More
than 900 million people and 2 billion people in the world lack access to an improved
water supply and improved sanitation facilities respectively (1).Though 94%(2011) of the Bhutanese had
access to safe drinking water and access to safe excreta disposal increased
from 91% 2011 to 96.1% in 2012. (2)
However, 3046 per 10,000 (30.46%) patients who visited Kabesa BHU in 2012 were related
to poor hygiene and sanitation.
The
report ascribes the general assessment of hygiene and sanitation level in Kabesa
locality. The findings includes the present programs and strategies to achieve
goals, disease prevalence related to poor hygiene and sanitation, conditions of
rural households, access to safe drinking water and sanitation facilities and also the gaps and opportunities. Recommendations are drawn for further improvement
of hygiene and sanitation in kabesa vicinity.
Situation analysis
One
sixth of the world's population and approximately 1.1 billion people do not
have access to safe water and about 2.4 billion lacks basic sanitation (3).
Six thousand children die every day from diarrheal diseases which is due to
poor water, sanitation and hygiene accounting
for 5.3% of all deaths (4) (5) (6).
In Bhutan, the population has been encouraged to build a latrine as early as
1978, and in 1992, His Majesty the fourth King issued a Royal Decree stating
every household should have at least a pit latrine (7). Since then, annual health bulletin recorded increase in
safe drinking water supply from 78 % in 2000 to 91 % in 2011 and 95% access to
safe sanitation in 2012 (8).
However, on basis of quantity, quality, reliability, cost and proximity to
source (country paper for south Asian conference on sanitation); only 58.4% of
the Bhutanese populations have access to improved sanitation (9) (10)
and more than 30% of cases in health facilities can be attributed to poor
sanitation and hygiene practices. (2)
Although health record in Kabesa
shows 90% access to safe drinking water and improved sanitation, 27(out of 503)
households still doesn’t have latrine, 0.8%(4-5) were not functional and only 418 household uses pit for waste disposal. (11) 424 households has access to safe
drinking water but 29 households piped water were non-functional and Households
who own livestock but do not have separate animal shed increased from 3 (2008)
to 22 in 2011. Despite numerous health advocacies, 3046 per 10,000
(30.46%) patients who visited Kabesa BHU in 2012 were related to poor hygiene
and sanitation such as diarrhea and dysentery(352),
skin infections(461) and intestinal worm(185) (12). The number of village health worker under Kabesa BHU
also dropped from 11 in 2008 to 5 in 2011 and only 3 were in Kabesa geog
(Petari, Chorteninbug and Wokuna). Rests two are under Chubu geog.
The
BHU also conducts school health program which covers 1 middle secondary school
and 3 community schools (873 students) (13).
Health staffs visits schools and conducts awareness on health and hygiene
and has also conducted demonstration on hand washing in 2012.
Program status review of Kabesa BHU and geog
Kabesa
Geog has a astonishing case; access to improved hygiene and sanitation facilities
reached 90% (453 households) and population within the reach of health
facilities such as out Reach clinics and BHUs increased from 218(8.1%) in 2009
to 2707(100%) in 2011 but BHU saw 1161(3046 per 10,000) patients suffering from
diseases related to poor hygiene and sanitation (14) (15). Ministry of Health also initiated the Village
Health Worker (VHW) program in 1979, (16)
but number of VHWs decreased to 3(as of 2012) as compared to 11 in 2009
and 15(83%) villages doesn’t have VHWs (14).
The decrease in number, according to Kabesa Gup was due to least
requirement of VHWs for villages near BHU and zero payment from government. Safe
drinking water for all- Supported by RWSS (Rural Water Supply Scheme) has
reached up to 90% of the households(targeted to achieve 100%) and Collaborative
water testing services by Headquarter, District, and BHU are conducted annually
(10). They also have a
villager to look after water sources and bi-annual cleaning of sources by
villagers (17). Despite the
initiatives taken, 47 households doesn’t have access
to safe drinking water and 6.9% (29 households) piped water were non-functional
which according to elderly woman in village was due to limited assets(labor and
financial) for maintenance. Pilot
Waste Management Community-monthly cleaning (to develop a model village for
cleanliness) was initiated in Eusakha village (49 households). This according
to local resident has helped in keeping surrounding clean and they desire to
carry it on. Pilot pit construction was also carried by local government in
compliance with local government act (18)
and developed a common waste disposal with a roofed pit. They also made
each household to have a pit for waste disposal but only 418(83%) has
constructed as of 2011, which according to villager was due to limited space
and situation of settlement(clustered). Geog and BHU target to achieve 100%
toilet (pit/VIDP/flush latrine) coverage and 472(93%) has constructed one each
on their own (11). Although
there were no data’s recorded, health assistant states that more than half (toilets)
were either not up to standard or non-functional while conduction of test-out
in 2013 (17).
Gaps, challenges and opportunities
Of
the total population in kabesa, 90% have adequate toilet for sanitation and
access to safe drinking water. it is widely understood that diarrheal diseases
can be aggravate in environments where sanitation is poor and Kabesa still has relatively high number of
diarrheal cases, of 322 per 1000 population. Health advocacies and campaigns
are stressed on to improving hygiene and sanitation in the locality but total
population who lived with their livestock without a separate shed for the
animals was 0.59%(3households) in 2008, 2.20%(10) in 2009, 2.46%(14
households) in 2010, 4.02%(19 households) in 2011 and 4.63%(22 households) in
2012 (12).
The households who doesn’t have toilet increased from 5.5% in 2010 to 7% in
2011. (13)
These were aggravated by limited space for construction and low financial
assets. However, the situation is likely to improve with the Geogs plan for
construction of community toilets.
Health
records recorded 100% access to health facilities in Kabesa geog. However, the
BHU has only two working staffs (as of 2013) and has to cover 20 villages
including two under Chubu geog, 1 middle secondary school (565 students) and
3(308 students) community primary schools (19)
(20). The ratio of health staff and population was 1:1790 as of
October 2013, and also has to visit 4 ORCs monthly (14). This may however subside with the governments mandate
to train higher number of health staffs in the country and sent for trainings
outside.
With
the relative shortage of health staffs, health assistant wishes to achieve 100%
access to medical care by increasing the number of VHWs which contradicts with
the statement of Kabesa Gup who wishes to cut down the number of VHWs and
improve their effectiveness by paying them regular payments. This is in the
view of least requirement of VHWs for villages within the reach of BHU and to
further enhance effectiveness of VHWs. Such co-ordination gaps can be resolved
by joint sitting of local government officials and health staffs to further
discuss the issue.
Recommendation
1. Geog
and Dzongkhag administration: Kabesa Geog has seen great improvement in hygiene
and sanitation level. However, prevalence of poor hygiene and sanitation
related diseases is still high in the catchment area and most of the sanitary
toilets and water supply were not functional. Since Dzongkhag Tshogdue and Geog Tshogde has
mandate to ensure the provision of such social and economic services for the
general wellbeing as enshrined in local government act, the basic maintenance
of water supply should be carried out by distribution of geog development fund
provided by government. Local government should focus on developing markets and
improving cash crops (paddy and chili) to improve household income and
financial asset.
2. BHU
and geog Administration: Since BHU has shortage of man power and to cater
health check up to nearly 3580 people will be very difficult. Moreover, having
to visit villages for hygiene and sanitation monitoring and regular visits to
ORCs shall further exacerbate the problem. The geog official’s notion on
decreasing the number of VHWs at present seems irrelevant and needs a joint
sitting of health staff and geog official to discuss the matter. Thus to improve
sanitation level at village level, VHWs should be elected in villages of Bjangsarphu,
Serigang, Rangrikha, Dophukha, since they are far away as compared to others.
They can be paid by collecting amount of Nu.100 as done in the past.
3. Construction
of public/community toilets: at rural villages, they may be able to construct a
simple latrine, but are left with no options for the maintenance due to low
income and labor shortage. Working in group to construct toilets is impossible
due to income gap and social status. Thus, educating people about the
importance of social relations should be the first priority. It would also be
far better if government could at least construct 2-3 public toilets in a
community (with low financial assets) as suggested by local government official
through local government funding and man power from the community (users)
Reference
1. Bill and Melinda
Gates Foundation. Landscaping and review of approaches and technologies
for water, sanitation and hygiene: Opportunities for action. AGUA Consult.
seattle : consortium of Cranfield Universityand International Water and
Sanit, 2006.
2. BIMS. Annual
Stastical Report. Thimphu : Ministry of Health, 2011.
3. Sandy.C &
Valdmanis.V. Water, Sanitation, and Hygiene Promotion: In Disease
Control Priorities in Developing Countries. New York : Oxford
University Press, 2006.
4. UNICEF. Why
improved sanitation is important for children. Sanitation Year 2008. [Online]
UNICEF, 2008. [Cited: september 27, 2013.] http://esa.un.org/iys/health.shtml.
5. WHO. World
Health Report 2002. Geneva : world Health Organisation, 2002.
6. A. Prüss, K.
David , F.Lorna , and B.Jamie. Estimating the Burden of Disease from
Water, Sanitation, and Hygiene at a Global level. Environmental Health
Perspectives. May 2002, Vol. 110 2002 •, 5.
7. SSH4A.
Sustainable Sanitation and Hygiene For All. SSH4A. [Online] 2010.
http://www.snvworld.org/en/countries/bhutan/sectors/water-sanitation-hygiene/sustainable-sanitation-and-hygiene-for-all-rural-0.
8. BMIS. Annual
Health Bulletin. Thimphu : Thinley Pelbar Printers and Publishers,
2013.
9. COUNTRY PAPER
FOR SOUTH ASIAN CONFERENCE ON SANITATION. SACOSAN. New Delhi,
India : s.n., 2008.
10. SACOSAN. Bhutan;
Country Paper on Sanitation. Thimphu : Ministry of Health, 2013.
11. Kabesa BHU.
Annual Statistical book. 2012.
12. assistant,
health. Hygine and Sanitation in Kabesa Area. [interv.] group 1.
september 27, 2013.
13. BHU, Kabesa.
School Health Program Record. 1999-2012.
14. BHU, Kabesa.
Annual Health Record. 2012.
15. Basic health
Unit. Out reach clinics/OPD Registar. 2012.
16. UNICEF. What
Works for Children in South Asia: Community Health Workers. Kathmandu,
Nepal : Health and Nutrition Section; Regional Office for South Asia,
2004.
17. Assistant,
Health. Hygiene and sanitation leveel in kabesa area. september
friday, 2013.
18. RGoB. Local
Government Act. Thimphu : Royal Government of Bhutan, 2007.
19. Kabesa BHU.
School Health Programe Record. 2013.
20. —. Health
Education Registar. 2013.
21. Assembly,
United Nations General. Millinenium Development Goal. s.l. :
UNDP, 1999.
22. WHO. The
Primary Health Care Worker: Working Guide. Geneva : World Health
Organization, 1990.
23. dietvorst.
Bhutan: despite the “toilet revolution”, high coverage has not lead to high
use. Sanitation Updates; News, Opinions and Resources for Sanitation for
All. [Online] August 22, 2008.
http://www.snvworld.org/en/sectors/water-sanitation-hygiene/our-work/sectors/water-sanitation-hygiene/sustainable-sanitation.
24. National Health
Policy. MoH. Thimphu : Ministry of Health, 2008.
25. National
Statistical Bureau. Statistical Yearbook of Bhutan. s.l. :
Royal Government of Bhutan, 2011.
26. Cooke,
Jeanette. IFAD. [Online] 2008.
www.ifad.org/english/water/innowat/topic/sanitation.htm.
27. Public Health
and Environment. EXPOSURE TO AIR POLLUTION:A MAJOR PUBLIC HEALTH
CONCERN. 20 Avenue Appia, 1211 Geneva, Switzerland : WHO Document
Production Services, 2010.
Comments