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The Value of Water and Sanitation in Development: A Case Study of Agyementi

Sangu Julius Delle

A thesis submitted to the Department of African and African American Studies in partial fulfillment of the requirements for the degree of Bachelor of Arts with Honors

Harvard College Cambridge, Massachusetts March 11, 2010


Table of Contents

List of Acronyms………………………………………………………….............3 Introduction……………………………………………………………………….5 Chapter 1: The Challenges of Clean Water and Sanitation……………………...11 Chapter 2: Ghana – A Case Study….....................................................................15 Chapter 3: On the ground in Agyementi…………………………………………28 Chapter 4: Sanitation Intervention and Hygiene Education………………….….55 Chapter 5: Findings and Analyses……………………………………………….77 Conclusion..…………………………………………………………………….112 Bibliography...………………………………………………………………….114 Appendix……………………………………………………………………….131


List of Acronyms

ACDEP – Akuapem Community Development Program ACWA – Access to Clean Water for Agyementi ASMA – Akuapem South Municipal Assembly CWSA – Community Water and Sanitation Agency DA – District Assembly DANIDA – Danish International Development Agency DFID – (UK) Department of International Development FGD – Focus Group Discussion GWSC – Ghana Water Sewerage Corporation IRP – Iron Removal Plant KVIP – Kumasi Ventilated Improved Pit MDG – Millennium Development Goal MWST – Municipal Water and Sanitation Team NGO – Non-Governmental Organization UNICEF – United Nations Children‘s Fund VIP – Ventilated Improved Pit WATSANC – Water and Sanitation Committee WHO – World Health Organization


Map 1: Administrative Map of Ghana (Study area shaded in red)


Introduction In 2008, the United Nations-designated ―International Year of Water and Sanitation,‖ two Harvard undergraduates and I co-founded Project Access to Clean Water for Agyementi (Project ACWA), with the goal of providing clean water and sanitation to Agyementi, a village in southern Ghana. 1 We chose Agyementi after a visit to Ghana in 2007 to meet with the Ministry of Water Resources, Works and Housing and the Ministry of Local Government and Rural Development to inform them of our intention to design and implement a water and sanitation project in an area of need in the country. We were looking for a community with poor access to safe clean water and poor sanitation. We were also interested in a location near the capital city of Accra with good road access to facilitate monitoring visits, and a population sizable enough for the project to have a real impact on the lives of the people. Based on these criteria, the Director of Water at the Ministry of Water Resources, Works and Housing, Mr. Minta Aboagye recommended Agyementi, a village located in the Akuapem district in the Eastern region of Ghana. Approximately 56% of the rural population and 49% of the urban population in Ghana do not have access to safe drinking water and Agyementi was one of those several rural regions. Sanitation is an even greater public health problem in the country; barely 11% of the rural population and 40% of the urban


The project was spearheaded by the author Sangu Delle (African and African-American Studies and Economics secondary concentrator), Darryl Finkton (Neurobiology and African-American Studies secondary concentrator), and Ndubuisi Okereke (Economics and African and AfricanAmerican Studies secondary concentrator), all students in the Harvard College class of 2010.


population have access to hygienic means of preventing human contact with hazardous wastes. A significant number of people in Agyementi, like other villagers in that region of the country, suffered from trachoma, a preventable disease which causes blindness, as well as guinea worm, skin diseases, and diarrhea, all of which resulted from contact with contaminated water and poor sanitary conditions.2 The project was collaborative, drawing on academia, nongovernmental organizations, traditional government, and local and national agencies of government. 3 This paper examines our efforts through the lens of Social


100% of households in Agyementi reported suffering from diarrhea. Interview with Attah Arhin, Project Manager, Water Directorate, Ministry of Water Resources, Accra, 17/08/2008. 3 In academia, the team worked with an interdisciplinary group of professors and scientists spanning Harvard‘s Economics, African and African-American Studies and Anthropology departments, the School of Public Health, and the Medical School. Professors and engineers from the Massachusetts Institute of Technology, the University of Minnesota and the University of Ghana were also engaged. The academic group of advisors included Professor Evelyn Higginbotham (Department of African and African American Studies, Harvard University), Professor Emmanuel Akyeampong (History Department, Harvard University), Professor Henry Louis Gates Jr. (W.E.B. Du Bois Institute, Harvard University), Professor Richard Freeman (National Bureau of Economic Research and Economics Department, Harvard University), Dr. Molly Kile (Department of Environmental Health, Harvard School of Public Health), Professor Duana Fullwiley (Anthropology Department, Harvard University), Professor Allan Hill (School of Public Health, Harvard University), Professor Michael Kremer (Economics Department, Harvard University), Professor Amartya Sen (Economics Department, Harvard University), Dr. Susan Murcott (Massachusetts Institute of Technology), Dr. Raymond Atuguba (Faculty of Law, University of Ghana), Dr. Matthew Simcik (Environmental and Occupational Health, University of Minnesota School of Public Health), Dr. Michael T. Osterholm (Center for Infectious Disease Research and Policy, University of Minnesota), Dr. Deborah Swackhamer ( Environmental Health Sciences in the School of Public Health, University of Minnesota). NGOs involved in the project included the World Health Organization (WHO) office in Accra, Water AID Ghana, the Akuapem Development Program (ACDEP) and the African Commission of Health and Human Rights Promoters. The traditional rulers consulted included Nana Takyi, Chief of Agyementi; Nana Yiadom II, and the elders of the village. Local government agencies included the Community Water and Sanitation Agency (CWSA), Municipal Water and Sanitation Team (MWST), and the District Assembly. Branches of National Government involved in the project refer to the Ministry of Water Resources, Works and Housing and the Ministry of Local Government and Rural Development.


Engagement, a pedagogical initiative of the Department of African and African American Studies. Motivated by the concept that by stepping outside the ivory tower students are better able to understand what they study, Social Engagement emphasizes how and why academic ideas and even technological discoveries are challenged by the lived experiences and cultural prescriptions of communities we work with. Thus, I discuss Project ACWA as the product of academic study combined with practical experience and fieldwork.4 This paper analyzes the quantitative and qualitative benefits of the project in the broader immersion of African Studies and the challenges of development. In doing so, this work provides an understanding of the broader impact of the social and economic transformations that such interventions enable. It assesses the impact of access to clean water and sanitation on Agyementi in terms of education, health, governance, and economics. It also seeks to identify and examine the project implementation strategies, major success factors and key challenges of the project, and to make recommendations for possible replication. This report also presents an overview of the rationale for designing and implementing Project ACWA. Water and sanitation have a very broad impact, covering all genders and age groups, and affecting health, economics, education and the central features of life in the community. With the assistance of local engineers and the members of 4

Begun in September 2006 under the leadership of Evelyn Higginbotham, Chair of the Department of African and African American Studies, Social Engagement includes coursework and the senior thesis. This year marks the first to witness the completion of a Social Engagement thesis.


the Agyementi community, the project entailed the installation of a borehole fitted with a hand-pump to tap into safe, underground water. Other interventions included the construction of household latrines to improve sanitation in the community and the construction of a water treatment plant following the discovery of iron ore and manganese deposits in the water. These interventions involved our conducting community health seminars for both adults and children, which focused on hygiene at the individual, household and community-wide levels. The technical training in these seminars was jointly sponsored by the Akuapem Community Development Program (ACDEP) and the Community Water and Sanitation Agency (CWSA). In Chapter 1, I discuss the challenges of water and sanitation as they relate to the Millennium Development Goal. In Chapter 2, I underscore how Agyementi is representative of many communities in Ghana and the developing world. Chapter 2 also raises the question of who is responsible for the provision of water and sanitation in Agyementi and how to begin such an intervention. Chapters 3 and 4 are detailed chapters that discuss the design and implementation of Project ACWA. They comprehensively discuss the components of the project, with Chapter 3 focusing on water and Chapter 4 focusing on sanitation and hygiene education. Chapter 5 brings together qualitative and quantitative ways of evaluating Project ACWA and reviews the project across a broad array of impacts – health, education, economic status, and gender relations – underscoring the transformative impact of the project on the community.


The paper is accompanied by a video documentary that presents the methodology of the project and makes the case for a holistic approach to development. As environmental engineer Daniel Okun argued in 1998, the benefits of water supply and sanitation interventions are contingent upon active community participation and hygiene education. In order to realize the full benefits of water and sanitation interventions, more is required than installation of the structures, pumps, and pipes. Years of efforts by international agencies in assisting developing countries with the provision of water supply and sanitation (WS&S) facilities have demonstrated that community participation in the planning, construction, operation, maintenance and financing of a project is essential to successful continued performance of the facilities and their use by the people to be served. 5 The importance of community participation and a holistic approach to the success of development projects including Project ACWA is explored in the documentary, and the documentary thus serves as an essential methodological and intellectual component of this paper. It covers the human dynamics of the project and documents the kinds of local issues that came up during the execution of the project. The video documentary also highlights the need to be sensitive to local norms and mores to guarantee full and effective community participation. I spent five months in Ghana in 2009 working on the documentary, with assistance from Ghanaian film-maker, Kwaku Sintim-Misa and with editing support from A19 Media House.


Daniel Okun (1988), ―The Value of Water Supply and Sanitation in Development,‖ American Journal of Public Health 78 (11): 1463-7


Agyementi is a community that is not new to outside interventions. Several attempts have been made in the past to tackle the problem of water and sanitation in the village, including installation of a solar powered spring cleaning system, building of a well, and construction of

public latrines. All these

interventions failed. This paper and the accompanying video documentary reveal why these interventions failed, and how Project ACWA used lessons from their failure to design an intervention that has become successful in getting the community access to safe, clean water and improved sanitation.


Chapter 1: The Challenges of Clean Water and Sanitation The challenges of water and sanitation to the people of Agyementi are not unique or specific to their community. In fact, Agyementi is illustrative of a truly global crisis. The World Health Organization estimates that, at current trends, the world is expected to fall short of meeting the drinking water and sanitation Millennium Development Goal (MDG) target of reducing by half the proportion of people without sustainable access to safe drinking water and basic sanitation.6 Currently, UNICEF and WHO estimate that 1.1 billion people lack access to improved water supplies and 2.6 billion people lack adequate sanitation. 7 Yet, while the challenges of clean water and sanitation are clearly global, Sub-Saharan Africa faces some of the worst problems.8

Lack of access to clean water and basic sanitation is undermining efforts to end extreme poverty and disease in the world's poorest countries of SubSaharan Africa where people in rural areas continue to be disproportionately underserved. Indeed, six out of ten people in such regions do not have access to clean water and eight out of ten people do not have access to sanitation facilities.9 Together, unclean water and poor sanitation are the leading causes of child


Jamie Bartram, Laurence Haller, Gay Hutton, ―Economic and Health Effects of Increasing coverage of low-cost household drinking water supply and sanitation interventions in countries off-track to meet MDG target 1,‖ World Health Organization. 7 World Health Organization (WHO) and United Nations Children‘s Fund (UNICEF) Joint Monitoring Programme for Water Supply and Sanitation, ―Progress on Drinking-water and Sanitation: Special Focus on Sanitation,‖ p. 2 8 Of the estimated 2.6 billion people worldwide without access to improved sanitation, 75% live in Asia (1.98 bn), 18% in Africa (0.47 bn) and 5% (0.13bn) in Latin America and the Carribean. 9 ―Water and Sanitation Issue Brief,‖ Accessed Tuesday, April 21, 2009.


mortality: about 4 billion cases of diarrhea per year cause 2.2 million deaths, mostly among children under five. Intestinal worms also infect about 10% of the population of the developing world, sometimes leading to malnutrition, anemia or retarded growth. Another 6 million people are blind from trachoma, a disease caused by the lack of water combined with poor hygiene practices, while over 200 million people are infected with schistosomiasis, of whom 20 million suffer severe consequences.10

As with many challenges in development, females are disproportionately impacted because of their higher exposure rates. Indeed, twice as many females as males are responsible for water collection. In addition to higher exposure rates, females in the developing world walk six kilometers each day to collect water, time which could be spent in school or at work. Studies show that more than half of girls who drop out of primary school in Sub-Saharan Africa do so partly because of a lack of separate toilets and lack of access to safe water. The effects of the lack of access to water and sanitation have a macroeconomic impact as well. In total, the World Health Organization estimates that 40 billion working hours are spent collecting water each year in Africa.11


You get a schistosoma infection through contact with contaminated water. Symptoms include fever, blood in the urine, abdominal pain and diarrhea. World Health Organization and United Nation‘s Children‘s Fund (2008) Joint Monitoring Programme: Progress on Drinking Water and Sanitation. 11 ―Water and Sanitation Issue Brief,‖ Accessed Tuesday, April 21, 2009.


Map 2: World Map showing population without access to improved sanitation

As part of the Millennium Development Goals, developing countries and donor governments committed to reducing by half the proportion of people without sustainable access to safe drinking water and basic sanitation by 2015. Sub-Saharan Africa, which lags dangerously behind in achieving both of these goals, happens to be the only region in the world not on track to meet the MDG drinking water target.12 If current trends continue, the region will miss the water target by 25 years and the sanitation target by 61 years. The headline for a story in the Telegraph newspaper in the UK aptly represented this situation: ―SubSaharan Africa will be without sanitation till 2100.‖13 Or in other words, over 250 million people in Sub-Saharan Africa will be without sanitation till 2100.

Moreover, water and sanitation scarcities will be exacerbated through challenges such as climate change and urbanization. Projections indicate that by 12

World Health Organization and United Nation‘s Children‘s Fund (2008) Joint Monitoring Programme: Progress on Drinking Water and Sanitation. 13 Alice Klein, ―Sub-Saharan Africa Will Be Without Sanitation Till 2100,‖ <> 09/10/2008. Accessed 02/01/2010.


2020, an additional 75 to 250 million people in Sub-Saharan Africa will be unable to meet their water needs because of climate change. At the same time, water and sanitation systems in cities will struggle to provide for an urban population that is expected to double between 2000 and 2030. Past experience demonstrates the stress that this increased demand will place on water and sanitation services: between 1990 and 2007, Africa saw a 100% increase in its urban population and a doubling in the number of urban dwellers without access to water and sanitation.14


Supported by data from the World Bank Regional Fact Sheet from the World Development Indicators 2009: ―A rapidly urbanizing region—Sub-Saharan Africa‘s population growth in both rural (1.9 percent annual increase) and urban (4 percent annual increase) areas is the highest in the world. Since 1990 its urban population has doubled to 290 million people in 2007. Although SubSaharan Africa remains predominantly rural, rapid urbanization—from 28 of the population in 1990 to 36 percent in 2007—has put significant pressure on urban services. Still cities offer more than rural areas. In 2006, 57 percent of the urban population had access to improved sanitation facilities, compared to 23 percent of the rural population.‖ World Bank Regional Fact Sheet, . Accessed Tuesday, April 21, 2009.


Chapter 2: Ghana - A Case Study In Ghana, where Agyementi is located, there are huge challenges with regards to water and sanitation infrastructure.15 Table 1: Water and Sanitation Statistics Population 2003 – total (rural/urban)

20.2 (11.8/8.4) million

Population projection for 2015 – total (rural/urban)

26.6 (14/12.6) million

Population growth rate (rural/urban)


Present access to safe water – (rural/urban)


Present access to basic sanitation – (rural/urban)


Productive days which would be gained with 100% access to water and sanitation


School days lost to diarrhea by five to 14 year olds


Monthly number of households requiring access to reach water MDG


– increase required (on performance since 1990)


Monthly number of households requiring access to reach sanitation MDG


– increase required (on performance since 1990)


Current annual water spend1


Water/sanitation sector annual finance need for MDGs


Water sector annual MDG spending gap

$68m $670m

Annual national debt service payment2

Source: Water AID Ghana (2006)

As Table 1 illustrates, only 44% of the rural population and 61% of the urban population have access to safe water. The table further indicates even lower rates for sanitation coverage: a mere 11% of rural Ghana and 40% of the urban population have access to basic sanitation facilities. Water AID Ghana, an NGO and Project ACWA‘s local partner, estimates a water sector annual spending gap of $68 million to reach the MDG goals of halving the proportion of Ghanaians


Water Aid, ―Ghana Country Report,‖ January 2006


without access to clean water and sanitation by 2015. The Government of Ghana and its development partners (such as the Danish International Development Agency), in the first ever Ghana Water Forum held in Accra from 20-22 October 2009, jointly acknowledged that access to water and sanitation should be treated as a human right, with the understanding that right to water does not mean free services. At the Forum, the government also agreed to progressively increase its budget allocation towards meeting the MDG target for water and sanitation, and to give greater attention to investments in water infrastructure.16

Table 2: Ghana: Human Development Indicators


Water AID Ghana Press Release, â&#x20AC;&#x2022;Ghana recognizes water and sanitation as human rights,â&#x20AC;&#x2013; 23 December 2009.


As Table 2 illustrates, the problem of more than nine million people having no access to safe drinking water in Ghana is best understood in the context of a nation with adult literacy rates of 54%, life expectancy of 56 years and 39.5% of the population below the poverty line. In many rural communities, water is one of the scarcest commodities. During the wet season, unsafe sources of water become more contaminated by run-off from polluted sites. In the dry season, even contaminated water becomes scarce when the streams dry up.

The difficulty of obtaining clean water compels women and children to walk long distances to bring back water for a family‘s domestic chores and for drinking. The women and children carry very big pans and containers on their heads to enable them carry as much water as possible. The heavy load on their heads, the long distances they walk, and the myriad other physical chores they perform throughout the day contribute to health problems such as spine curvature, exacerbating those caused by contaminated water or dehydration. 17 In economic terms, such health issues reduce their productivity. In health terms, poor health among the women and children can result in higher morbidity rates throughout the community through decreased access to clean water supplies. In personal terms, women and children in poor health face public ridicule.18


Load bearing on the head, particularly bearers of heavy loads, produced more radiographic degenerative signs, much stiffness in the neck and more reported pain than the control group. J. Ecchari and F. Forriol, ―Influence of the type of load on the cervical spine: a study on Congolese bearers,‖ The Spine Journal 5(3): 291-296 18 Interviews with women in the community revealed that women would be publicly ridiculed as ―bad mothers‖ if their children often fall sick. Interview with Vida Ankrah, Member of Community, 20 August 2008.


Although cities and small towns generally have better access to clean water and sanitation than do the rural areas, they, too, harbor alarming water problems. Cities in Ghana tend to develop without the benefit of planning. Many newly developed or occupied sites continue to be unconnected to the water network. The worst communities are those of slums. Because the municipal and metropolitan authorities do not recognize such slums as legal communities, they do not possess the right to water facilities. Without such facilities, however, water-related diseases such as diarrhea and trachoma, dominate peopleâ&#x20AC;&#x2DC;s everyday health.

Moreover, in many poor rural and urban communities in Ghana, people have no access to decent places of convenience. As cited earlier, only about eleven percent of rural dwellers in Ghana have access to adequate sanitation facilities. In northern Ghana especially, there are hundreds of communities without any forms of latrines at all. Since they have no option, people are obliged to practice open defecation in these communities. In the arid areas of northern Ghana during the dry season, when there is little vegetation, people, especially women, have to walk for a few kilometers before they can even find an obscure place to ease themselves.

In addition to thousands of diarrhea cases every year, Ghana ranks second worldwide in guinea worm cases. The Northern Region alone, as of October 2002, represented more than 70% of Ghana's total guinea worm cases that year. Nationwide, there were 4,101 reported cases. Other water and sanitation related 18

diseases include trachoma, cholera, hepatitis A, bilharzias, typhoid, malaria, polio, hookworm, and tapeworm. According to Water AID surveys, many Ghanaians seem ignorant of the effects of bad hygiene practices on their own health. Ghana's health authorities have said that about 80% of diseases in the country are preventable since they are caused mainly by high-risk hygiene and eating and drinking habits.19

The water and sanitation problem in Ghana may not only have been caused by lack of facilities. Public policies and decisions sometimes create or compound the problem. Some policies and decisions can easily deny the voiceless poor access to potable water and effective sanitation. For instance, if the government decides to allocate only one percent of the budget to the water and sanitation sector, millions of Ghanaians may have to be in the queue for years before they are provided with potable water and effective sanitation facilities.20

Historical Study of Rural Water Provision in Ghana The provision of rural water supply in post-independent Ghana has been largely the government‘s responsibility. However, the Project ACWA team‘s examination of the government‘s role revealed serious limitations, mainly financial and logistical, to the agencies of government that deal with water and sanitation.

19 20

Water Aid Ghana, ―Ghana Country Report,‖ 2006 Ibid


Although the government-run Ghana Water and Sewerage Corporation (GWSC) had been responsible for urban and rural water supply from 1965 until the early 1990s, for most of these years, little attention was paid to the rural water supply. For example, it was estimated by the government that within this period only 28% of the rural population had access to improved water whilst urban coverage was over 60%. This led to the creation of the Rural Water Department within the GWSC in 1986 to focus more attention to the provision of water and sanitation to rural people. Some GWSC facilities could not be sustained due to non-payment of tariffs by beneficiary communities resulting in little or no maintenance of the facilities by the Centralized Maintenance Units of GWSC. The government efforts came in response to the United Nations General Assembly declaration that the period 1981-1990 was the International Drinking Water and Sanitation Decade. The United Nations goal was for nations to make significant strides in the delivery of water and sanitation facilities to their people by the end of the decade. 21 The Ghanaian Government, in line with the original agenda for the decade, initiated a review of its policies on water and sanitation provision to keep pace with the changing conditions in the country. In 1987, a donor conference on water and sanitation was held at the Ambassador Hotel in Accra, eliciting pledges for water development. In February 1991, about sixty participants from water sector institutions and External Support Agencies met in the town of Kokrobite for a workshop to prepare the grounds for the Rural Water and Sanitation Sector 21

Source: Brochure from the Community Water and Sanitation Agency, Ghana


Strategy.22 After four years of consultations with development partners and NGOs, a National Community Water and Sanitation Program (NCWSP) was launched in 1994 by Ghana‘s then President Jerry John Rawlings, in line with the Government‘s decentralization policy at the time. This culminated in the creation of the Community Water and Sanitation Division (CWSD), a semi-autonomous unit within the then GWSC to manage rural water and sanitation delivery. After four years of existence, the government decided to grant complete autonomy to the Division to give it greater impetus to perform its duties. Subsequently, in December 1998, the Division was transformed into the Community Water and Sanitation Agency (CWSA) by an Act of Parliament, Act 564, with the mandate ―to facilitate the provision of safe drinking water and related sanitation services to Rural Communities and Small Towns in Ghana.‖23 CWSA operates on a demanddriven approach. That is, communities, through their local representatives are required to seek CWSA support through their District Assemblies. In addition, the cost sharing arrangement financing policy of the CWSA is as follows: 

External Support Agency – 90%

District Assembly (Government of Ghana) – 5%

Beneficiary Community – 5%


External Support Agencies include donor agencies and development partners such as DANIDA (the Danish International Development Agency) and DFID (the UK Department of International Development) 23 Source: Brochure from the Community Water and Sanitation Agency, Ghana


This policy means that 90% of the financing is dependent on external support from donor agencies and other development agencies such as the Danish International Development Agency and the UK Department of International Development. For communities like Agyementi whose members survive on less than $1 a day and who cannot afford the 5% contribution (which for a $30,000 project would amount to $1500), the national policy is unrealistic. The five percent requirement in an upfront cash contribution has been criticized by many civil society organizations, who claim that it denies poor communities access to good drinking water.

While the CWSA is mandated by Parliament to focus on the provision of water and sanitation facilities for rural areas, water and sanitation development involves lots of other institutions and organizations including: ď&#x201A;ˇ

The Ministry of Water Resources, Works and Housing o Sets water and water related sanitation policies for water resource management and drinking water supply for both urban and rural o Coordinates budgets and mobilizes resources for the water sector o Plans sector investment, planning and advocacy as well as intersectoral and sub-sectoral coordination


The Ministry of Local Government and Rural Development o Handles general policy for sanitation


Development Partners


o Provide financial, technical, and logistic support for the implementation of the National Community Water and Sanitation Program ď&#x201A;ˇ

The District Assembly and the District Water and Sanitation Team (DWST) o Implements water and sanitation programs at the district level


The Community o Participates







maintenance of the water facilities. ď&#x201A;ˇ

The Private Sector o Plays a role in service delivery via local contractors and latrine artisans, area mechanics, spare parts suppliers, and partner organizations and consultants that support projects. In our (Project ACWA team) interviews with local government officials,

we discovered that the National Budget allocates an average of $300 per annum towards the development needs of a small community like Agyementi -- a budget that falls far short in covering the water, education, and health needs of the community.24 Agyementi was thus reflective of the various levels at which development was negotiated: international, national, regional/district and community, and showed the huge gap between international resolutions and local realities. This


Interviews with officials from the Office of the Member of Parliament (names withheld upon request), Akuapem, Ghana, August 2009.


gap called for the involvement of outsiders such us the Project ACWA team, so development in communities like Agyementi ends up being an international collaborative effort. Review of Past Interventions Agyementi thus presented an interesting crossroad: while the lack of access to clean water and sanitation in Agyementi was a very specific and local reality, it was simultaneously emblematic of the regional, national, continental and even global challenges of water and sanitation facing a billion people worldwide. In figuring out the best solution to the problem of water and sanitation in Agyementi, the team conducted a comprehensive study of existing and past projects in Ghana and elsewhere to determine what would be the most costeffective, sustainable and pragmatic intervention. We considered several interventions including solar disinfection, hygiene education, and sanitation interventions such as Ventilated Improved Pit (VIP) latrine construction. 25 Data from thousands of past interventions showed that a project combining improved water with improved sanitation would have the greatest impact on public health. A project that focused on improved water only or on improved sanitation solely 25

R. Conroy, Meegan M., Joyce T., McGuigan K., and Barnes J (1999), "Solar Disinfection of Water Reduces Diarrheal Disease: An Update." Archives of Disease in Childhood 81 (4): 337–8. ———. 2001. "Solar Disinfection of Drinking Water Protects Against Cholera in Children Under Six Years of Age," Archives of Disease in Childhood 85 (4): 293–95. V. Curtis and S. Cairncross, 2003, "Effect of Washing Hands with Soap on Diarrhea Risk: A Systematic Review," Lancet Infectious Disease 3 (5): 275–81. D.L. Daniels, S. Cousens, L. Makoae, and R. Feachem, 1990, "A Case-Control Study of the Impact of Improved Sanitation on Diarrhea Morbidity in Lesotho," Bulletin of the World Health Organization 68 (4): 455–64.


did not produce optimal results in terms of reducing diarrheal incidence rates and morbidity rates.26 In determining the intervention, Harvard University development economist Michael Kremer advised the group on the critical import of the economic case for community water infrastructure. His advice was grounded in his 2006 evaluation of spring projects in Kenya, which demonstrated little evidence for substantial effects of communal water infrastructure on diarrheal disease. However, Kremer also argued that community water projects can be justified on other grounds such as saving women‘s time and lowering household expenses on health care. It was these broader social and economic transformations that the project sought to achieve as opposed to a narrowly-focused project aimed solely at reducing diarrheal incidental rates.27 Agarwal‘s research on the role of gender in collective action alerted the team to an understanding of the dynamics of gender relations in the community and to take note of the documented role of women in the project. 28 For example, projects in India that empowered women and gave them agency witnessed greater success rates and greater community participation rates. 29 As my video documentary of Project ACWA highlights, women play key roles in achieving the goal of Agyementi‘s access to clean water and basic sanitation. 26

S.A. Esrey, R. Feachem, and J. Hughes, 1985, "Interventions for the Control of Diarrheal Diseases among Young Children: Improving Water Supplies and Excreta Disposal Facilities." 27 M. Kremer, J. Leino, E. Miguel, and A. Zwane, 2006, "Spring Cleaning: Results from a Randomized Impact Evaluation of a Source Water Quality Improvement." 28 B. Agarwal (2000), "Conceptualizing Environmental Collective Action: Why Gender Matters." Cambridge Journal of Economics 24 (3): 283–310. 29 R. Chattopadhyay and E. Duflo (2004), "Women as Policy Makers: Evidence from a Randomized Policy Experiment in India," Econometrica 72 (5): 1409–43.


The Project ACWA team undertook a thorough analysis of public health scholarship such as that of Steven Esrey, Michael Kremer, Sandy Caincross and others.30 We also consulted with the group of faculty advisors (see footnote 3), the World Health Organization office in Accra, Water AID Ghana, Community Water and Sanitation Agency, the District Assembly and the Akuapem Community Development Program. Then, the Project ACWA team together with the target community decided on a community water system (a borehole) that would improve water quality and water supply, and on a latrine construction program to improve sanitation. The decision to combine improved water supply with improved sanitation and hygiene interventions was largely influenced by a study published in 2005 by Fewtrell, et al. that estimated the following impacts: 

Improved water supply reduces diarrhea morbidity by between 6% and 25%, if severe outcomes such as cholera are included

Improved sanitation reduces diarrhea morbidity by 32% on average

Hygiene interventions including hygiene education and promotion of hand washing can lead to a reduction of diarrheal cases by up to 45%

Improvements in drinking water quality through household water treatment, such as chlorination at point of use and adequate


M. Kremer, J. Leino, E. Miguel, and A. Zwane, 2006, "Spring Cleaning: Results from a Randomized Impact Evaluation of a Source Water Quality Improvement." V. Curtis and S. Cairncross, 2003, "Effect of Washing Hands with Soap on Diarrhea Risk: A Systematic Review," Lancet Infectious Disease 3 (5): 275–81. S.A. Esrey, R. Feachem, and J. Hughes, 1985, "Interventions for the Control of Diarrheal Diseases among Young Children: Improving Water Supplies and Excreta Disposal Facilities."


domestic storage can lead to a reduction of diarrheal episodes of 35% to 39%. 31 The integrated approach was also influenced by the philosophy of Water AID Ghana, our development partner on the ground. We shared their belief that together water, sanitation and hygiene education provide the key to poverty reduction. According to Water AID, by focusing on projects that combine these three elements, health benefits are maximized and the results are long lasting and wide reaching. Studies from UNICEF also found that adequate water supply and sanitation could reduce infection rates of schistosomiasis by 77% and could reduce the infection rates of trachoma by 25%.32 With the theoretical framework for establishing the intervention to provide Agyementi with clean water and sanitation in place, and with linguistic (Twi), cultural and historical knowledge, the team began Project ACWA in Ghana.33


Lorna Fewtrell et al., ―Water, Sanitation and Hygiene: Quantifying the Health Impact at National and Local Levels in Countries with Incomplete Water Supply and Sanitation Coverage,‖ Environmental Burden of Disease Series 15 : 22 32 World Health Organization and United Nation‘s Children‘s Fund (2008) Joint Monitoring Programme, ―Progress on Drinking Water and Sanitation.‖ 33 Pursuant to the Harvard University Committee on the Use of Human Subjects regulations, the team also received training from the Harvard Ethics Training in Human Research Program and certification from the Institutional Review Board.


Chapter 3: On the Ground in Agyementi Map 3: Akuapem Region (Agyementi located in Aburi region highlighted in red)

Source: Google Maps

Background of Agyementi Agyementi is a small village of 500 people near Aburi, which was founded 150 years ago. It is approximately an hourâ&#x20AC;&#x2DC;s drive from Accra, the capital city of Ghana. The community is mainly comprised of Akuapems (90%), but also has a harmonious representation of Ewes, Fantes, Guans and Gas. About 34% of the inhabitants are adult males, 29% are adult females, and 37% are children below the age of 18 years. There are 58 houses, and 130 households in Agyementi; the average household size is four members. Agyementi is governed by a chief 28

(Nana Takyi) and a Council of Elders. The community also has a Town Development Committee and a Unit Committee which are tasked with overseeing the development of the community. However, community members describe the committees as ineffective and dysfunctional. The community members identified two classes of poverty in the community: the poor and the very poor, with 60% of the community classified as poor and 40% as very poor. The characteristics of the poverty classes as described by the community are outlined below: Table 3: Poverty Classification by Community Very Poor Poor 1. Cannot afford hospital expenses 1. Can afford some hospital expenses 2. Can only afford 1 square meal a day 2. Can afford 2 square meals a day 3. Wear shabby or torn clothing 3. Wear neat and nice looking clothes 4. Shy away from public functions 4. Are respected and attend public functions 5. Have farm size of ½ an acre, and 5. Have farm size of 2-4 acres and cannot afford to buy fertilizers can afford to buy fertilizers 6. Do not have a profession

6. Have some profession (hair dresser, seamstress, tailor, mason, carpenter or driver)

7. Cannot afford to employ laborers 7. Can afford to hire laborers to work for them 8. Cannot pay community levies 8. Can pay community contributions 9. Cannot pay for electricity bills 9. Can pay for electricity thereby are disconnected. 10. Their children most often do not 10. Their children are able to eat a little eat before going to school food before attending school 11. Cannot afford to buy text books for 11. Can afford to buy text books for their children their children 12. Cannot afford to marry- in the case 12. Able to marry of men


The stratification of the community by the community members themselves was interesting because it revealed that the community conceded that everyone was ―poor.‖ Interviews with older members of the community clearly showed that international definitions of poverty, which are based on poverty lines in developed nations, had obliterated cultural distinctions between the ―haves‖ and the ―have-nots‖ to the point where the entire community perceived itself as poor, and thus created social divisions based on relative markers of poverty. In regards to occupations, about 60% of Agyementi engages in crop farming, with the remainder involved in artisanship, which includes hair dressers, seamstress, tailors, masons, carpenters and drivers (20%), petty traders (10%) and construction workers (10%). The community had some basic infrastructure including a school (primary and junior secondary school), a public toilet in deplorable condition, and limited access to electricity. Profile of Water and Sanitation in Agyementi Along with a lack of a clean water source, Agyementi lacked a sanitation infrastructure. Open defecation was widely accepted; often fecal matter from humans and animals flowed into the water source. This source was an untreated spring used by both animals and humans. Due largely to these conditions, Agyementi had high rates of infant mortality, a common trait for villages with unimproved water sources and no latrines. In fact, the team discovered that in some households, almost 50% of the children born die before attaining the age of 30

five. There is strong evidence that the lack of sanitation causes the exceedingly high infant mortality and diarrheal rates, as statistics from UN and OXFAM studies show. More people in Africa die of diarrhea than of malaria and AIDS combined. Before the project, the community had no safe drinking water source. The sources of water included: 

A stream which was out of use due to high pollution and drying up in the dry season.

A hand-dug well which was constructed in 1992 and abandoned in 2002 after a 12-year-old girl with a mental health illness fell in the well.34

Rain water which was used by about 2% of the population.

A central spring which was the main source of water serving about 98% of Agyementi.

The community used the spring water for drinking, cooking, washing, cleaning and bathing. In the rainy season, usage was greater than 35 liters/head/day and in the dry season; usage was less than 15 liters/head/day.35 Baseline studies conducted in Agyementi to assess the problems with the spring and rain water before the intervention revealed multiple problems. Surface water ran into the spring, contaminating the water with particles. Community members complained that the spring water changed color every time it rained and that the


Refer to the documentary for interview with Abu Abduramane, Operations Manager of the Akuapem Development Program, on why the community refused to use the well, even after rehabilitation. The 12 year old girl was rescued and did not die in the well, yet the community perceived some kind of persistent contamination associated with her fall into the water. 35 In the dry season, the spring dries up and the quantity of water available drops significantly.


spring water stained their water receptacles, indicating the presence of iron ore (an issue the team faced in our own intervention later). The spring also had low yields. Several neighboring communities, namely Adenkrabi, Ayim, Kitase, and Amoakrom depend upon the water from this same spring, especially during the dry season, which puts pressure on the spring supply, and results in quarreling and disputes among women and children of the neighboring towns especially during peak hours and peak periods. Agyementi community members also complained of having to travel over 500 meters to get to the spring site. They indicated that they lacked knowledge about hygienic ways of harvesting rain water and could not afford to buy big receptacles to harvest the rain water. In the developing world, sanitation generally refers to access to excreta disposal facilities, specifically access to an â&#x20AC;&#x2022;improvedâ&#x20AC;&#x2013; latrine. In addition, adequate sanitation also includes a clean, private environment, as well as knowledge and understanding about the connection between hygiene and disease. In Agyementi, there were no safe excreta disposal systems in the community, resulting in indiscriminate open defecation. The single public latrine was choked up with cracks in the slabs. The community occasionally cleaned the latrine floor but, there was no management system in place to ensure maintenance of the facility. Out of the entire community, only six households had their own latrines, but they were the open traditional pit latrines which were not sanitary or safe. The community had many weedy compounds and surroundings and exhibited indiscriminate refuse dumping. We developed a questionnaire and surveyed community members as to their hygienic practices. Our surveys revealed that 32

community members were not washing their hands with soap before eating and after visiting the toilet. In addition, water storage receptacles were not covered and were not kept clean. Agyementi is a prime example of how development done with all of the right intentions can lead to negative results when the necessary training and follow-ups do not occur. In 1992 an international NGO built a hand-dug well in the village. The well was not covered and as a result, it became contaminated with animal and human excreta, worms, and bacteria. Worst of all, a twelve year old girl with mental health problems fell into the open well. Fearful of being contaminated with the girlâ&#x20AC;&#x2DC;s spirit even though she had been rescued, the village stopped using the well in 2002. Aside from the obvious health hazards, the water situation in Agyementi also had effects on education, female equality, food supplies, and other basic human rights. From the baseline data we gathered, we learned that the burden of water collection falls on young girls. These young girls traveled 45 minutes roundtrip in the raining season and at least 90 minutes in the dry season to collect water. Because of their poverty, the girls could not afford to buy large water receptacles and therefore had to make three to four trips per day to gather water infested with E. Coli and compromised by high turbidity. During the dry season, the spring dries up and people are not able to gather the minimum 15 liters per day per person that the UN recommends, leading to quarreling amongst the women from the neighboring villages. Once in homes, available water became even more contaminated as most people did not use closed storage containers, 33

allowing children and animals to touch the water and drink freely from communal serving cups. The water situation also adversely affected education. A donor from the US had built a beautiful school house in the village but because of water collection duties, girls were not able to reap the benefits to the extent that boys were. The local teacher complained of high absenteeism and tardiness among children who were delayed by their water gathering duties. Such absenteeism and tardiness more negatively impact the girls, whose water-bearing duties are typically more onerous than the boys. Girls lose approximately six to eight hours a day to water bearing duties. Since their water-bearing chores prevent them from arriving to school on time, they typically suffer in the classroom. These gendered chores have an inequitable effect on the quality of education the children receive with an unequal share of the burden falling on the girls. In our development assessment of the village, the people of Agyementi requested assistance from the team to tackle the problem of lack of access to safe, clean water and improved sanitation. Through the data gathered from our baseline survey, with help from Water Aid Ghana, we hypothesized that an improved water source would reduce and/or eliminate the number of diarrhea cases and other water and sanitation related diseases, increase income and production via saved opportunity costs, improve school attendance, allow people to practice good hygiene, reduce migration, and improve relations with neighboring villages. Leaders in the community confirmed our hypotheses, adding that the enhanced


access would also smooth social relations between the ―poor‖ and ostracized ―very poor‖ within the community. Testing the Water Our intervention was two-pronged; including a ―hardware‖ and ―software‖ component, as our partner on the ground, Abu Abduramane, the Operations Manager of the Akuapem Community Development Program, coined them. The hardware elements centered on the physical installation of the borehole, construction of the treatment plant, and the construction of the latrines. The ―software‖ components included community development, capacity building, and hygiene promotion. Using 3M Petrifilm E. coli / Coliform count plates, we gathered counts on the E. coli and total coliform levels in the current drinking source, stored water, surface water, and water from the borehole. These tests were conducted on site, both before and after the project. In order to detect low levels of E. coli and total coliform simultaneously, we performed the Colilert MPN (Most Probable Number) Test using Colilert MPN tubes from IDEXX Laboratories. 36 The coupling of these two tests allowed us to quantify the amount of coliform and E. coli in high-risk waters as well as perform presence / absence tests in areas with


Palintest Colilert is a dry blended reagent system used for the detection, specific identification and confirmation of total coliforms and E.coli in water in 24 hours or less. Experimental data show Palintest Colilert to be sensitive and specific for the detection of total coliforms and E.coli at the 1 CFU level in the presence of up to 200,000 heterotrophic bacteria present per 100 ml. The test is carried out simply by mixing the Colilert reagent with the water sample and incubating at 37°C for up to 24 hours. Positive samples are detected by a visual color change, the presence of E.coli is confirmed by observing fluorescence under UV light. Source: Accessed March 08, 2010.


little to no contamination. In addition to these tests, we took samples back to a lab in Accra to conduct a chemical water quality analysis on all of the aforementioned water sources, testing for arsenic, fluoride, nitrate, sulfate, and various ions. We also conducted turbidity tests to observe the NTU values of the water using a turbidimeter.37 We also conducted water quality tests at each household and the results were striking: 100% of households in Agyementi used untreated water for their drinking needs.

Chart 1: Household Water Quality


Household Water Quality 120 100 80 60 40 20 0


Households w/ Untreated Water

Households w/ covered water

Households w/ Negative Coliform Tests

Households w/ Negative E. Coli Tests

We visited all of the households over the course of three months to have discussions about water supply, health, hygiene, development aid, and other related topics. We explained what we were doing, and we showed the results of the water quality tests to the household members. One woman challenged the results and said she had to perform the test herself before she would believe us. 37

NTU = Nephelometric Turbidity Unit - a measurement of particles in water


This forced us to change our strategy. We then went with representatives from each household to the spring to collect a sample, and then tested the sample using the Colilert MPN tubes. We asked each household to sleep with the tube, and gave them a control tube. We explained that the water containing E. Coli would change color. The next morning we visited the households and as expected, the tubes with water from the spring had all turned yellow. The households were visibly disturbed by this and became more interested in the project.38 Community Development In order to ensure long term sustainability and maximum benefit of the scheme to the health and quality of life of the community, we considered many non-technical points before proceeding with our borehole intervention. Research has shown that the involvement of communities in the design, implementation, monitoring, review and evaluation of a project enhances their sense of ownership. In turn, this empowers people to make decisions, relevant to their perceptions and needs, concerning the work which will help to safeguard the long-term sustainability of the project.39 Based on this, the team sought out and involved community participation in all facets of the project. This meant commitment at all stages, including: (1) appraising the project, beginning with setting up a baseline survey from which to measure improvements; (2) setting aims and objectives; (3) designing the project


Chapter 3 discusses this in detail as part of the ―Trigger‖ approach. Garvey Davis and Wood (1993), ―Developing and Managing Community Water Supplies,” Oxfam Publication. 39


with the involvement of all the stakeholders; and (4) setting up a monitoring system.40 We spent a considerable amount of time collecting baseline data in Agyementi. This was important because analysis of our baseline data collection was imperative to the planning, design, implementation, monitoring and evaluation of our interventions in the community. We collected baseline data using participatory methods to ensure that the community had a stake in the success of the project and to reveal any hidden issues that could affect the design and implementation of the interventions. The baseline data that we collected included the background of the community, population (gender disaggregation), socio-cultural practices, past interventions, infrastructure, existing committees/groups and their various roles, hygiene practices, economic activities, water and sanitation facilities, leadership structure and communication channels, norms and taboos, common diseases, community perception about their community and gender roles. We used the participatory rural appraisal (PRA) or participatory learning approach (PLA) tools to collect the data, including social mapping, questionnaires, focus group discussions, transect walk, observation, interaction, inspection, seasonal calendar, wealth ranking/scoring, storytelling and the problem tree method.41 After collecting the data, we analyzed the results together with the


Scinivasan L (1990), â&#x20AC;&#x2022;Tools for Community Participation,â&#x20AC;? PROWESS/UNDP Bulletin.


Participatory rural appraisal (PRA) or participatory learning approach (PLA) is an approach used by NGOs and other agencies involved in international development. The approach aims to incorporate the knowledge and opinions of rural people in the planning and management of


entire community at community meetings. We did this to ensure that the community had an ownership stake in the entire process and as a result would be more likely to stay committed to the decisions derived from the analyses.

We then introduced a problem tree (a PLA tool) to the community to enable them identify the root causes of problems/challenges/gaps identified during the analyses and to find possible solutions to address them.42 Some of the problems/challenges mentioned by community members included the following: 

Community members do not attend meetings and contribute towards communal labor

They do not have safe water to drink

They travel for long distance to fetch water from the stream

They spend too much time in searching for water during the dry periods

The communal latrine is full, causing people to defecate in the latrine cubicles

Most people openly defecate in the backyards and community compounds

There are too many flies in the community

No one in the community contributes money for any development work

development projects and programs. A transect walk is a tool for describing and showing the location and distribution of resources, features, landscape and main land uses along a given transect. ―World Bank PRA Tools Manual,‖…/Resources/…/1_Transect_walk.pdf. Accessed March 03 2010. 42 A problem tree is a PRA tool which assists in analyzing an existing situation by identifying the major problems and their main causal relationships. The output is a graphical arrangement of problems differentiated according to ‗causes‘ and ‗effects,‘ joined by a core, or focal, problem. This technique helps understand the context and interrelationship of problems, and the potential impacts when targeting projects and programs toward specific issues. Accessed March 03 2010.


People get ill at frequent intervals

Most of them are poor and cannot afford to pay for their basic needs.

The community members were then asked to suggest solutions to these problems. They recommended the following solutions: 

Institute Bye-Laws to guide the actions and behavior of community members

Enforce the Bye-Laws by punishing all defaulters

Install a borehole within the community

Ask every household to construct a latrine

Ask the chief to close down the public toilet

Invite community health nurses to educate the community on safe hygiene practices

Form a committee to supervise the implementation and management of the project

Need to have micro-credit facility so community members can access micro-loans to improve upon their businesses (farming and petty trading)

The whole exercise, including data collection and analyses, took three months to complete by a team including personnel from ACDEP and a member of the Municipal Water and Sanitation Team, who had the skills to use the PRA/PLA. Before any construction began, the team considered the issue of final ownership over and responsibility for maintenance of the well and latrines. We considered the best methods to manage day-to-day operations, however small, the 40

method of payment for any repairs and maintenance, and plans for possible future extensions to the project after neighbors could see the actual benefits. In agreement with the community itself, and in accordance with District Assembly guidelines, the Project ACWA team turned final ownership of and responsibility for the borehole and latrines over to the community. Following the recommendation of the community in the PLA exercise, the Project ACWA team decided to facilitate the formation of a Water and Sanitation Committee during one of the community meetings. The Water and Sanitation Committee (WATSANC) oversees the operation and maintenance of the Water, Sanitation and Hygiene (WASH) activities in the community. Through open discussion the criteria for the selection of the committee members were as follows: 

Any eligible member should be at least 18 years of age

Any eligible member should be prepared to work voluntarily

The team must be comprised of both women and men

Eligible members must have lived in the community for at least one year

Eligible members must have no criminal record

Members must be tolerant and hard working

Members must have good communication skills and speak the local language.

Members must be selfless

Members must be ready to work towards positive change

After setting out the criteria for the membership, the team then discussed the roles and responsibilities of the Water and Sanitation Committee (WATSANC) as 41

well as the responsibilities of the various positions within the committee with the community. The team and the community agreed that the collective task of the WATSANC is: 

To repair the hand pump on the well and concrete pads when it breaks down.

To collect dues from community members for the maintenance of the facility

To operate a bank account for dues collection

To promote good hygiene practices in the community by organizing educational sessions and communal labor frequently

To advise and encourage every household to build a latrine

To account for all monies collected

To build a new water system when the population increases

To organize regular meetings

Initially, a pre-existing committee comprising eight male elders responsible for water unilaterally decided to take over control of the WATSANC. This resulted in an uproar. A woman in the community rose up and emotionally addressed the community, ―Who wakes up in the morning to fetch water? Who carries the buckets? Who cooks? Who washes the clothes?‖ As she spoke, all the women at the community meeting nodded in agreement. One of the elders, the Saahene (warrior chief) intervened and decided that the community would hold elections for the WATSANC. Eligible members were democratically elected 42

through voting by simple majority for each position. At the end of the voting women occupied five (5) out of the seven (7) positions. The remaining two positions went to men. The community unanimously endorsed a woman as their chairperson. This is uncommon in most rural settings in Ghana. The positions occupied by women included the chairperson, treasurer, hygiene promoters (2) and caretaker positions while men had only two positions -- secretary and assistant caretaker. The team probed further to understand the motive behind the selection of females as committee members and the men explained that the issue of water, hygiene and sanitation is mostly the responsibility of the women. They also conceded that women are better placed than men to impart knowledge to their children for positive change since the women have closer relationships to the children. Thus, women took the lead role in the management of the facilities. The elected WATSANC members were inaugurated the same day. The opinion leaders (chief and elders) then asked them to pledge to the community leadership and the entire community that they will perform their duties well which the chairperson obliged to do on behalf of the community. The committee in return demanded full cooperation from everyone in the community. Next, field officers from ACDEP and the District Assembly in charge of capacity building training conducted a training-needs assessment on all the WATSANC members to assess their knowledge and skills gaps based on their individual roles before the training program was designed. The following topics were identified after the training-needs assessment was conducted: ď&#x201A;ˇ

Leadership skills 43

The roles and responsibilities of WATSANC and its members

Team building

Communication channels/skills

Community Ownership and Management (COM) (Facilities Management Plan-FMP, opening of WATSAN account, etc.)

Meeting and meeting skills

Record keeping

Funds mobilization and management

Involvement of women in water and sanitation programs

Operation and maintenance (O&M)

Action planning

Based on the above, a 3-day capacity building training workshop was organized for the WATSANC in the community

Drawing the Facilities Management Plan (FMP) The Project ACWA team then drafted a Facilities Management Plan (FMP), also known as the sustainability plan between the community as one party and the Akuapem South Municipal Assembly and the Project ACWA team as the counterparty. This document shows the type of facilities the community has chosen and details how the facility will be managed, maintained and financed. Later, we organized a community meeting to present the draft FMP to the opinion leaders and the entire community members for their input before finalizing the FMP. 44

We then helped the WATSANC to draw an action plan. The action plan was later submitted to the community at a durbar ground to enable community members to make their suggestions before a finalized plan was adopted. This was done to ensure that the community owned the plan. Borehole Intervention Following the community development work, the Project ACWA team, in consultation with the community and our development partners initiated construction of the borehole. A borehole is the generalized term for any narrow shaft drilled in the ground, either vertically or horizontally. A borehole may be constructed for many different purposes, including the extraction of water or other liquid (such as petroleum) or gases (such as natural gas), as part of a geotechnical investigation or environmental site assessment, for mineral exploration, or as a pilot hole for installing piers or underground utilities.

Boreholes are also used as water wells. Typically, a borehole used as a well is completed by installing a vertical pipe (casing) and well screen to keep the borehole from caving. This also helps prevent surface contaminants from entering the borehole and protects any installed pump from drawing in sand and sediment. When completed in this manner the borehole is then more commonly called a water borehole.


Image 1: Illustration of a Borehole


Site Selection Siting of borehole facilities has been a problem in most parts of the country. Past projects that have been sited without community participation and involvement have resulted in the community abandoning these facilities. We therefore decided to involve the community in selecting the site for drilling the borehole. We discussed the process at a community meeting and we gave guidelines to the community members about where a borehole could and could not be located. Some of these guidelines included the following: 46

A borehole should not be sited downstream of a cemetery

A borehole should not be sited up on a hill

A borehole should be away from erosion paths

A borehole should be at least 50 meters away from latrines, refuse dumps and all other contaminants

A borehole should not be sited in waterlogged areas

With these guidelines, the community was then asked to select three sites of their choice. On a later date the contracted borehole engineer, Mr. Daniel Ansah, was engaged to use siting equipment to determine the suitable site. Some households wanted the facility to be sited closer to their homes and this created some misunderstanding among community members; however, it was later resolved by the opinion leaders.

We then worked with Mr. Daniel Ansah, the engineer, and a technical team from Water Aid Ghana to install the covered borehole with a hand-pump. This design, unlike the well installed in 1992, is not vulnerable to falling accidents as it is covered and can only be contaminated by direct contact with the pump spout. Before excavation, information about the geology, water table depth, seasonal fluctuations, recharge area and rate was determined by Mr. Ansah.

The drilling, development, air lifting test, apron and drainage channel construction took one week to complete. While the drilling was in progress all the community members gathered at the site to observe how the borehole was drilled.


The community members were so excited when they saw the water gushing out from the well. They shouted “Yen sa aka ooo” meaning ―We have got it ooo!!‖ We then tested the water from the borehole, and as expected, the water quality from the borehole was substantially better than the spring water as our E-coli and Fecal Coliform Count tests showed:

Chart 2: E. Coli and Fecal Coliform Count

Colonies per 100mL

E. coli and Fecal Coliform Count per 100mL 5000 4000 3000

Spring Source



1000 0 E. Coli Levels

Fecal Coliform Levels Source

The borehole was fitted with a high lift pump to operate at depths of 60 meters or more. Intermediate and high lift piston hand pumps are designed so as to reduce, by means of cranks or levers, the physical effort required when pumping. They have to be more robust and are provided with bearings and components capable of handling the larger stresses which are imparted by the pumping efforts required, as illustrated below:


Image 2: Handpump

Source: Technology Notes, Water AID

The VLOM concept We also adopted the VLOM (Village Level Operation and Maintenance) concept in our approach. VLOM was a term coined during the World Bank / UNDP Rural Water Supply Handpumps Project which, from 1981 - 91, considered the availability around the world at that time of hand pump technologies and maintenance systems. 49

A series of performance tests were undertaken involving laboratory testing of 40 types of hand pump and field performance monitoring of 2700 hand pumps. It was concluded that centralized maintenance systems were the cause of many problems and that village level maintenance was desirable, but only feasible if the design of the pump made it possible. 43

Initially the VLOM concept was applied to the hardware, with the aim being to develop pumps which were designed to be: 

Easily maintained by a village caretaker, requiring minimal skills and few tools

Manufactured in-country, primarily to ensure the availability of spare parts

Robust and reliable under field conditions

Cost effective

Subsequently, the VLOM concept was extended into software and organizational matters. Thus the "M" in "VLOM" has become "management of maintenance", for the success of a project was generally seen to be dependent on a strong emphasis on village management. Therefore the following elements were added: 

Choice by the community of when to service pumps


Rural Water Supply Handpumps Project: Laboratory Testing, Field Trials and Technology Development. UNDP/World Bank Report No. 1 March 1982.


Choice by the community of who will service pumps

Direct payment by the community to the caretakers

The application of VLOM principles, when considering pump selection, often involves compromising one principle to take advantage of another. A hand pump with a low rate of breakdown might be thought preferable to another with a higher rate. However, a hand pump that breaks down monthly, but can be repaired in a few hours by a local caretaker, is preferable to one that breaks down once a year but requires a month for repairs to be completed, replacement parts to be imported, and for skilled technicians to be available.44

Iron Removal Plant Intervention Three months after the borehole had been installed and the team had departed for Cambridge, Massachusetts, a follow up with the community was undertaken on our behalf by the Akuapem Community Development Program. Their report to the team indicated that the community members had stopped using the borehole because ―the water tasted funny‖ and ―it stained our white clothes.‖ Tests conducted on the water revealed high concentrations of iron ore and manganese, exceeding WHO standards.

Further research with the Community Water and Sanitation Agency (CWSA) showed that currently, over 95% of water provided to small communities and towns for domestic use is extracted from a groundwater source. 44

Rural Water Supply Handpumps Project: Laboratory Testing, Field Trials and Technology Development. UNDP/World Bank Report No. 1 March 1982.


However, the occurrence of high levels of minerals including metal compounds, especially iron and manganese, in most of these groundwater sources has been identified as a challenge limiting the extent to which this resource can be exploited. According to CWSA, drilling records have revealed that on the average, about 20% of boreholes drilled for domestic water supplies contain high concentrations of manganese or iron, or both metal compounds above the Ghana Standards Board permissible limits of 0-0.1 mg/1 (manganese) and 0-0.3mg/1 (iron) for domestic water supply in some regions in the country including Eastern, Greater Accra, Central, Northern, Ashanti, Volta and Western. Low pH (water acidity) levels are also associated with groundwater in most of the geological formations in these regions. Agyementi joined the list of communities with this problem.45

Manganese and iron occur naturally in most of the geological formations in Ghana. In the Eastern Region for instance, where Agyementi is located, the Togo Series, Voltaian and Birimian formations are noted for high levels of iron and Manganese. Up to 41.5mg/1 of iron and about 10.0mg/1 of manganese levels were detected in some boreholes.46

Research from CWSA further showed that about 40% of drilled wells with high iron or manganese levels have been abandoned by user communities while the remaining 60% are used only marginally for purposes other than drinking,


Community Water and Sanitation Agency (2006), â&#x20AC;&#x2022;Overview of Water Quality Challenges in Rural Water Supply,â&#x20AC;&#x2013; Community Water and Sanitation Agency Publication. 46 Ibid


cooking and laundry. According to CWSA, this places 20% or more of the investment in groundwater exploitation for water supply to small communities under threat of being wasted. This translates approximately to $600-$1600 of losses on every borehole drilled in the affected regions in Ghana.47

In an effort to ensure that water supply to rural communities and small towns is potable, CWSA implemented a new treatment technique called the MWACAFE Iron Removal Plant, which was designed and developed by Mr. Worlanyo Kworlanyo Kwadjo Siabi, the Eastern Regional Water and Sanitation Engineer of the Community Water and Sanitation Agency. This technique is based on adsorption properties of granular activated carbon, applied as filter material under oxygen supply. Following successful trial of MWACAFE on some boreholes, a concept paper on water treatment using adsorption properties of carbon and performance of MWACAFE was published on the Ghana Web site ( in 2003. Thereafter three papers were presented on the subject at conferences in Nigeria in 2003 and 2004, and also at the World Water Congress in Morocco in 2004.48

The plant uses charcoal as its carbon source because it is readily available and universally acceptable, unlike carbon prepared from animal bones, which may be rejected based on tradition and cultural beliefs. The new techniques and


Ibid Community Water and Sanitation Agency (2006), â&#x20AC;&#x2022;Overview of Water Quality Challenges in Rural Water Supply,â&#x20AC;&#x2013; Community Water and Sanitation Agency Publication. 48


processes of water treatment in this plant ensure ease of operation and sustainability.49

In consultation with CWSA, and the Akuapem Community Development Program, the team engaged Mr. Daniel Ansah, the borehole engineer, to construct a MWACAFE treatment plant in Agyementi. The documentary visually explains how the plant works.




Chapter 4: Sanitation Intervention and Hygiene Education As previously discussed, research has shown that water interventions alone are not sufficient in reducing diarrheal incident rates and in reducing infant mortality rates. The benefits of water interventions are optimized when combined with sanitation interventions and hygiene promotion.50 If pathogens from human feces enter a person‘s mouth and are swallowed, they will cause diarrhea. If proper treatment is not given, this can prove fatal, particularly to children. The pathogens can enter the mouth in a number of ways; these include: 

Directly from a person‘s hands or fingers; pathogens get onto the hands or fingers if: o hands are not washed after a person has defecated, or o hands come into contact with someone else‘s feces on the ground (such as when small children are crawling or playing on the ground or when adults clear up a child‘s feces)

Indirectly from a person‘s hands, if not washed after defecation: o

from food which has been prepared by them

o from food which is eaten with dirty hands o from cups or other utensils, handled by dirty hands 

From food: If this has been contaminated by flies which settle first on excreta


Lorna Fewtrell et al., ―Water, Sanitation and Hygiene: Quantifying the Health Impact at National and Local Levels in Countries with Incomplete Water Supply and Sanitation Coverage,‖ Environmental Burden of Disease Series 15 : 22



From water: If it has been contaminated by feces


From soil: If this contains feces, they can be transferred: o by hands which are not washed before eating, or o by crops which are not cleaned properly before cooking, or not cooked properly

These routes are shown in the following diagram: Image 3: F-diagram

Image 4: Blocking the fecal-oral routes

Source: Water AID Ghana


Blocking the fecal-oral transmission route The likelihood of diarrhea can be greatly reduced by blocking the various fecal-oral transmission routes. The Project ACWA team sought to achieve this by a combination of building latrines which incorporate blocking mechanisms and hygiene education which is designed to result in changes to peopleâ&#x20AC;&#x2DC;s personal behavior. The process is illustrated by Image 4 above.

Community-Led Total Sanitation (CLTS) The Agyementi community was initiated into a modified version of Community Led Total Sanitation (CLTS). CLTS was pioneered by Kamal Kar (a development consultant from India) together with VERC (Village Education Resource Centre), a partner of Water Aid Bangladesh in 2000 in Mosmoil, a village in the Rajshahi district of Bangladesh, whilst evaluating a traditionally subsidized sanitation program. CLTS is an innovative methodology for mobilizing communities to completely eliminate open defecation. Communities are facilitated to conduct their own appraisal and analysis of open defecation and take their own action to become open defecation free. CLTS is premised on the understanding that merely providing toilets does not guarantee their use, nor necessarily result in improved sanitation and hygiene. Earlier approaches to sanitation prescribed high initial standards and offered subsidies as an incentive. But this often led to uneven adoption, problems with long-term sustainability and only partial use. It also created a culture of dependence on subsidies. Open defecation and the cycle of 57

fecal–oral contamination continued to spread disease. In contrast, CLTS focuses on the behavioral change needed to ensure real and sustainable improvements – investing in community mobilization instead of hardware, and shifting the focus from toilet construction for individual households to the creation of ―open defecation-free‖ villages. By raising awareness that as long as even a minority continues to defecate in the open everyone is at risk of disease, CLTS triggers the community‘s desire for change, propels them into action and encourages innovation, mutual support and appropriate local solutions, thus leading to greater ownership and sustainability.51 The baseline analysis revealed that community members were practicing open defecation and the communal latrine was also in a deplorable situation. It was therefore necessary to employ CLTS to sensitize community members to collectively address the menace. However, while we focused on total sanitation coverage and a total end to open defecation in Agyementi by the end of 2010, we still employed the use of subsidies to reward the most actively involved households.52

Consultation of Community Leadership From the outset, the team observed that the success of CLTS lay largely with the chiefs and opinion leaders. The team, therefore, consulted the leaders of the three communities, explaining the concept in detail so that they would 51

Kamal Kar and Robert Chambers, 2008, Handbook on Community Led Total Sanitation, IDS and Plan International. 52 See page 90 for discussion of rewards and benefits


appreciate the need for the entire community to embrace the concept and encourage them to sustain it. Recognizing the importance of the consultations with community leaders as a key step in ensuring the success of safe sanitation, the team spent a total of over six hours talking to leaders, working around their personal concerns, and responding to their questions. Incorporating Language and Cultural Idiosyncrasies At a community durbar where all the chiefs/opinion leaders and the entire communities were present, it became clear that the community was not conscious of the fecal-oral routes of diarrheal disease. Furthermore, we discovered that the community members frowned on the use of the term ―ebin‖ in the local language which means ―shit,‖ but preferred terms like ―agyanan‖ or ―babiso‖ which are more euphemistic and mean ―human waste.‖ These euphemisms allowed community members to downplay the gravity of the open defecation practices, and they became complacent and did not exhibit any resolve to take action. In response, we adopted the phrase ―yedi yen bin‖ in our sensitization campaigns, meaning ―we are eating our own shit.‖ Community members were repulsed by the imagery of eating their own ―shit‖ and the slogan thus triggered the community to accept the challenge to end the practice of open defecation and to exhibit good hygiene behavior. Sanitation profiling was then undertaken in three communities to enable them to assess the number and type of toilet facilities they have, the state of the various latrines and refuse dumps as well as the challenges that they faced.


Drawing of Defecation map After the sanitation profiling, we asked the community to show the location of all sanitation facilities without going to the various sites. Some community members suggested drawing a map on the ground. At this stage, community participation was very high as every member of the community wanted to locate his or her house, latrine and refuse dump on the map. The households were asked to indicate their defecation routes on the map using grounded charcoal and emergency defecation routes using ashes. It was interesting to note that some households were defecating in back yards and open spaces in the community. A group made up of women and men were tasked to translate the drawing on the ground onto a flip chart paper. This would serve as a reference point for any future monitoring and assessment. Transect Walk After drawing the social/community map, the team and the community undertook a transect walk to all the various facility sites indicated on the map, e.g. latrines, water points, refuse dump areas, community compounds etc. Before embarking on the walk, the facilitators explained the purpose and the importance of the exercise to the community members. The community then decided where to begin and end the transect walk and to re-convene at the meeting grounds to discuss the findings during the trip. Below were some of the findings: ď&#x201A;ˇ

Both communal and household open pit latrines were not covered and were exposed to flies and fowls.


Open defecation was spotted at the backyard of some houses. 60

Spots of weeds were observed around houses.

Communal and households refuse dumps were not managed well. Refuse was scattered all over.

There were a lot of flies in the surroundings.

Bathrooms had no soak-aways which resulted in stagnant water which breeds mosquitoes.

We also observed blame games where the husbands blamed their wives while the wives in turn blamed their children for the unsanitary conditions of the house.

It was observed that some community members did not come back to the meeting ground after the transect walk, especially, households with unsanitary conditions. The purpose of the transect walk was achieved in all the three communities. F-Diagram After a thorough discussion on the transect walk, the F-diagram was used to educate community members on the oral-fecal transmission route and prevention methods. The tool was very effective in the sense that it was able to bring out most of the hygiene high risk behaviors observed during the transect walk. One example was the practice of open defecation. The communities were able to draw meanings from the F-diagram on open defecation and its consequences to their health.53


See Image 3 and Image 4 for illustration of the F-diagram


Action planning The next activity was action planning. With assistance from ACDEP and DWST, the communities were assisted to draw an action plan in their respective communities. All the issues raised after the transect walk exercise were used as the basis for preparing the plan. The action plan was for a period of three months and after the three months, the plan will be reviewed and a plan for the next three months will be established. This will translate into four action plans in any given year. Household Latrine Construction Program Following the action plan, the team initiated the Household Latrine Construction Program. Community meetings were becoming a challenge over time as a number of people refused to attend meetings even though they were given prior notice. In order to reverse this situation, we decided to motivate the few households who attend the meetings by giving them subsidies for their latrine construction. In that particular meeting, twenty (20) out of the sixty two (62) households attended the meeting. The twenty households were then given subsidies based on the type of latrine type selected. The sanitation ladder was used to expose the community to the various types of latrines available right from the traditional pit to ventilated improved pits up to water closets. The advantages and disadvantages of each of the latrine options were discussed. All the twenty households selected the lined Mozambique latrine type.


The table below shows the commitments of the households and the subsidies received from the project.

Table 4: Household Commitments to Latrine Project Household Commitment

Subsidies provided by the project for each household

Excavation of pit

6 bags of cement


3 pieces of iron rods


3 pieces of iron sheets

Blocks for the super structure

Artisan fee of GH¢60.00 (~ US$42.00)

Door and door frame Wood for roofing Unskilled labor to assist the artisan

Most of the households could not dig the pits themselves and had to employ the services of other community members for a fee. While we anticipated a timeframe of one month for completion, it ended up taking six (6) months to complete the latrines. The delay was primarily due to the householdâ&#x20AC;&#x2DC;s inability to provide their parts of the commitment on time as well as enormous difficulties encountered in breaking the rocks in the pit during the excavation. It was also difficult to find artisans in the area, so we had to import artisans from Koforidua, a city about an hour from Agyementi.


Apart from the twenty household latrines subsidized by the project, one additional latrine has been completed by a household while two other household latrines are at various stages of completion. The number of existing household latrines in the community before the intervention was six (6). This brings the total number of completed latrines in the community to twenty seven (27). Some households provided seats on their latrines since squatting was a problem to some household members especially the aged. Beneficiaries reached with safe sanitation (latrines) total 290 people. This represents about 50% percent of the population. Project ACWA is still supporting and providing technical support to all households to assist them in constructing a VIP latrine, and is working with the WATSANC at local solutions to achieve 0% open defecation by the end of 2010. Image 6: Ventilated Improved Pit Latrine

Source: Water AID Ghana


The ventilated improved pit latrine was introduced in Africa in the 1970s and has proved successful in rural areas in overcoming problems with flies and odors. Its essential features are illustrated in the diagram below: Image 7: VIP Latrine Structure

Source : Water AID

The interior of the superstructure is darker than the daylight outside and the superstructure building is well ventilated so as to allow the flow of air into the pit. The pit has a vent pipe which is at least 100mm in diameter and extends from the pit to about 1 meter above the roof, and the top of it is fitted with a fly-screen. Flies which are drawn by smell into the pit will be attracted up the vent pipe by 65

the brightness of daylight at the top it, but cannot escape because of the screen. Wind passing over the vent pipe will cause an updraught, removing any smell and helping to draw flies up to the top of the pipe.54 The diagram below illustrates how the VIP latrine works: Image 8 : How the VIP Latrine Works


Brandberg B (1997) Latrine Building, IT Publications


User Education As soon as the latrines were completed the various households were educated on how to use and maintain the latrines to ensure that it lasts longer and to prevent illness. The guidelines given to community members included the following directives: 

Wash the latrine seat and floor regularly

Always ensure that the vent pipe is exposed to sunlight

Check the fly screen regularly and repair it if needed.

Check erosion around the latrine

Always put the anal cleansing materials in the latrine pit

Do not pour wastewater into the pit as it will fill up the pit quickly

Do not put empty bottles, cans and stones into the pit

Teach children how to use the latrine

Hygiene Education Hygiene education is an important component of water and sanitation projects as it maximizes the potential benefits of improved water supply and sanitation facilities. It also helps users to appreciate the need for their proper operation and maintenance and creates a willingness to contribute to their costs. It is not just sufficient to construct improved water supply and sanitation facilities. Technical and behavioral changes must go hand in hand in order to maximize the benefits of improved water supply and sanitation. Technical developments or 67

improvements will give maximum benefit only if they are part of a wider hygiene education program. This may involve the changing of long held attitudes and practices and may well take considerably longer to achieve than the actual construction of the scheme. Hygiene education must be a community activity so that everyone goes forward together without any group being left behind and so the team planned community-wide hygiene programs. In many Ghanaian communities, women are the ones who are primarily responsible for the health of the family, and so the education concentrated on empowering them. However, we observed that it is also the case that the children are the easiest to educate regarding the benefits of hygiene education, and they in turn can insist on changes being made within the family unit, so we also planned educational campaigns for the classrooms. The focal areas of hygiene promotion in Agyementi included training the community members on the following key areas: 

Disposal of Fecal Matter o Proper disposal of feces o Promotion and construction of latrines o Proper use and maintenance of latrines o Proper hygiene after defecation

Hand washing and food handling o Hand washing with soap and water 

After use of toilet

After cleaning a baby 68

 

Before handling food

Safe water o Sources of safe and unsafe water o Keeping sources of water clean and safe o Keeping water safe during transportation from the source to home o Keeping water safe at home o Proper use of water and maintenance of water facilities

Water-borne, water related and excreta related diseases o Types of water and sanitation related diseases o Prevention of the diseases

Environmental Cleanliness o Importance of the environment o Methods of refuse disposal o Management of waste from latrines and bathrooms

Training Of Community Hygiene Volunteers Every WATSANC has two (2) focal persons who lead the promotion of safe hygiene practices in the community. The community selected them during the formation of the WATSANC. Considering the complexity and critical nature of behavioral change in communities, we decided that all the WATSANC members should participate in the hygiene promoters‘ training sessions instead of training only two hygiene focal persons. This was to ensure that all the WATSANC members have the skills to assist the hygiene focal persons to educate and promote safe hygiene practices in the community. In all, ten (10) participants participated in the training workshop comprising seven (7) 69

WATSANC members and three (3) opinion leaders which covered the following key topics: 

Definition of Health And Hygiene

The Responsibility of Hygiene Promoters

Water Management

Water storage, transport and use

Sources of pollution and prevention

Pump site cleaning

Common diseases related to water and sanitation related diseases


Open defecation and its effects

F-Diagram (fecal oral transmission route)

Sanitation Ladder

Household latrine promotion and construction

Eco sanitation

Waste water disposal (Construction of soak-aways)

Refuse disposal (household/ communal)

Hand washing techniques/ hand washing facilities

Identification of Hygiene High Risk Behaviors and Assigning of Responsibilities to Each WATSAN Committee Member

How to Promote Hygiene at Household And Community Level

Hygiene Action Planning 70

Documentation of Hygiene Activities

Identifying Hygiene High Risk Behaviors After training the hygiene volunteers, we organized a community meeting to identify hygiene high risk behaviors in the community that needed urgent attention. To introduce this activity to the community, we asked a question that if someone in the community traveled to one of the neighboring communities, what indicators would show whether the community was unhygienic or hygienic? Through open discussions the following were mentioned as good and bad hygiene practices: Unhygienic community 

Weedy compounds

Indiscriminate open defecation

Children‘s feces are left unattended to

They drink contaminated water

The surroundings have many flies

They cook in filthy environments

Children do not wear sandals or slippers

There are no soak-aways in the bathhouses resulting in stagnant water

They wear dirty clothes

They do not wash their hands properly before they eat

They do not cover their water storage receptacles

Most inhabitants look unhealthy

Conversely they cited the following characteristics of a hygienic community: 71

The compounds are kept clear of weeds and rubbish

They have well-maintained latrines

There are no flies

Children and adults wear decent dresses and have foot wear

They cover their water storage containers

They drink clean, safe water

They cook in a clean environment

There are soak-aways constructed behind their bathhouses to drain away the water

The inhabitants are healthy

A follow up question was: What could account for this situation in that community? The responses by the community members varied but included the following: 

They are not civilized

There is a breakdown of leadership command

There are no bye laws in the community

They are not united

They do not organize communal labor

No dedicated group to take lead role in community development

There is apathy

The community is lazy

They lack education 72

Similarly, they were also asked to account for a hygienic community and they described such a community as follows: 

They are civilized

There is a strong community leadership command

Bye laws exist and are respected

They are united

They attend meetings and employ communal labor

They are hard working people

They are enlightened

We then asked the community members to conduct a transect walk within the community. We asked the community members to observe good hygiene practices, bad hygiene practices and the changes they would want to see based on their findings. The facilitators and the entire community members embarked on the walk through the community compounds, backyards of households‘ latrine sites, refuse dumping areas and homes. Thereafter, the whole group converged at the meeting ground to discuss the findings. Below was the outcome of the exercise: Good hygiene practices observed 

Neat household compound

Drinking water storage containers covered

Clean kitchens

Children wear footwear and nice dresses


Bad hygiene practices observed 

Weedy household backyards

Uncontrolled waste water from bathhouses

Indiscriminate open defecation

Uncontrolled households and communal refuse

Traditional latrines were exposed to animals and rodents

Communal latrine in bad conditions as the latrine is full-up and not clean; anal cleansing materials were scattered all over.

Strong offensive odor especially near the communal latrine

Lots of flies

Spaces in between houses were weedy

Water for other uses were not covered

Households admitted that they did not practice washing of hands with soap before eating and after visiting the toilet, however they did wash their hands with soap after eating.

Thereafter, the community members were asked to compare the first scenario from the neighboring community to their own community. They realized that their situation was even worse than that of the community used in the case study. The whole community was shocked about the outcome of this exercise. Voices from community members after the exercise included: 

―I now know my community better‖

―I feel ashamed‖ 74

―Why didn‘t we realize this situation until now?‖

―So, what should we do?‖

―I am lucky to be part of today‘s meeting‖

The community was then asked to prioritize the bad hygiene practices identified that would require prompt action. The first four hygiene high risk behaviors chosen by the community for action were: 

Cleaning and burning of all refuse in the community

Weeding of bushes in between houses

Covering all traditional latrines that were exposed to animals and rodents

Building household latrines in all households

They gave themselves six months to accomplish these tasks.

Households and Community hygiene sessions Community hygiene volunteers and health professionals conducted hygiene sessions in all the houses in the community and at a community forum. The hygiene education and promotion were related to the hygiene high risk behaviors identified for positive change. The initial hygiene messages promoted at the household level included: 

Washing hands with soap before eating and after visiting the toilet or after returning from funerals, the market, or the farm.

Providing hand washing facilities at home

Constructing soak-aways behind bathhouses


Managing the storage and transportation of water to ensure that the water doesn‘t get contaminated

Constructing household latrines

Managing household refuse

For the exercise, we used a number of participatory tools including: 

F-Diagram – for oral fecal transmission route

Three pile sorting cards for assessing their knowledge on safe hygiene practices

Sanitation ladder- to promote latrine construction

In all, 257 out of 450 people in 38 households were reached with safe hygiene messages in the first phase of the educational campaign, representing 57.1% of the population. The campaign is on-going and seeks to train 100% of the households in safe hygienic practices by the end of 2010.


Chapter 5: Findings and Analyses This study moved away from conventional assessments where project impacts are evaluated mainly in terms of mechanical measures of inputs and outputs. Instead, it situated projects within the social context of the community, and measured impact using largely qualitative methods supported by some quantitative means. Rather than just report the changes as reflected by figures and statistics, it calls in community members like Olivia Ottopah who is interviewed in the video documentary. Her voice and other ordinary community members whose tales of relief from suffering and anecdotes of increased personal empowerment provide a greater sense and meaning to the concept of impact than the ―number of latrines built‖ or ―percentage served by hand-dug wells‖ can communicate. Instead of just making deductive conclusions from the empirical evidence collected, it attempts to capture the complex reality in impoverished villages along with the drama of people‘s daily struggles. An evaluation team was established to identify broad ‗domains of change‘ such as health, socio-economic status, gender relations, education, environmental conditions, community management and support services for community organizations. A nearby ‗control‘ community (i.e. where no project intervention had taken place) Kitase was chosen. Facilitated by the evaluation team, the communities themselves also generated their own impact indicators. This in itself revealed the key ways in which water and sanitation projects had affected and changed their daily lives. 77

These impact indicators, which covered the breadth and depth of community life, show how the impact of the projects turn out to be further reaching than the initial project objectives. The evaluation study was a two-way learning opportunity for both the communities and the study teams. It raised the challenge of how the formal social science skills of ‗outsiders‘ and the traditional community knowledge of ‗insiders‘ can be blended together for the mutual learning advantage of both. The research also provided opportunities for increased dialogue and improved collaboration between development partners. The study provides a valuable insight into the benefits and challenges that water and sanitation interventions bring to communities. Objectives and Intended Outputs The overall objective of the evaluation was to analyze the quantitative and qualitative benefits of the ACWA project and provide learning opportunities on the challenges of development and the broader impact of social and economic transformations of the interventions tested. The objectives of evaluating the ACWA project were as follows. 

To assess the impact of the project on Agyementi in the areas of health, socio-economic status, education, and gender relations

To identify and examine the project implementation strategies, identifying the major success factors and key challenges of the project

To make recommendations for possible replication 78

Description of Evaluation Team Apart from our internal evaluation, the Project ACWA team also commissioned an independent evaluation team made up of four key persons with experience in water and sanitation. Their skills and experience ranged from public health, engineering, social and community development, project monitoring and evaluation, and communication skills in terms of ability to facilitate group discussions, interviews and organization of the activities of the team. The team had a leader to facilitate the exercises. The roles and responsibilities of the evaluation were shared amongst the team. The team members were also given an orientation by ACDEP, the Project ACWA Team and the District Assembly before the exercise commenced.

Evaluation Schedule

The exercise took part in three stages. In the first phase, we constituted and prepared our evaluation team. During this preparatory stage, we studied all the documentations of the projects and conducted briefings with all the members of the implementation team. We then developed a set of questionnaires and tested for identified target groups. We spent a week on the first phase. The second stage involved the actual information gathering for the evaluation. The Project ACWA team collected data over a period of a year to allow for seasonal variations, whereas the independent evaluation team took five days of intensive field work to compile their report. The final stage was the preparation of a joint evaluation report. 79

Sampling strategies We planned to cover a large population of the community via more segments and target groups. We agreed with the community to adopt purposeful sampling. First, the team met with the community opinion leaders to identify and agree on target groups for the exercise. In all, we agreed on seven target groups namely Men, Women, Water and Sanitation Committee (WATSANC) members, Children, Household Latrine Beneficiaries, Key Opinion Leaders, and the Youth. With the target groups in mind, we agreed on specific participatory tools and methods for each of the groups taking into consideration many factors, including the number of people in each focus group, their estimated time commitment, their level of involvement in the project, and their literacy levels as well.

Methods and Tools Used for Investigation and Analysis

We used impact assessments to evaluate the various responses and programs which have been implemented in Project ACWA. They test the assumption that Project ACWA leads to â&#x20AC;&#x2014;sustainable improvementsâ&#x20AC;&#x2DC; in peopleâ&#x20AC;&#x2DC;s lives in Agyementi. But there are many methodological issues involved in making these assessments, which mainly deal with problems about validity (or the truthfulness of claims being made) and reliability (whether observations of a particular impact will be seen similarly by different observers). Validity is improved by quantification and measurement; for instance by showing figures on the incidence of diarrheal diseases before and after the implementation of a water 80

and sanitation project. But quantitative approaches are rather narrow measures of impact; for example, they are not likely to show how the household latrine built in Margaret Akuffo‘s house will have changed relationships within her family, or how the quality of Margaret‘s relationship with her children has improved as a result of water becoming more readily accessible. Yet the qualitative approach also has its flaws as it has the tendency towards being ‗anecdotal‘ in the use of data and of being subjective in its analysis. Hence, reliability problems are raised. Therefore, this study adopts a mixture of both quantitative and qualitative approaches. Baseline data was collected and analyzed where available. Data collection was strengthened in two ways: a) by study teams relying on community recall to understand the nature and extent of change using participatory tools such as force field analysis; and b) by having a control community (in this case Kitase) to provide an indirect means by which impact could be assessed. Establishing causation within a social development context is very difficult and therefore the study teams decided not to attempt to prove it precisely. Instead the study relied on the qualitative information collected from interviews, observations, and participatory rural appraisal (PRA) techniques to ascertain whether the community attributed the key changes to project interventions or other causes, and to disaggregate developments in a community according to different agency interventions. The key component of the study was that the community participants undertook complex analytical tasks to arrive at their own conceptualization of impact. 81

Finally, to improve the overall reliability and validity of the data collection process, we employed a number of methods. Field pre-tests were made after the study teams‘ orientation workshops in order to inform team members on the methodologies. Triangulation was applied to the data (crosschecking information gathered, using one method, with information collected from alternative sources, including the use of secondary data from government agencies and schools when available). Key informant interviews were tape-recorded to minimize observer bias in simple note taking. The teams had multidisciplinary backgrounds, and at the end of each piece of fieldwork, findings were shared with the community so that other community members could express their opinions or challenge the interim results. In line with this, a large variety of methods and instruments, which help to encourage participation of target groups were employed and these included: 

Community walk

Direct Observation


Structured and semi-structured interviewing/Informal interviews

Focus Group Discussions

Participatory programming

Project Activities and Schedule

We undertook a series of activities to implement the project and the information gathered from interviews with WATSANC and FGD revealed that 82

the project followed through with the planned activities for each component of the project i.e. community mobilization, water supply, sanitation intervention, and hygiene education. Community members reported that there was scheduled time for specific activities though some overlapped and ran concurrent. Through FGD with men and women, it was revealed that there were clear roles and responsibilities for each of the key stakeholders involved in the execution of the project. These stakeholders included the community itself, the project sponsors, the Akuapem South Municipal Assembly and ACDEP. Project ACWA had one year duration for fixed outputs and expected results. However, there were different scheduled durations for community mobilization, water provision, household latrine provision, and hygiene education components of the project. Project Implementation Approaches The approaches used for the implementation of the project were thoroughly assessed. A wide range of strategies and approaches adopted aimed at encouraging active participation by stakeholders involved to ensure ownership and sustainability of the ACWA project. These included extensive consultations and collaborative meetings; community contributions; and building local level capacities for maintenance and management of water and sanitation facilities.

Effectiveness of Implementation Approaches The project promoted active grassroots participation and heightened awareness at the planning stages during community entry processes. In addition, 83

the community members, particularly household beneficiaries, were highly involved in the construction of water and latrine facilities. The “Trigger” Method One of the most effective implementation strategies employed was the ―trigger‖ method that aimed to empower community members with information about the dangers of lack of access to clean water and adequate sanitation. The team employed this strategy in a number of different ways. For example, we visited some households and told them about the high levels of Ecoli detected in the spring water and explained the F-diagram to them, showing how the contaminated water and the practice of open defecation contributed to diarrhea and other water-borne diseases in the community. We were not getting responses of shock or alarm as we would have expected. This forced us to change our strategy. We then started going to the households with E-colilert tubes and explaining to them that these tubes contained food for bacteria. If we put water in the tubes, and there are bacteria in the water, the bacteria will eat the food, and grow and the water will change color. They were intrigued by this experiment and agreed to participate. We initially just gave them one tube with the spring water in it. However, when we visited one of the households, a woman challenged our experiment. This woman, who had ―formal‖ education only up to 6th grade, queried us ―How do I know that this change in color wouldn‘t occur with all kinds of water or that you haven‘t put coloring substance in the tube?‖ We were shocked, and responded by adding a control tube with the borehole water. We asked all the households to 84

sleep with the tubes to provide some warmth since bacteria needs warm environments to grow. The next morning, we visited all the households, and as we expected, the test tubes containing water from the spring all turned yellow, whereas there was no color change in the test tubes containing the borehole water. The community members were repulsed by this. Some were ashamed to show us the tubes because they were now faced with the truth that they had been giving ―bad water‖ to their children. Seeing the benefits of this ―trigger‖ approach, we also employed the same method to demonstrate to the community how clean water from the borehole can be contaminated if stored in a dirty receptacle. In one household in particular, the man was so enraged by the results of the test that he called his wife and children and scolded them and forbade them from using the spring water. He then asked them to take out all their water receptacles and made them wash them with soap in front of us. We were encouraged by this reaction. We also used the trigger method in our latrine sensitization program.55 Project Outputs The planned outputs for the projects included construction of one borehole, construction of 20 household Ventilated Improved Pit (VIP) latrines, and community and household hygiene education for the people of Agyementi. Through community walks, discussions, and reviews of available records, the


See page 60


evaluation team observed that the ACWA project has achieved the above mentioned water and sanitation outputs within the stipulated time period.

Mobilization and Social Intermediation Process

The water and sanitation project commenced with mobilization and animation processes which entailed creating awareness, encouraging active participation of end users or beneficiaries, and building a sense of ownership and management of facilities to be provided. In meeting these standards, the ACWA project set on key indicators for smooth implementation and also built in sustainable factors. Almost all key stakeholders at the national, district, local government and community levels were involved in the project planning stage through consultative meetings by discussing and incorporating vital inputs to ensure that the project meets desirable results. ď&#x201A;ˇ

National Level

At the national level engagement, the Director of Water at the Ministry of Water Resources, Works and Housing as well as international Non-Governmental Organizations (NGOs) including Water Aid Ghana and the World Health Organization, were consulted for policy guidance and direction. Lessons learned by the project team informed the decision on selecting Agyementi as the beneficiary community in Ghana. ď&#x201A;ˇ

Regional and District levels

The regional and district level consultations were more intensive than the national ones. It brought together experiences from Community Water and 86

Sanitation Agency (CWSA), Akuapem South Municipal Assembly and Local NGOs in water and sanitation, particularly Akuapem Community Development Program (ACDEP) to ensure effective implementation by adopting appropriate and tested approaches, and coming up with innovative alternatives to approaches that had not worked. ACDEP became the main partner for the implementation of ACWA project. The inclusion of the District Assembly (DA) was purposely for supporting implementation, monitoring and evaluation of the project. 

Community Level

Through FGDs with youth, men and women, it was established that over 90 percent of the community not only knew about the objectives of the ACWA project but were also involved in the discussions on the project outputs during the community entry processes. The level of awareness of the project was manifested in the high understanding for project deliverables and lucidity of roles and responsibilities of stakeholders particularly that of the community and the project sponsors. The community entry and mobilization phase produced certain outputs including 

Baseline information on water and sanitation facilities and hygiene situation; demographic facts; socio-economic activities; and local institutional management structures.

Formation of WATSANC to implement, manage and sustain the project

Capacity building for the WATSANC based on the needs assessed.

Selection and training of hygiene education volunteers 87

Establishment of Community Level Management Structure As part of measures to ensure effective management of the water and sanitation facilities, the community members confirmed that WATSANC was formed to oversee and sustain the project. Indeed, there was gender equity within WATSANC, which was democratically formed with membership of seven (7). In addition to the high representation of four (4) women, women also occupied executive positions such as Chairperson and Treasurer. WATSANC Performance FGD with the WATSANC showed that the WATSANC is aware and understands the functions expected to perform but inadequate support from the community leadership was weakening its strength and high spirits of voluntarism. The WATSANC members discussed the issue of enforcement with the team. They intended to ask the chief to establish bye-laws through which sanctions would be applied appropriately to serve as deterrence to community members who flout the rules. We discussed options of using reward-based or punishment based systems to stimulate cooperation. Voluntary punishments and rewards are the mechanisms used in the economic model of ―carrot or stick‖ to stimulate cooperation. As Andreoni, et al. discovered in their research, ―understanding what triggers the demands for each [reward and punishment] and their effectiveness may help us understand informal relations and to design institutions that can harness cooperation and improve social welfare.‖ 56 Andreoni, et al. considered 56

James Andreoni, William Harbaugh and Lise Vesterlund (2003), ―The Carrot or the Stick: Rewards, Punishments, and Cooperation,‖ The American Economic Review 93(3): 893-894


four conditions – punish or reward, reward only, punish only, and neither – and attempted to identity the effect each has separately and jointly. They discovered that rewards alone are relatively ineffective in moving the modal offer away from the most selfish one possible. Second, punishments improved cooperation by eliminating extremely selfish offers. Combining rewards and punishments had a very strong effect. While acknowledging that more work needs to be done, they concluded that ―cooperation…is most successfully enforced in an environment in which both punishments and rewards are available. The process suggested by our data is that the stick can help by getting people to move away from perfect selfishness and to test the waters of cooperation. The carrot can then take over by encouraging further cooperation, rendering the stick a rarely used but necessary tool.‖57 On the basis of these findings, the team has recommended a system that incorporates both rewards and punishment. This could take the form of a system where every member of the community contributes $1 every quarter for example (assuming a quarterly contribution of $0.25 per community member is needed for O&M). All community members who meet spelled out guidelines (for example, participating in cleaning the IRP, maintaining clean surroundings, etc.) would receive $0.75 back at the end of the quarter. More research is needed to determine the system that would work best in Agyementi.


James Andreoni, William Harbaugh and Lise Vesterlund (2003), ―The Carrot or the Stick: Rewards, Punishments, and Cooperation,‖ The American Economic Review 93(3): 901


Facility Management System For the management system of the water facility, we instituted measures in place to control and maintain the facility. These include the training of a pump caretaker within the community coupled with the agreed upon mobilization of monthly water levies per adult. In addition, the community through WATSANC is linked to the Area Mechanics in the district by the Municipal Water and Sanitation Team (MWST) to assist the community when any technical faults on the borehole facility arise that are beyond the ability of the trained pump caretakers in the community. Practically speaking, fundraising activities need to be strengthened to raise adequate funds for the operation and maintenance of the water facility.

Water Supply On water supply, the specific outputs achieved included hydro-geological survey; installation of a drilled borehole with hand-pump; and water quality tests. Interaction with the cross section of the community coupled with observation during evaluation period confirmed that the borehole facility provides clean and safe water to the entire community especially during the dry season. The community assessed the most important impact of the provision of the borehole against a number of impact indicators they identified including increased access to clean water; reduced distance and saved time for accessing safe water; increased sleeping time for children; increased punctuality for school attending


children; and reduced prevalence of water-borne and water-related diseases. The result from this assessment is represented in the pie chart below. Chart 3: Community Assessment of Borehole Impact

IRP Challenges The borehole has good yield but the results of water quality test confirmed the presence of high iron content in the water making it undesirable for drinking and for use in other domestic chores. As a result, an Iron Removal Plant (IRP) was constructed close to the borehole. This was an additional unplanned output which was done to achieve the objective of providing access to clean, safe water for the people of Agyementi. The borehole facility is conformed to approved standard with high yield. The IRP has reduced the iron content level to minimum acceptable levels for consumption as mandated by the WHO. As part of strategies to ensure maintenance of the water facilities, some critical measures were put in place for the water facility management. First was 91

the identification and training of pump caretakers on preventive maintenance. These pump caretakers have also been tasked with ensuring the regular cleaning of the IRP. The IRP has to be cleaned bi-weekly to prevent the iron ore to form clots and therefore block the flow of the water from one chamber to another. However, the community complained that the cleaning process of IRP is tedious work. In fact, the community was not cleaning the IRP per stipulated maintenance guidelines. Initially, one member of the community, popularly called ―Rasta Man‖ who happens to live literally right next to the borehole took it upon himself to clean the IRP. However, he stopped doing this because ―no one is paying me, and the community is not helping.‖ This resulted in the IRP getting choked up resulting in poor water flow. The community has recognized this problem and has acknowledged the need to clean the IRP since it benefits everyone. Yet, no one wants to assume responsibility for cleaning it.

Household Latrine Program

The team inspected twenty (20) VIP latrines. All were completed and are being used. The principle of cost sharing was adopted and agreed to by the entire community. For this strategy, each beneficiary agreed to assume certain responsibilities towards the construction of the household latrine. The beneficiary households were responsible for the provision of blocks, sand, stone, wood, and the latrine door, and the excavation of the latrine pit. Project ACWA supported the beneficiary households with cement, iron sheets, PVC Vent pipes, iron rods, screen nets and assumed the cost of the latrine artisan fees. 92

The household latrines constructed conformed to national approved standards making them safe for use. The latrines have good superstructures to ensure adequate privacy, concrete slabs and a safe floor to stand on, and a drop hole small enough to be safe for children, The household latrine project had a major impact on the community as a whole and the beneficiaries in particular due to the social and health benefits gained. These include access to a safe place to defecate at all times i.e. during rain, sunshine, night and in times of diarrhea attacks; high social classification and prestige; drastic reduction in open defecation practices; reduction of snake bites as well as savings of time and distance to defecate. In fact, it is now considered modern and â&#x20AC;&#x2022;coolâ&#x20AC;&#x2013; to have a household latrine. The various households customized and personalized the latrines. Some households saved up and tiled the floors over time. Others built wall extensions and started to construct bathhouses. For the household latrine project, the beneficiary cost per latrine was estimated to be higher than that of the project support cost but the beneficiaries mobilized resources to construct them. Households contributed as much as $50 in cash, labor and materials (mostly in labor and materials) to construct latrines in their premises. These same households balked at contributing towards the operation and maintenance fund for the borehole. Understanding why this happened could help inform future interventions. I propose two explanations for this observation:


The Public Goods Dilemma The problem of getting individuals in a polity to pay for the costs of goods that will benefit everyone – such as the borehole in this case—is analytically defined in the economist‘s concept of a public good. A public good is defined as a good that is non-divisible; that is, it is available to everyone whether or not they pay for its costs. Since the voluntary contribution of a single individual toward the cost of this good obviously would not make much difference, and since by definition a public good is available to everyone, there is no rational economic reason for an individual to make a voluntary contribution. 58 Thus, since the borehole is available to the entire community, as opposed to the household latrine, whose use is restricted to the household, the public goods model offers an explanation for the unwillingness of the community members to contribute towards the borehole, yet their enthusiastic willingness to pay for a household latrine. How do we address this problem? Bolnick suggests that we can tackle the public goods problem with community development leaders, arguing that ―community development workers can serve as foci for the development of new leaders, since they themselves will generally be accorded high status due to their expertise and position. In all, the rewards of leadership, highlighted by role expectations and perhaps some prodding, can induce organized activity necessary


David O‘Brien, ―The Public Goods Dilemma and the Apathy of the Poor toward Neighborhood Organization,‖ The Social Service Review 48(2): 236


for the success of voluntary collective action.‖ 59 Bolnick further argues that community leaders, by virtue of their high status in the community have channels for influencing the decision calculus of the rest of the community in favor of active participation in self-help activities. These channels of influence are enhanced if the leaders urging contributions have face-to-face contact with all members of the community. In sum, leaders can influence behavior, and their ability to affect the decision calculus of their followers depends on their status and the amount and quality of communication, as well as the characteristics of the community itself.60 Bolnick‘s findings make the case for the involvement of the traditional rulers (Nana Takyi and the Council of Elders) in ensuring that the community supports the maintenance of the borehole facility with the same energy with which they have supported the household latrine program. The “Trigger” Approach An alternative explanation could be that households felt more strongly about the household latrines largely owing to the success of the trigger approach which employed the slogan ―yedi yen bin‖ (we are eating our own shit). This suggests that using culturally relevant approaches to ―trigger‖ or ―shock‖ the community into action could result in greater willingness to contribute financially and otherwise on the part of the community members.


Bruce Bolnick, ―Collective Goods Provision through Community Development,‖ Economic Development and Cultural Change 25 (1): 140 60 Neisser Charlotte (1955) , ―Community Development and Mass Education in British Nigeria,‖ Economic Development and Cultural Change 3: 353-65


Hygiene Education We facilitated a number of hygiene education sessions at both the community and household levels based on our hygiene assessments of Agyementi. FGD with WATSANC revealed that the community was assisted to identify and prioritize high risk hygiene-related practices. In addition, the hygiene volunteers were selected and their needs were assessed which served as a guide in tailoring their sanitation and hygiene training. Hygiene education at the community level concentrated on environmental cleanliness while household sessions targeted those with latrines and educated them on proper use and maintenance of their latrine facilities. Household level hygiene education focused on proper use and maintenance of latrine, and was very effective. It was observed that 100% of the latrines constructed are being used properly and well maintained because they were all very clean, reasonably free from smell, with anal cleansing materials kept inside the pit, and the surroundings free from weeds. The data collected on hand washing was disappointing. Only 25% of households in Agyementi had hand washing facilities close to their latrines while 75% had no permanent hand washing facilities but claimed they washed their hands inside the house. Similarly, the community scored unsatisfactory marks in environmental cleanliness as the surroundings were weedy and full of rubbish. Community members cited lack of a designated place for communal refuse disposal as the key reason for the refuse problem, and this was confirmed by the WATSANC. 96

Follow up Mechanisms Monitoring is a crucial process for the success and quality service delivery of every project by ensuring that activities are implemented as planned. Similarly, Project ACWA recognized the need for monitoring mechanisms at two levels: external and community level. For the external monitoring, through interviews with the Community Water and Sanitation Agency (CWSA) and Municipal Water and Sanitation Team (MWST) it was clear that those agencies were aware of their roles to undertake periodic follow ups on the project. Their involvement is intended to provide support to the WATSANC and the community as a whole in the post implementation period. Our investigations revealed that monitoring forums have already been developed by the above mentioned agencies to support this course. We learned, however, that the number of planned follow up visits by these agencies is usually not achieved due to limited resources to undertake this exercise. At the community level, WATSANC capacity was built to undertake regular monitoring on the use of improved water facilities, household latrines and environmental cleanliness including adoption of safe hygiene practices. The WATSANC has agreed to meet once a month to discuss progress on the work, challenges and actions to be taken to address the identified challenges. To this effect, roles are shared among the members of WATSANC. According to the community members, it was also agreed that general meetings would be organized monthly by WATSANC to discuss water and hygiene issues of 97

concern. However, interaction with WATSANC members and analysis of records of minutes of WATSANC meetings confirmed that the committee was not meeting as often as it should. We expect that when WATSANC improves its performance, the community level monitoring will be effective. We also expect that the MWST will provide more support visits to the community for the project to prolong its benefits and success. Summary of Impact of Project ACWA on the people of Agyementi The following summaries bring together the research findings within the different themes or ‗domains of change‘ in the lives of members of the Agyementi community. Enhanced livelihoods and incomes The impact that projects have on communities which previously did not have potable water supply or sanitation facilities are quite broad as illustrated by the summary table. However, the community members themselves best describe the real meaning and relevance of these changes. Rebecca Agyeman, for instance, was widowed ten years ago and has since been the family‘s breadwinner: ―I have to go to the farm every day and in addition, I am responsible for carrying out household activities. In the past, I used to spend sometimes up to five hours a day to fetch water. Since you put in the borehole, my life has somehow become easier. I now have more time, and can do other activities. I can now cook food to sell in the community to earn some extra income.‖61 As a result of Project ACWA,


Interview with Rebecca Agyeman, Community Member, Agyementi, Ghana, 09/14/2009


Rebecca can now spend more time on her farm and can now sell banku in the community - activities which will boost her income levels and help reduce her poverty.62 Margaret Brown added that, â&#x20AC;&#x2022;Since 2008, when the borehole was put in place, I have realized that my children do not get sick as often as they used to. Before they used to drink water from the contaminated spring and they would always get diarrhea, boils and other sicknesses. Nowadays, we only drink borehole water in my house, and we no longer suffer from these diseases.â&#x20AC;&#x2013;63 For Yaw Obroni, access to safe, clean water has aided his local business of distilling Akpeteshie, a local alcoholic drink.64 Beneficial shifts in socio-cultural norms Equally important are the changes brought about in the socio-cultural life of villagers. The research participants in Agyementi measured the introduction of water points in terms of improvements in the quality of their family life. The Saahene (warrior chief) of Agyementi reported that women no longer needed to wake up as early as 4am to go fetch water. This allows for more bonding time between husbands and wives. More attention can be given to domestic duties and children are also able to spend more time with their families.65 The time saved is obviously reallocated to other activities. Farmers are able to spend more times on their farms, masons are able to spend more time being productive and working on jobs, and students have more time to learn. 62

Bank is a local dish made from maize and eaten with soup Interview with Margaret Brown, Community Member, Agyementi, Ghana, 09/15/2009 64 Interview with Yaw Obroni, Community Member, Agyementi, Ghana, 09/14/2009. 65 Interview with Saahene, Elder of the Community, Agyementi, Ghana, 09/15/2009. 63


Communities find more time to interact with each other, participating in funerals, marriage ceremonies and other social activities. Improved health and hygiene Communities have experienced a significant reduction in diarrhea and other water and sanitation related diseases. Community members reported a drastic reduction in diarrhea, bilharzia, scabies, boils and yaws.66 Women‘s personal hygiene, especially during their menstrual period, improved dramatically as they are now able to bathe more regularly. Diana Obeng adds, ―Water presence near our homes has improved our menstrual hygiene and made us feel secure even in front of others.‖67 Pregnancy and childbirth are also critical times for women‘s health. Adequate water supplies have improved the task of traditional births. Children in Agyementi no longer need to walk through the bush in the early morning to fetch water, which had previously led to numerous cases of snakebites. The school children reported feeling healthier and experiencing ―less stomach pains and toilet runs.‖ This is in contrast to the control community of Kitase where the results indicated that the children were in poor health and continued to suffer from diarrhea and other water and sanitation related diseases. The contrast in general household and personal cleanliness was not as clearly demonstrated. Agyementi still has problems with indiscrimate dumping of refuse and untidy surroundings which needs to be tackled.

66 67

Number of diarrhea cases in households with latrines dropped by 40% Interview with Diana Obeng, Community Member, Agyementi, Ghana, 09/16/2009.


Psychological impact: Diminished anxiety and heightened self-esteem Another critical concern of community participants in the research was the psychological impacts. When the women travelled long distances fetching water, stress and anxiety were high for the whole community. In Agyementi, the children were exposed to snake attacks. This is still seen today in the control community of Kitase. On the other hand, a sense of pride and self-esteem is consolidated with the building of the borehole and the household latrines. In Ghana, where receiving visitors with hospitality is socially important, people in Agyementi can now offer potable water to their guests and can now also offer private KVIPs for guests to use. When the team first visited Agyementi in 2007, and one member of the team wanted to urinate, he had to go into the bushes. In 2009, the team was able to use one of the KVIPs installed. Improved Access to Education The impact on education was reflected most clearly in the results of the focus group discussion with school children in Agyementi. Whereas previously, over 50% of school girls were often late to school or would miss several days because they are needed to help their families in fetching water, today over 90% of the girls are able to attend school on time.68 Gender Equity and Changes in Social Mores In Agyementi, there was some indicative evidence suggesting changes in gender roles. With the WATSANC formation for example, the community took the unprecedented step of electing four women out of the total membership of 68

Information from school records and interview with Head of School, Agyementi, Ghana, 09/17/2009.


seven, and electing women as the Chairperson and Treasurer of the Committee. This is very unusual in many traditional societies in Ghana. In addition, when the male caretaker of the pump was failing to attend meetings, the women took the unusual step in sacking him from the WATSANC and lobbying to replace him with a female leader, Margaret Kyiri. Pump caretaker is a position that has traditionally been assigned to men so it was interesting to see how women were empowering themselves to tackle issues of water and sanitation which affect them most directly. The women on the WATSANC reported that their leadership roles have developed their confidence and they are hoping to leverage their experience from this committee to organize themselves in other areas of concern, such as finding micro loans to grow their businesses for example. Some of the sociology literature has predicted that increasing the involvement of women in user committees will improve the management of collectively owned natural resources because women‘s social networks provide them with prior experience with collective action.69 In addition, since women are major users of these goods, women‘s involvement in creating the rules may be especially important for compliance.70 However, as Kremer has documented, ―the evidence on the impact of women‘s involvement in public goods management is limited. It is difficult to determine whether the inclusion of women causes a particular outcome to occur, whether the fact that an outcome occurs encourages the participation and inclusion of women, or whether some other factors are 69

B. Agarwal (2000), "Conceptualizing Environmental Collective Action: Why Gender Matters." Cambridge Journal of Economics 24 (3): 283–310. 70 M. Zwarteveen and R. Meizen-Dick (2001), ―Gender and Property-Rights in the Commons: Examples of Water Rights in South Asia,‖ Agriculture and Human Values 18 (1): 11–25.


driving these results. This problem affects both retrospective analyses and case studies, neither of which is able to establish a causal relationship between women‘s participation and observed outcomes.‖71 Chattopadhyay and Duflo identify a causal relationship between women‘s participation and project outcomes in their study of a randomized policy change in India that increased the role of women in policy decision making. They show that village councils headed by women were more likely to invest in public infrastructure for drinking water, and, more generally, that councils dominated by one gender were more likely to invest in goods important to that gender.72 Their findings are consistent with the experience in Agyementi: the old water committee composed of old men failed, whereas the new WATSANC with its unprecedented representation of women and female leadership has been largely successful in managing the water and sanitation facilities and overseeing the public health campaign. Community management and sustainability Project ACWA employed the standard model for maintaining donorfunded infrastructure projects by establishing user groups (WATSANC in this case) responsible for maintenance and management. Giving communities direct control or ownership over key project decisions is intended to improve the quality of public services and increase financial sustainability, thus reducing the need for ongoing donor funding or involvement. Kremer argues that there is little convincing empirical evidence, however, that ―local user-committee management 71

Michael Kremer and Alix Zwane (2007), ―What Works in Fighting Diarrheal Diseases in Developing Countries? A Critical Review,‖ World Bank Research Observer. 72 R. Chattopadhyay and Duflo E (2004), ―Women as Policy Makers: Evidence from a Randomized Policy Experiment in India,‖ Econometrica 72 (5): 1409–43.


of local public goods such as improved drinking water sources results in either greater financial sustainability or better quality service than ongoing centralized funding from public budgets.‖73 Kremer concedes that other goals may also be important, for example, ―community-based development may be expected to empower poor people or strengthen local governance.‖74 He notes that collective action problems may be difficult to overcome, and voluntary committees tasked with collecting user fees may be difficult to sustain or empower. The rural water sector is characterized by both significant infectious disease externalities and by weak fundraising capabilities because of weak local institutions. In a recent comprehensive review of community-based development projects, Mansuri and Rao (2004) note that existing research examining ―successful‖ community-based projects does not compare these projects with centralized mechanisms for service delivery or infrastructure maintenance (for example, city or state financed).75 This makes it difficult to determine whether alternative project designs would have had different results. The limited empirical evidence suggests the impact of the communitybased development approach on infrastructure maintenance is mixed at best. In the context of communities like Agyementi, community-based projects are the best option insofar as sustainability is concerned because local and national


Michael Kremer and Alix Zwane (2007), ―What Works in Fighting Diarrheal Diseases in Developing Countries? A Critical Review,‖ World Bank Research Observer. 74 Ibid 75 G. Mansuri and V. Rao (2004), ―Community-Based and -Driven Development: A Critical Review,‖ World Bank Research Observer 19 (1): 1–39.


government simply do not have the capacity or resources for state-financed provision of water and sanitation infrastructure. With proper training and technical assistance from the beginning of the project, the WATSANC management system can function effectively and can be a proven viable for running projects on a sustainable basis. It is important to install follow-up mechanisms and to continually support the WATSANC. Analysis of other WATSANCs in various villages where ACDEP and Water AID Ghana conduct projects revealed that the most effective WATSANCs are the ones with representation of women and with women in leadership positions.


Table 5: Summary of Impact Indicators Impact Indicator


Health and Hygiene 

Sufficient quantity and quality

Incidence of stomach pain

of safe water supply

reduced by 50% in 80% of

Reduced distance to fetch water


Reduced workload for women

Number of households with

reduced by 40% in households


with latrines

Hand washing

Incidence of diarrheal cases

Reduced fatigue for women and children

Distance to fetch water significantly reduced by 300600 meters

Quantities of water for domestic duties increased from 15 liters/per person/day to over 50 liters/per person/day

Number of household latrines increased from 6 to 29 (27 completed and 2 still under construction)


Increased incidence of hand washing after defecation increased from 0% to 25% in 6 months

Increased use of soap for hand washing before handling food

Refuse disposal has not improved

Very little improvement in level of cleanliness of community

Education 

School attendance

Increase in attendance rates of students, especially girls (90% of girls attended school regularly and on time in 200809 school year vs. 50% in 200708)

Improvement in punctuality, especially among girls

Students have more time (average of three hours) for studying


Economic Status 

Time saved

Household income

reduced from an average of six

Opportunity for work

to eight hours per day to twenty

Time spent collecting water

to sixty minutes per day 

More time devoted to agricultural activities

Women potters have improved their trade and increased production

Income of households improved

Housing structures improved

Ability to sell iced water

WATSANC trained in financial literacy

Increase in palm wine tapping

No more quarrels with

Social/ Psychological

neighboring communities 

Over 90% of community members reported strong improvement in pride and


dignity in community 

Improvement in color and general appearance of cooked food

Ability to serve visitors with safe potable drinking water

Improved status of women

More time spent with family

Social/ community interaction increased

Summary of Recommendations For replication of future projects like Project ACWA, I have outlined the following set of recommendations that are rooted in lessons learned in Agyementi: 

Promote active community participation and heightened awareness at all stages of the project including appraising the project, the setting up of a baseline survey from which to measure improvements; establishment of aims and objectives; project design; and setting up a monitoring system.

Incorporate language and cultural practices in project methodology in order to effectively ―trigger‖ the community into action.

Institute a system that incorporates both rewards and punishment to ensure maintenance of facilities.


Involve local government and traditional rulers in project design, implementation and monitoring.

Need to strengthen fundraising activities to raise adequate funds for operation and maintenance of the water facility.

Involve women in all phases of the project since they are the ones largely responsible for water and sanitation in their households.

In future projects, invest in training local latrine artisans within the project community. This promotes transfer of technical knowledge and skills to the community.

Need to support WATSANC beyond one year duration for effective monitoring and management of the project.

Given the importance of government policy in the provision of water and sanitation in Ghana, I also offer the following policy recommendations which if adopted by the Government of Ghana would go a long way towards enabling communities like Agyementi gain access to clean water and sanitation: 

Local government should develop comprehensive monitoring plans to undertake follow up of projects in their jurisdiction in relation to functionality and proper use of the facilities. In addition, they should institute monitoring plans which should include measures to support and sustain adoption of safe hygiene practices.

Government needs to allocate a greater share of the national budget to water and sanitation. With 1% of the national budget currently allocated to water 110

and sanitation, the agencies that deal with water and sanitation are woefully underfunded and are consequently confronted with financial and logistical constraints in fulfilling their mandates. ď&#x201A;ˇ

Government needs to amend the 5% contribution requirement from an upfront cash contribution system to one that allows for a mix of cash labor and in-kind contributions, or a system that taxes the communities proportionally to their income levels.


Conclusion Without Project ACWA, Agyementi would have remained with the 1.1 billion people globally without access to clean water and the 2.6 billion without access to adequate sanitation. The infants in Agyementi would have continued to die from diarrhea, adding to the 2.2 million deaths attributable to diarrhea every year. These hardships are compounded by associated hygiene problems, all of which affect the physical, economic, social and cultural well being of communities. The Project ACWA team listened to the women and men of Agyementi. In doing so, we have heard how water and sanitation projects produce immeasurable benefits far beyond those of reducing disease and the burden of long distance water collection. Time saved was allocated not only to improving livelihoods, but also to spending more time with family and attending to other social obligations. Mental as well as physical health improved, along with school attendance. In addition, the self-esteem of individuals and entire communities was dramatically improved. Economic opportunities for women increased, as did the chance for girls to take part in formal education. The narratives of the members of Agyementi spoke volumes. They showed how community members are capable of assessing the impact of interventions, and provided lessons on the challenges needed to realize changes in sanitation and hygiene behaviors, and on the training schemes that need to be set up alongside infrastructure.


This paper concludes that water supply and sanitation interventions can have significant and positive impacts on peopleâ&#x20AC;&#x2DC;s lives. It provides evidence that improvements in access to water and sanitation should form the cornerstone of any poverty reduction strategy. It also argues that involving community members in assessments of their own projects is essential if the true impacts are to be appreciated and for future projects to reach their full potential. Project ACWA also revealed that communities like Agyementi, more so than anything want to be empowered to tackle their own problems, not just be passive recipients of aid. The Project ACWA team has already taken some of these lessons and is using them for future projects. Under the auspices of the African Development Initiative, a 501c3 organization founded by the members of the Project ACWA team, we are now working with three communities in Northern Ghana, St. Lucia and Ethiopia on economic development initiatives that seek to empower these communities to tackle their own development problems. All these projects employ the themes of grassroots community participation, collaboration among the various actors of development, and an innovative research-driven methodology in determining the most effective interventions.76


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Appendix Article in the Harvard Magazine:

A Real-World Response Paper by Elizabeth Gudrais November 1, 2009

Courtesy of Sangu Delle

The Har var d tea m: Darr yl Fi nkton ‘10, Sangu Dell e ‘10, and Ndu Ok erek e ‘10



in the fall of 2006, Sangu Delle and Darryl Finkton sat talking on

the steps of Weld Hall. In Ghana, Delle, whose father works for the African Commission on Health and Human Rights Promoters, had grown up with firsthand awareness of human-rights abuses: he met refugees, sexual-assault victims, ―people who had had limbs chopped off by warlords.‖ As a boy in 131

Indianapolis, Finkton saw problems more common to American inner cities: drugs, gun violence, and absent fathers. They came from places half a world apart, but Delle and Finkton (now seniors and roommates in Quincy House) discovered they shared a response to the adversity they‘d seen. ―It taught us a lot about the resilience of the human spirit and the capacity to move forward in spite of it all,‖ says Delle. A few weeks into their freshman year at Harvard, they felt a desire to help people who didn‘t have access to such plentiful opportunities. They weren‘t sure what they wanted to do; they just knew they wanted to do something. They gave themselves two years to get that something off the ground. Project Access to Clean Water for Agyementi (ACWA)—serving Agyementi, a village 24 kilometers north of Accra, in Delle‘s home country—has brought clean water to a population of 2,000 that previously used a water source designed for 300. Delle hopes this will be just a first step; they are also building latrines there, at the pace of 25 per year, and they hope future Harvard College students will carry on similar work through the Harvard African Development Initiative, a student group that has also applied for federal tax-exempt status. The reason Delle and Finkton chose water and sanitation as their issues is simple: 1.6 billion people worldwide still lack these basic necessities. ―It baffled us how we are able to send men to the moon but we cannot ensure access to clean water and sanitation,‖ says Delle. They both enrolled in a Harvard course in Twi, the local language in Agyementi, so they would be able to conduct their own surveys and tests of water in people‘s homes. (Delle spoke some Twi, but grew up speaking mainly other languages: Hausa, Dagaare, English, and French.) They cobbled together funding from 132

sources including the Du Bois Institute, the Committee on African Studies, and the department of African and African American Studies, and raised substantial private donations as well with their ―20-10‖ campaign (asking students to give $20 each and spread the word to nine friends). And in December 2007, they traveled to Ghana to meet with people from the government and nongovernmental organizations (NGOs), sharing their ideas and asking for recommendations on ―a community large enough to make an impact, but small enough to be feasible.‖ The minister of water proposed Agyementi. The students‘ initial idea included state-of-the-art water purification powered by solar energy. Nice idea, the minister of water told them, but would they come back to Ghana to repair the solar panels if they broke? They pared down their plans to something simpler and more easily repaired, in the process learning the importance of responding to local needs and—even more rudimentary—asking about local needs. Back at Harvard, Delle, an African studies concentrator who after graduation is headed for the Harvard Business School ―2+2‖ program, developed the project into an alternative thesis for that concentration‘s new social-engagement initiative. Taking a truly multidisciplinary approach, he consulted not only his thesis adviser, professor of history and of African and African American studies Emmanuel Akyeampong, but also economist Michael Kremer; health economist David Cutler (now serving in the Obama administration); anthropologist Duana Fullwiley; and Allan Hill, a demographer at Harvard School of Public Health. He also read roughly 200 academic journal articles on development topics, assigned by Akyeampong during an independent study. His work in Agyementi brought the articles‘ arguments into sharp relief; his criticisms were based on experience, rather than the theoretical impressions of most student response 133

papers. ―You get to see how what you learn in the classroom is challenged by the cultural prescriptions of the communities you‘re dealing with,‖ he says. Delle spent last summer in Ghana and is also spending fall semester there; conveniently, Akyeampong is also there, on sabbatical. (Finkton, a neurobiology concentrator, was in Ghana in 2008 for the borehole construction, but spent last summer working in a lab in Paris.) Delle was originally an economics concentrator, but switched to African studies after noticing that the most successful strategies in one community may not work well at all in another. ―The flaw I saw in economics was that there aren‘t data points for culture,‖ he says. ―I can‘t put cultural idiosyncrasies into my model, and they‘re important.‖ Nonetheless, he believes firmly in an entrepreneurial approach to development. After graduating, he hopes to merge lessons from Agyementi with what he has learned during summer internships at Bear Stearns and Goldman Sachs. ―Instead of dollars being my returns,‖ he says, ―I‘m looking at life expectancy as my returns. If we apply entrepreneurial models to the nonprofit world, we‘ll have things that work.‖ He also believes in the power of creativity and even naïvete—of being too young and idealistic to listen to all the reasons why you shouldn‘t try to solve a particular problem. ―Students are not professional development workers,‖ he says. ―We are generators of ideas. Because we are not corrupted by the limitations of the real world, we can imagine solutions.‖


The Value of Water and Sanitation in Development: A Case Study of Agyementi  

by Sangu Delle

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