How ring-fenced budgets, WASH interventions reduced disease burden

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In the small village of Abongo in Amuru District, Northern Uganda, twenty-year-old Fiona Lamara faced a parent's worst nightmare. Her seven-month-old baby became gravely ill, suffering severe diarrhoea.

This was the first time her child had developed such a condition, and she struggled to understand the cause.

The nearest health facility was miles away. With no easy access to medical help, she resorted to the only solution she could manage – giving her baby water to prevent dehydration.

One day, a miracle happened. Health workers from Okunggedi Health Center II organized outreach programs in her area and provided much-needed medical care during visits.

Two non-profits, Primary Healthcare Grants and Amref Health Africa-Uganda (AMREF–Uganda) supported them through the project “Water Sanitation and Hygiene for Sexual Reproductive Health Rights in the COVID-19 Era” in Amuru District.

Having understood the underlying causes of rampant diarrhoea, health workers educated locals about essential hygiene practices.

They emphasized the importance of having a latrine, a rubbish pit, a drying rack, and maintaining a clean home. These practices were crucial in preventing the spread of waterborne diseases, a common issue in the village.

Namara’s family practiced defecating in the bush, a norm in the entire village due to the absence of latrines. This practice led to contamination of the water sources, perpetuating a cycle of diseases.

However, the teachings of health workers from Okunggedi Health Center II shed light on the critical link between sanitation and health, inspiring Namara and others in her village to make changes.

Namara and her neighbours began constructing latrines with the health workers' guidance.

Kenneth Ojok, the In-Charge at Okunggedi Health Center in Amuru district, says the outreaches have notably lessened the burden of waterborne diseases in Amuru district.

Ojok says diarrheal diseases, once rampant, have seen a significant decline due to the outreaches.

The facility receives Ush2.5 million every quarter from the Primary Health Care (PHC) Fund allocated to Water, Sanitation, and Hygiene (WASH) initiatives and integrated community outreach activities conducted weekly.

The community outreaches comprise family planning, antenatal clinics, immunizations, and malaria testing and treatment.

Cissy Atek a midwife at Labongogali accompanies an expectant mother to the Washroom at the facility where Amref Health Africa Uganda - connected water. (Credit: Violet Nabatanzi)

The Ministry of Health monitors the allocation of the 30% Primary Health Care (PHC) grant, intended for preventive and promotional interventions. These interventions primarily focus on sanitation, hygiene, and ensuring access to safe water.

"WASH interventions remain a priority, especially for lower health facilities facing water supply challenges," says Dr. Herbert Nabaasa, Department of Environmental Health Commissioner.

He says health facilities should embrace innovative solutions such as water harvesting tanks and boreholes to supplement the interventions already being applied through ring-fenced budgets and sustainably curb cases of waterborne diseases in Uganda.

A portion of the funds given to Okunggedi Health Center is used to purchase handwashing facilities and detergents. Ojok proudly reports that cases of diarrheal diseases have reduced thanks to the outreaches supported by PHC funds.

Despite having only six employees, the health facility serves six villages with over nine thousand people.

Ojok reveals that PHC grants and WASH interventions have significantly boosted waterborne disease prevention efforts. Improvements in home hygiene practices have led to a drastic reduction in diarrheal diseases.

According to the Ministry of Health in Uganda, 75% of diseases are preventable. Investing in prevention yields high returns and improves productivity, as a sick population is highly unproductive.

Improving access to clean water, sanitation, hand hygiene, and waste disposal in healthcare facilities can lower infection risks.

Mutema Health Center II, just like Okunggedi Health Center II, used to register many cases of waterborne diseases, ranging from diarrhoea and intestinal worms to bacterial conjunctivitis.

The health facility mainly relies on two million Uganda shillings quarterly grants for PHC and specific community activities.

Kenneth Ojok, the In Charge of Okunggedi Health Center II measuring a patient's blood pressure. (Credit: Violet Nabatanzi)

Steward Afuke, the health facility's in-charge, stated that 40% of the grants go towards integrated outreaches, where health workers and some Village Health Teams (VHTs) offer services every week.

Other services include water source inspections, where the health assistant visits different water points to check their quality and offer advice or propose improvements.

Thirty percent is spent on home improvement and VHT supervision. The rest is used for administrative costs, including compound maintenance.

Afuke says the health facility has also benefited from the AMREF solar-powered water system, with at least one water point installed on the premises.

The water system has reduced waterborne diseases. Afuke says many diarrheal diseases were caused by people fetching water from swamps and unprotected water points in the community.

These water sources were often shared with animals, and the community had low latrine coverage, leading some members to practice open defecation. When it rained, faeces would wash into the points where people collected water.

With all these interventions, there has been a decline in waterborne diseases since the water consumed by the residents is now safe compared to the water they used to fetch from unprotected springs.

“The number of diarrheal diseases and other waterborne conditions have reduced. Our current burden is malarial cases and respiratory tract infections,” Afuke said.

At least 17 cases of diarrheal diseases occurred in January 2024, and two cases occurred in February: March 39, April 22, and June 22.

They registered 13 intestinal worm cases in December last year, nine cases in January, none in February, 40 in March, and none in April and May.

For bacterial conjunctivitis, they recorded 30 cases in December, 20 in January, none in February, 29 in March, 11 in April and May, and only 8 cases in June.

Kenneth Ojok, the In Charge of Okunggedi Health Center II talks to patients who had turned up for health services. (Credit: Violet Nabatanzi)

Labongogali Health Center III has also significantly transformed since being connected to the water supply, drastically improving hygiene and infection control practices.

Previously, the health center relied on boreholes located two meters away, which presented challenges for staff and patients.

Cissy Atek, a midwife at Labongogali, highlighted the positive impact of the water connection, which Amref supported.

"In delivery, every step requires washing your hands. Even for family planning methods, handwashing before and after the procedure is essential. We're fortunate to have water available now," she said.

The health center in Northern Uganda's Amuru District receives PHC grants of not more than sh2.2 million. This funding is partly allocated for repairing broken pipes and conducting integrated outreach programs involving VHTs, vaccinators, mobilizers, and health workers.

The facility consequently recorded decreased diarrheal diseases due to clean and safe water availability. Mothers attending Antenatal services at the Outpatient Department are encouraged to wash their hands before and after meals and when handling newborns, further promoting hygiene and reducing infection rates.

The addition of a reliable water source has not only enhanced healthcare delivery but also underscored the importance of basic amenities in fostering a healthier community.

I also visited Bukanga Health Centre III in Luuka district, Eastern Uganda. The health center receives sh6.3m quarterly for PHC and Results-Based Health financing, with WASH receiving less than a quarter of this allocation.

However, with support from Water Mission the health facility is maximizing available resources to prioritize WASH initiatives.

Water Mission has been instrumental in connecting treated water to critical areas like the labor ward and maternity, significantly improving WASH conditions. However, monthly payments ranging from sh70 000 to sh120 000 are used for maintenance costs, ensuring sustained operations.

Dr. Andrew Segongga, the health facility's assistant superintendent, prioritizes utilities like electricity and water in budgeting. Despite a modest allocation of sh1.4m for health promotion, focusing on WASH has notably reduced sanitation-related diseases, mainly diarrhea.

The Ring-fenced budgets and WASH interventions have substantially increased latrine coverage in Bukanga Sub-County from 50% to 80%, with cases of diarrhea decreasing significantly at Bukanga.

More needed

Michael Lakony, LCV of Amuru District, states that the Primary Health Care (PHC) budget is insufficient to maintain a health center for four months.

He said the limited funds cover Village Health Teams (VHTs) in health campaigns. They are also used within the health facility for minor repairs and rehabilitation, such as fixing roofs damaged by wind. Additionally, the funds are allocated for WASH.