Modelling Wash services in public hospitals

APPALLING—Some bathing shelters that are being replaced

Livinesi Banda sits on a veranda of an old and dilapidated kitchen at Mdunga Health Centre, 105 kilometres east of Kasungu, waiting for porridge as the clock ticks away under the hot day. At 42, she is already a mother of eight but expecting her ninth child.

“Home deliveries are outlawed in this community, thus I had to rush here as time is due,” she says while gazing at a poster pasted on the smoked walls. The poster advises on the ways of preventing cholera, a poor hygiene-related disease that has already affected over 800 people this season.

She mulls over the irony of the campaign advising women to deliver in hospitals where there are no proper sanitary facilities ideal for safe deliveries and infection prevention needed for both mothers and babies.


“This will be my third delivery at Mdunga. Whenever I come here, I think about the bathrooms and toilets which are not only few but also in bad shape. There is one bathroom and one toilet for all the people you see around here. You either have to wait for a long period of time just to take a bath or you have to use the nearby maize fields. So you can imagine what that means for those women who have just given birth; it’s not healthy,” she says.

Mdunga Health Centre, which serves a population of 29,000 from 386 villages, conducts 40 to 50 deliveries per month.

According to Banda, women are aware of the importance of delivering in hospitals but are discouraged by the unhygienic environment in the health facilities. Largely, most health centres in the country lack safe water, latrines, placenta pits and incinerators for disposal of medical waste despite some of the facilities conducting as many as 50 deliveries per month.


“This hospital serves so many people; but you will be shocked to learn that there is only one bed used for deliveries. The maternity is a very tiny room. If you see many women here, it is because of the fines that are imposed on those that give birth at home,” says Banda.

Another heck at Mdunga, like in many other health centres across the country, is lack of water. Pregnant women, patients and guardians are forced to draw water from a borehole located over 100 metres downhill. They have to make four trips each to fill some two rusty tanks. That water will serve the hospital for a day. The following day, the trend continues meaning pregnant mothers and their guardians have to keep on drawing water for as long as they will stay there.

“This is one of the reasons people are reluctant to come to seek help at the hospital. You come here as a patient but you are asked to draw water. And as you can see, the borehole is located downhill meaning we have to climb up the slope with a pail on the head. That is not easy for us,” Banda laments.

The woes at Mdunga are also ubiquitous in many public health centres across the country’s rural areas where there is lack of safe water, sanitation and hygiene. This gap does not only undermine efforts by health programmes to reduce mortality and morbidity from communicable diseases such as diarrhoea but also efforts to improve maternal and newborn health.

However, not all is lost, thanks to National Initiative for Civic Education (Nice) Public Trust and WaterAid Malawi who are implementing a Maternal and Neonatal Health (MNH) governance project which seeks to provide water and sanitation (Wash) facilities and model the delivery of health services from a governance perspective in selected health centres.

With funding from Department for International Development (DfID), WaterAid partnered Nice to implement the MNH governance project christened “Kubadwitsa Chamoyo” [Deliver Life] in Machinga, Kasungu and Nkhotakota to model the delivery of health care, especially in the Wash sector.

“The primary focus under this project is to address the lack of safe water, sanitation and hygiene at community level. Through this project, communities have benefited from solar-piped water, modern pit-latrines, bathrooms, incinerators and placenta pits in selected health centres in those three districts,” said Enock Chinkhuntha, Regional Civic Educator at Nice who coordinates the project.

Construction works are being implemented by Evangelical Lutheran Development Services and Amref International while the role of Nice is to mobilise communities to be part of these development processes so that there is citizen participation, transparency and accountability.

“We believe that most of the challenges we face in relation to Wash and MNH are a result of poor governance. Corruption is compromising the quality of most community projects. As such, Nice, through community structures such as citizen forums and women action groups, provides checks and balances so that we get the best out of this project,” said Chinkhuntha during a tour to appreciate the project’s progress.

“Through various capacity building initiatives Nice has been implementing, communities through citizen forums and women action groups are more proactive in engaging with duty bearers which is in line with the spirit of representative democracy,” he added.

Chinkhuntha pointed out that there still remains a gap in addressing the linkages between the absence of Wash and maternal and neonatal morbidity and mortality despite efforts by various organisations working to reduce maternal and newborn mortality at different levels.

“Put simply, when pregnant women attend healthcare facilities, there is an expectation that they will receive good medical care and that they and their newborn will be at reduced risk of complications. However, in many cases, they will be attending a facility that lacks safe water and has no latrine.”

A 2015 World Health Organisation and Unicef report on the state of Wash in health facilities in low-and middle-income countries shows that 38 percent of health facilities do not have improved water source and 19 percent without improved sanitation. Consequently, mothers and babies can often be at greater risk of complications and can experience a worse level of care than if they had stayed at home.

Malawi’s maternal mortality still remains one of the highest in Africa with 510 deaths per 100,000 and infant mortality rate of 23.1 per 1,000, according to 2014 figures. And according to United Nations Programme’s Human Development Index (2013), there remain 344 million people without safe water and 644 million without basic toilets in sub-Saharan Africa.

“WaterAid is aiming to drive change so that Wash is considered a key component of healthcare provision so that this is no longer the case,” said Chinkhuntha.

While the new facilities are yet to be opened for public use at Mdunga, the community is already excited at the development. Eretina Phiri, Chairlady for Mdunga Women Action Group, said the community feared cholera would break out at the facility owing to poor sanitation.

“With these modern bathrooms and latrines, our fears are gone. Even the burden of drawing water will soon be over. As mothers, we have no reason now to hesitate delivering at the hospital. We are thankful to WaterAid and Nice for respecting the dignity of women as we will no longer be taking a bath in maize fields where people could take glances of our naked bodies,” said Phiri.

Sub-Traditional Authority (ST/A) Mdunga also chipped in calling on political leaders to pay attention to Wash in health facilities.

“Giving birth to a child should not be a death sentence but a blessing; a source for joy, not sorrow. We are happy that we have finally got facilities which will immensely contribute to the safe delivery by our women,” he said.

In a show of ownership of the project, the communities have employed a watchman to guard the solar pump which is planted some 700 metres from the health facility, the ST/A said.

Hilton Chisiza, a nurse, said the inclusion of provision of water in the project is expected to greatly improve efforts on infection prevention which is one of the challenges faced by health centres.

“Like everyone else here, I am happy and relieved because even our work will be eased,” said Chisiza.

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