STUDY: IMPROVING AVAILABILITY OF SAFE WATER AND HYGIENE TO REDUCE CASES OF DISEASES AND TREATMENT COSTS FOR KINONDO KWETO HEALTH CLINIC, A RURAL HEALTH POST IN KWALE COUNTY, KENYA

Kwale County is located in Kenya’s south coast region neighbouring Mombasa County to the north and Tan-zania to the south. The county exists in two contrasting zones: upper hilly relatively cold zone and low hot coastal strip. This review focuses mainly on the coastal strip. This is a stretch of land from Vangaon the Ken-ya- Tanzania border to Likoni-Mombasa which stands at an elevation of 0-30 m above sea level, mostly on coral stone layer that hampers sinking of bore hole for water or a pit latrine. Consequently, inhabitants in the area often relieve themselves in the bushes surrounding the homesteads. This habit poses a health hazard which often leads to outbreaks of waterborne diseases including typhoid and cholera. Also there is an ongoing environmental degradation occurring in the area because the inhabitants use wood as their source of energy for cooking, heating and boiling water. The collection of wood for heating and boiling water-often carried out by the women is a time consuming task since there has to be enough wood to cover the needs for all household activities. The alternative is to buy the wood which is a financial burden for the households. Due to lack of firewood, clean water is a scarcity. Only a few family members are able to wash themselves in clean, water during the colder months and children easily catch respiratory infections after being exposed to indoor air pol-lution and poor hygiene.


Incorporation of Innovative Health Intervention


In early year 2016, increased diarrhea cases suspected to be water-borne, were reported in children less than 5 years old attending Kinondo Kwetu Clinic for treatment. Subsequently, Solvatten Foundation donated 276 Solvatten jerry cans to Kinondo clinic for health intervention. A Base Line Draft was provided to Kinondo Kwetu Health Clinic to be a guide for selection of the target groups. Improvement of health in malnourished children less than 2 years old, and improvement of children under 5s health in a water, sanitation and hygiene (WASH) disadvantaged area were the main objectives of the project. In 2017 a second donation was given to Kinondo so that total 636 families or near 4.000 people are given access to Solvatten jerry cans on conditions described in methodology below.


Project Objectives
1. Improve children under 5s health
2. Evaluate the method for achieving no 1
3. Explore the cost benefit by the intervention for kinondo health clinic
4. Use control group to have better data
5. Evaluate nudging effect for hygiene behavior when safe, hot water is available at home


Target group

  • Families with new borne children or with children <5 years
  • Parentless households
  • Single parent household and families especially vulnerable to waterborne and hygiene related diseases.

Effects and outcomes
Improved hygiene, improved health, soil and water, less firewood used in households, less burn injuries, bet-ter quality of life, better financial results for clinic.


1st stage: INITIAL STAGES
Sessions put in place to make sure that every stakeholder is involved in the progress, the distribution and the other processes have delayed.

1st introduction meeting was held in Msambweni on 12th February 2018 which involved the sub- county man-agement team. The objectives of the program were vividly explained to them by the program head (Mr. Harri-son).
2nd meeting was held with area chiefs, sub- chiefs and the village elders since they are directly involved in the community in terms of teaching and explaining the importance of the units to the community members.

A tool to be filled by the beneficiary was developed in Kiswahili, for them to understand the questions and re-spond to them well. Identification of the beneficiaries was on, utilizing the clinic days in Kinondo Kwetu health facility which are always on Thursdays for those with children below 5 years, and the single parents. For the orphans, we visited the community.


2nd stage: Actual distribution of Solvatten

Actual distribution began in March and ended in July, 2018. We were able to distribute 360 solvatten units, during phase one, to targeted mothers that have children who are vulnerable and are below 5 years. Second phase saw us distribute the remaining 72 units restricting ourselves to the area of scope that was kinondo A, B Matunda bora, Chale and Makongeni including smaller villages around them. Units as distributed have tabulated in excel sheet and to be attached to the main report. 1st month uptake was low since it involved mobilizations and sensitization, community members were not yet seeing the importance.  April uptake went high due to the fact that everyone was on board and was willing to take in information and the units for use. Activities were disturbed by heavy rains that ran through May, June and July but at the end of it all, we were able to distribute 360 units. Community members came in numbers and so far we are able to account for a good of them. We tried our level best to reach families with new born children, children under- five, single parent households and added some few CCC clients and especially who in support groups at the facility.


Methods of Distribution  of Solvatten

Meetings for the distribution of Solvatten jerry cans were convened at Kinondo Kwetu Clinic grounds through the area chief, village chairmen, by Mosque announcements and home visits. Those who attended were bore-hole owners who were listed down and demonstrations for use of the Solvatten Units conducted. The Units were then distributed to the beneficiaries for use. 

Traditional birth attendants (TBAs) are based at the community level. Initially they assisted mothers in deliver-ing from their houses. This posed a lot of risks to the mothers due to unexpected complications that needed specialized care. At that time, maternal deaths were overwhelming because of the complications that came about. Kinondo Kwetu approached them and requested them to insist on delivering in the hospital where it was more safe. TBA’s gave in to the engagements and have been reporting to the facility on a daily basis while ac-companying pregnant mothers to their first ANC.  This became the best avenue of  using them for Solvatten sensitisation on the importance to the mothers.


Qualifications for a borrower of Solvatten included 1). Residency of Kinondo Kwetu area (2) Being a parent or caretaker of a child under 5 years of age (3) unavailability of safe drinking and poor faecal disposal where the children lived. The borrower agreed to it was a conditional loan and if Solvatten was not used regularly and with satisfaction they would return them  to the clinic so that other could better benefit from it.

The role of Traditional Birth Attendants and Their Importance For Successful Outcome

TBA’s encourage and escort women in labor to the clinic for deliveries. Where it is not possible to get to the clinic in time, they conduct the deliveries on the way to the clinic where any further assistance is provided. 


TBA’s  presence at the facility have really brought an impact to the pregnant mothers. Their major role is to identify pregnant mothers at the community level and refer them to the facility for their 1st ANC visits and pro-filing. CWC’s staff took advantage of that and used the TBA’s as first hand informers to the mothers about Solvatten usage. Staffs reported that using TBA’s to mobilise, inform  and create more awareness on Solvatten brought an impact. Hygiene practises was emphasised by them to the mothers on how hygiene is improved by both pre-natal and post natal mothers. In this observation study, the effect of Solvatten water purification jerry cans in malnourished children under 2 years of age , the water sanitation and hygiene (WASH ) disadvantaged  persons and assessment of the <5 year olds health improvement were the objectives of this project.

Feedback from Solvatten users confirmed that they trusted the containers to provide safe drinking water, it has helped to improve hygiene and it does reduce diarrhea cases. Those results were similar to those obtained in other projects elsewhere in Kenya, Angola and Mali.


Feedback from TBA confirmed that the lending model works well to incentivise mothers to use it frequently and taking care of the technology. Using Solvatten has in most households formed to a regular habit. Much thanks to TBA’s closeness o the mothers, their trusted role in the community and positive influence that people are becoming aware of the importance to have clean water. 


In the under 2 year old group the beneficiaries are best identified in the welfare clinic where  the name and age of the child are recorded, baseline health data including general observation, clinical history and laboratory investigations conducted. The cost effectiveness is computed as the difference between the costs of treatment for those not using Solvatten jerry cans and those using the jerry cans. In the < 2 year and < 5 year olds, favourable outcomes would be improvement of nutrition after supplementation and use of Solvatten jerry cans and improvement of health after consistent use of Solvatten jerry cans, respectively. 


Interviews 

Interviews were conducted with stake holders who included
a) Solvatten Users
b) Traditional Birth Attendants
c) Child Welfare Clinic Stafff


Observations
-The community lives in large extended families in one homestead.
-The main source of water is shallow bore hole located within the compound.
-Water is drawn in a bucket tied to a long rope and transferred to 20 liter jerrycans for storage.
-In most households, there was no latrine. The residents relieved themselves in the bushes surrounding the homestead. Where a latrine was available, it was located within the compound, not far away from the borehole.
-Dishes were kept in a basin on the floor however it’s suggested that the clean dishes is kept up one some height above the ground so re-contamination is avoided.
-Drinking water is prepared in the Solvatten container and transferred to a bucket with lid for storage.
-All interviewees said that they washed hands with soap and water from Solvatten after toilet.
-The general health in families was now fine. In home visits, the health of children was determined through clinical history given by parents. According to mothers, cases of abdominal pains, diarrhea and vomiting had reduced following use of Solvatten. The situation was summarised as ‘fine or ‘okay’).
There were no costs incurred in water collection from the borehole. The time that especially girls have to spend to collect fuel wood is significant. Time can be used in other ways, such as education and more productive ac-tivities.
-Solvatten containers were confirmed present in the households where they were provided.
-In one home, the container was not used. Suggestions to return the unit were resisted and the users insisted they too needed Solvatten for safe drinking water. It is a good advice that more emphasis be put by the TBA’s and community health volunteers because it was discovered that members of the household claimed that it was bit hectic to carry the units outside and returning them back. The units, being new to the members, patience is required with enough sensitization so that community members realise the importance. If efforts fail, then it should be advised that one returns the units to the facility, after several warnings of no usage, and at the facility it is given to another willing family member. This would be achieved by using the TBA’s and CHV’s because they are always visiting the households to meet check for their indicators.


RESPONSE SURVEY RESULTS
After issuing solvatten months ago, Kinondo Trust Fund gathered responses from the users to evaluate the the efficiency of the project. The family members who were interviewed were unanimous that the units:

· Provide safe drinking water
· Reduce abdominal pain, diarrhea and vomiting especially in children
· Promote hygiene by providing hot water for washing
· Reduce cost of getting hot water.


From the survey of 100 households using Solvatten, 77% of them have used less than 6 months. 82.0% of the population in possession of Solvatten uses it twice a week for treating water.


The main uses of treated water are drinking and bathing. The number of diarrhea cases has reduced in the past six months where only 11 households reported these cases. The areas affected are Matunda Bora and Kinondo B.


100% of Solvatten users recommend mothers to be given to others. However, besides many mothers enjoying Solvatten there are two main challenges in using it; 1. The need for sun making it not effective during rainy season 2. Users get tired of taking it outside and back.


Many mothers using Solvatten have saved between Shs. 0-200 shillings being the expenses for treating water and also diarrhea outbreak treatment.


Discussion
The health clinic lending of the jerry cans way of distribution is good as it helps to directly identify the child, age, mother/caretaker and contact for follow-up. That increases uptake to improve health. The Solvatten tech-nology also have a nudging effect on hygiene behaviour and improves health in the health in the community by conveniently help households to heat and treat water and this is also in an environmentally friendly way.


In areas where faecal disposal is inefficient, soil transmittable disease agents including round worms, whip-worms and hookworms may persist so improved hygiene habits is central to improve health during these cir-cumstances. Solvatten would be more effective when used among other sanitary methods including community led total sanitation (CLTS) program which seeks to create a safe faecal free environment. Where faecal contam-ination is not controllable, improvement of health by use of Solvatten may be more effective and at the same time needed.


Cost effectiveness
Solvatten, costing approximately 95 USD can be perceived as an expensive product but that is not the same as total cost for improved health, improved wellbeing. The cost per liter of clean and hot water is in fact very low. Looking at a cost for 95 USD for 5-6 people for a long time is economically justifiable when comparing with WHO reports on cost for ensuring communities have access to clean water, decent sanitation and hygiene is calculated to be 40 USD/person.


Conclusion
The Solvatten project at Kinondo kwetu clinic met the set objectives as the Kinondo community was sensitized on the use of safe drinking water to prevent cholera, typhoid and other water-borne diseases.


Recommendations
According to the geological formation of the coastal strip, the current problems of water and sanitation are un-likely to end in the foreseeable future. Consequently, more clinics should use Solvatten lending to improve the health of children under 5 years old. Adults who can afford Solvatten container should be allowed to procure one to protect themselves from cholera, typhoid and other water-borne diseases. Solvatten is preferable be-cause it is easy to use and maintenance free of service.
More supplies for the units in order to reach the mothers out of our catchment population. 


Summary/conclusion
To prevent cholera and other WASH related diseases goes with cost. In the WHO literature 40 USD/person is enough to prevent cholera and other WASH related diseases. 


Solvatten can be perceived as an expensive product but that is not the same as total cost for improved health, improved wellbeing, and for the cost per liter of clean and hot water. Furthermore, cost of Solvatten is justifia-ble for prevention of water-borne diseases.
Set aside a budget for MOH and NGO’s to include Solvatten Program Activities in Kwale County.


1. Establish a platform and a point of contact for Community Health Volunteers, TBA’s and volunteers for hygiene and clean water promotion that works closer with County Ministry of Health and in conjunction with the Kinondo Kwetu Clinic Administration.
2. Appoint a Coordinator to act for and on behalf of a scaled up program to be responsible for distribu-tion, promotion, training, sales and advocacy for the use Solvatten technology to the local authorities including County and National government where applicable.
3. Appoint the necessary staff for program operations.
4. Put in place operational mechanisms that would ensure success of a similar program.


For more information about the findings of this project just contact us! 
 

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