Clinicians and Health and approximately 100,000 direct beneciaries. The broad
Assistants. With support from CARE International in Uganda, objective of the NGO is to improve the health status of
(funded by the Bill and Melinda Gates Foundation), HIDO people living in the selected 15 IDP camps in Gulu District
is carrying out health promotion with focus on hygiene in by reducing the prevalence of communicable diseases. The
15 of the 33 IDP camps in Gulu District .The targets set by specic objectives are to conduct health sessions to mem-
CARE International in these 15 IDP camps were high, aiming bers in CHCs on a weekly basis and to monitor households
to provide 120,000 people with health promotion and build for impact of health education, as indicated by changes of
10,000 latrines within a six month Emergency Programme. hygiene behaviour and improved facilities such as drying
By any standards this is a challenge, but particularly in this racks, bathing shelters, and wash hand facilities.
area where the communities are traumatized, fragmented
and have developed a strong dependency on donor assist- Training
ance. To address these social constraints within a short time In October 2004, a set of illustrated cards on basic topics
frame the AHEAD methodology using Community Health (safe water chain, safe food chain, sanitation ladder, malaria,
Clubs (CHCs) was used. as it had proved its effectiveness bilharzia, worms and skin diseases) was developed from a
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combination and adaptation of existing materials (GoU- The number of drying racks for the safe storage of kitchen
Ministry of Health, WaterAid, and Zimbabwe AHEAD utensils has also increased signicantly but again, there is
Organisation) to provide the participatory tools needed for still a wide disparity between areas. In Paicho and Coope
the trainers, who were trained in the AHEAD and PHAST there is an over-coverage of 159% and 146%, again indicat-
Methodology in the following month. ing a spill over to non club members, who are emulating
the latest fashion in kitchen practice. With the lack of space,
Mobilisation the problem of thieves stealing crockery, and roaming live-
In January, 2005, HIDO eld staff moved to their posts stock destroying drying racks, it has been difcult in the
within the 15 camps and have integrated well with the IDP camps, but the CHC members have still adopted this
people becoming valued members of the IDP leadership. recommendation with 2791 of the 4480 new drying racks
Despite fears that CHCs would create a parallel structure being built inside the kitchen hut.
that would overload women, and undermine existing camp Bathing shelters have also proved popular with 6,062 be-
leadership, this has not been an issue. One strong indicator ing constructed in 4 months, of which Opit has 1,544, and
of the success of their mobilization is that they have man- Ongako with 1,133 have 68% and 77% coverage respectively.
aged to maintain the number of CHC members despite the Eight camps already have over 55% coverage of health club
fact it is the rainy season, when it is normally difcult to members whose homes now have a bathing shelter with
attract people, as they are busy in the elds. During the dry proper drainage and soak pits, which will improve the poor
season meetings take place under the shade of large trees, drainage system for grey water in IDP camps.
but in the rains there is seldom a large roofed area sufcient
for a meeting place. However despite the fact that the tor- Behaviour Change
rential rains make attending meetings uncomfortable, the It is evident that the method of using group cohesion and
membership has not fallen away. The trainers started up at peer pressure to adjust hygiene behaviour to minimize risk
least 5 community health clubs each, with a minimum of practices is effective. Changes are taking place in methods of
100 members per club (500 members per trainer). Working water and food storage and usage, as well as hand-washing
in tandem with the sanitation committee in each camp and with soap, and basic personal and home hygiene improve-
existing leadership, the people were successfully mobilized ments. Although the project has only been going for four
using drama presentations produced by a local group, to months, preliminary ndings appear to be outstanding, and
attract the crowds and encourage future members to join. this will be researched more rigorously when a post inter-
Membership cards were also popular with the new recruits, vention survey is undertaken later in the year which will be
as this was taken as an indication of the seriousness of the compared to the base line done in December 2004.
programme as they could see the topics to be covered and Although the target was to start 120 health clubs (100
plan to attend. They also enjoyed it as an identity card. members per club), the number of members has been ex-
Health Promotion Sessions ceeded and there are an average of 134 members per club,
By May 2005, all the clubs had completed 16 out of the with a total of 15,522. In some cases trainers have had to
20 topics to be covered (as listed in the cards) and the com- split their larger clubs and cannot meet the full demand for
munity was rapidly implementing the many recommended health sessions. The target was to involve 50% of the total
activities. The PHAST training method has been enthusi- number of households in each of these camps and although
astically received by the community and activities such as only 42% are currently involved, this should increase in the
Blocking the Route and Three Pile Sorting have captured next few months.
their attention and enabled them to participate easily in
problem-solving activities so helping them, as a group, to Latrine Construction
identify their own resources, and make plans to upgrade In an effort to reach the high target of 10,000 latrines it was
their own facilities. planned that sanplat production centres would be set up in
The only incentive was the donation of a cement sanplat, each camp to produce a total of at least 6,000 cement san-
for those who had dug their latrine pits. In addition the fast plats within six months. The programme has also piloted
adapters were rewarded with (ITN) mosquito nets and poly the use of ready-made polysanplats for the balance of 4,000
sanplats, and this provided added stimulation. The only other remaining latrines which are given as an incentive to the fast
incentive to join the club is the attainment of a certicate if adapters in order to speed up the programme. After only 4
all 20 sessions are completed. months, 8,583 latrines have been constructed and of these
1,387 have poly sanplats. There are also 1,735 pits ready
Home hygiene which means the target of building 10,000 latrines will be
To-date most of the health clubs have completed 16 out of surpassed within six months.
their mandatory 20 hygiene sessions. From January to May Fifteen Sanitation CBOs have been trained to manufac-
there were a total of 1,560 health sessions held with an aver- ture cement sanplats which are then brought by CARE and
age of 15 topics covered by each trainer at each of the ve distributed back to the members, so providing an income
clubs for which he/she is responsible. locally. Sanitation coverage varies between camps, due less
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WATERKEYN, OKOT and KWAME
to the enthusiasm of the health club members or the ability poly sanplat, (tried out for the rst time in this programme)
of the trainer, but to logistical problems, such as keeping is proving ideal in terms of instantly sealing latrines: it is
some of the more remote camps supplied with cement. In made of strong, light-weight polybre, and can be delivered
Opit, (which is being newly resettled with the overow of in bulk, obviating the time-consuming task of training com-
people from Pabbo) 2,280 health club members have built munities to make cement sanplats, as well as the difculty
2,723 latrines in the last three moths. This is encouraging as of transporting, storing and accounting for cement. In addi-
it shows there is a spill over involving non club members in tion is has a cleanable, plastic nish which enables proper
sanitation improvements. As latrines are built in blocks over hygiene, unlike home-made sanplats, with a rough cement
a trench, with between two to six stances, many non-club nish which are frequently urine-stained, faecal-contami-
members will be brought into the programme as neighbours nated, foul smelling and attract ies. Cement designs are
to share resources, regardless if they are in the health clubs also seldom found with lids, and if they are, these tend to
as regular members. Similarly in Palenga and Bobi Camps, be ill-tting or have handles that are faecal-contaminated.
sanitation has covered all registered club members and 8 By contrast, the polybre sanplat has a well tting manu-
camps are already well over the targeted 50% coverage of factured lid operated by foot, so that there is little cross
health club members. contamination from dirty hands. This foot-operated cover
is being tried out for the rst time in this project, and has
New technology for emergency been accepted by the community. In this project it has been
sanitation supplied alongside the cement sanplat, which is a cheaper
but less effective hygiene option.
For an emergency sanitation programme the new design of
Table 1. Number of Households, Health Clubs and Members and % achievement of recommended practices
already undertaken by health club members in 15 IDP Camps achieved in 4 months (2005)
IDP CAMP H/hlds CHCs CHCMembers Health sessions Latrines complete D/racks built B/shelter HWF
Bobi 3,460 10 786 (22%) 145 (75%) 817 (103%) 530 (67%) 525 (66%) 34 (4%)
Palenga 2,450 10 781 (32%) 160 (80%) 790 (101%) 431 (55%) 428 (55%) 356 (47%)
Abili 1,816 5 743 (40%) 80 (80%) 203 (27%) 371 (50%) 124 (16%) 435 (58%)
Lapainat 1,852 5 659 (35%) 80 (80%) 438 (66%) 580 (88%) 512 (77%) 184 (28%)
Ongako 2,166 10 1,522 (70%) 160 (80%) 1060 (70%) 1003 (66%) 1133 (74%) 122 (8%)
Lacor 1,403 5 821 (58%) 80 (80%) 265 (32%) 286 (35%) 126 (15%) 187 (23%)
Keyo 1,216 5 804 (66%) 80 (80%) 312 (38%) 16 (1%) ? ?
Awer 2,763 6 1090 (39%) 70 (70%) ? ? ? ?
Pagak 2,051 5 498 (24%) 80 (80%) 390 (78%) 162 (33%) 328 (66%) 73 (15%)
Pabbo 10,893* 10 1328 (12%) 155 (75%) 587 (44%) 391 (29%) ? ?
Coope 4,089 10 980 (23%) 160 (80%) 646 (66%) 1435 (146%) 218 (22%) 94 (9%)
Paicho 2,864 5 878 (30%) 165 (85%) 693 (79%) 140 (159%) 549 (63%) 39 (4%)
Teyapadola 1,427 5 781 (54%) 75 (60%) 9 (1%) ? ? ?
Opit 7,601 15 2280 (29%) 240 (80%) 2,723 (119%) 820 (36%) 1544 (68%) 10 (1%)
Lalogi 3,743 5 871 (23%) 75 (75%) 558 (26%) 251 (29%) 533 (61%) 18 (2%)
TOTAL/ Average 36,138 116 15,522 (42%) 1650 (80%) 8,583 (65%) 3372 (61%) 6020 (47%) 1,552
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WATERKEYN, OKOT and KWAME
Appeal to Scale Up Waterkeyn J & Waterkeyn A.. 2000. Demand Led Sanitation
The situation in the IDP Camps has been largely neglected in Zimbabwe. Dhaka. 26th WEDC
for the past 18 years, and their plight was recently cited Waterkeyn J. 1999. Structured Participation in Community
(UNHCR) as currently the worse humanitarian disaster in Health Clubs. Addis Ababa 25th WEDC
the world today. We hope that our concern over the appall-
ing sanitation situation in the IDP camps may help bring
this situation to light and that this case study will indeed
catch the imagination of agencies and government who are Contact address
welcome to visit and verify these claims. There has been Juliet Waterkeyn
enough debate over how to tackle this issue, and now that Director, Africa AHEAD Association
it clear that sanitation conditions can be rapidly improved [email protected]
we hope that this cost-effective pilot project may be taken
to scale by Government of Uganda and other genuinely Phillips Okot
concerned Agencies, to ease the suffering of the people of Director,
Northern Uganda. Health Integrated Development Organsiation
[email protected]
References
Waterkeyn J & Cairncross S. 2005 Creating a demand for Victor Kwame
sanitation through Community Health Clubs: a cost ef- Public Relations and Field Ofcer
fective intervention in two districts of Zimbabwe. (Soc. Health Integrated Development Organisation
Sci. & Med)
Waterkeyn J. 2003. Cost Effective Health Promotion: Com-
munity Health Clubs. Abuja. 29th WEDC
A session in one of the 116 Health Clubs in which
over 15,000 members each week learn about hygiene
(photo J.Waterkeyn)
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