Stopping the hurt caused by lack of water and toilets in healthcare centres in Malawi
Volunteer Health Centre Management Committees are demanding change to stop millions of people in Malawi enduring healthcare without clean water, decent toilets and good hygiene. To hear how, last November WaterAid UK's Lis Parham spent a night with a committee in rural Malawi, in the healthcare centre they are working to transform.
It’s just about midnight and I’m sitting on a stone bench in the waiting room of a remote, rural health centre in Malawi – Chikwewo. A single bulb flickers against the increasing wind, the room open to the elements, without fitted windows or doors.
We’re in Machinga District, southern Malawi, to talk to a small team of volunteers that represents the 98,000 people who rely on this centre for primary care – the Health Centre Management Committee (HCMC). They are the voice of the people – the watchdog – and they are making change happen even before our project work has started.
In Malawi, one in three people live without clean water, and more than half have no decent toilet. The situation in healthcare facilities is equally worrying, with fewer than a third (download PDF) having hand hygiene materials available at all points of care. This puts patients and healthcare workers at serious risk of catching deadly infections.
However, it is the law to give birth with a skilled birth attendant – an effort to reduce maternal and infant mortality in the country, which is one of the highest in the world. At least a month before their due date, women must come to health centres like Chikwewo, where they and their carers face a life-threatening lack of basic facilities.
Working together with local committees is a crucial part of what we do
The wind has built up to a crescendo now. We’ve been chatting to the team of ten for hours already, hearing about their hopes and fears for the new WaterAid project that will deliver water, sanitation and hygiene (WASH) facilities and transform Chikwewo and three other healthcare centres in the southern region. The project will be funded by the Scottish Government International Development Fund, Scottish Water and other UK major donors and trusts.
Made up of representatives from the surrounding villages brought together by district government, they are the bridge between the community and health staff, taking on tasks from resolving disputes to auditing stocks of medicine. They make reports to the Ministry of Health on everything from maintenance to mismanagement.
“The primary role of the Health Centre Management Committee, or HCMC, is accountability,” said Clifton Kawanga, Communications Specialist at WaterAid Malawi. “The communities need support to understand the situation at the health centre. This conversation aids transparency and manages the relationship between patients and staff. If they weren’t here, then the staff would have no effective way to share what the challenges are – such as limited access to water, sanitation and hygiene, medicine or equipment. And that’s when tension grows.”
Working with a local committee is therefore a crucial part of our work. Without community representation, involving women (at least 40% of the team is the requirement) and men, the real needs of the people would be missed.
“By making sure the community is involved in decision making right from the start, they can shape the project to make it their own, sharing their experience first hand. That’s what makes a project sustainable, because it will have ownership by the community. The members are usually already quite involved in affairs at their own villages, so know what challenges their community is facing. Without them, we couldn’t deliver our project work.
“It should be borne in mind that WaterAid in Malawi values community feedback. This helps in the delivery of our work in the areas where we are; we are able to know whether the communities are satisfied or not with the WASH facilities we rehabilitate or construct,” said Kawanga.
Committees build trust and overcome fears
But there have been failures at Chikwewo in the past – works by other organisations weren’t maintained and ended with promises broken. Empty water tanks loom over the main meeting area outside and dysfunctional pipes sit dormant below our feet. This hangs over our conversation at first, too. One word that keeps coming up is ‘hurt’ – the situation hurts the committee members. They hurt to see women forced into such conditions – conditions that have become normal. They hurt to wait, too, knowing that help is planned, but not yet started. The hurt of previous failures gives this anxiety real basis.
The committee knows that without water the centre fails national health and safety standards, and the fear of it being closed is real too. Earlier we met a woman who had walked more than 26 miles – the equivalent of a marathon – at eight months pregnant to reach this centre to give birth. Could she and others be asked to walk further to a different centre?
The nearest water point is in the local market, about a ten minute walk away. If a woman gives birth at night, it’s not unknown for her guardian (her companion carer – a family member, usually) to go and fetch extra water at that time. In the pitch dark, that’s not safe. In that situation it’s not unknown for a woman to instead ‘keep’ until morning. To keep is to sit as you are, without washing. It’s undignified. It’s unhygienic. And it’s all part of the hurt.
But life is changing
Since the district formed the HCMC in July 2018, they’ve challenged their communities to contribute to their own development. From liaising with village chiefs to build the committee’s local influence, to mobilising support from villagers to fund buying or making of bricks and cement, the HCMC are making things happen. As a result, women are receiving antenatal care and uptake of vaccines is increasing.
The committee has demanded more consistent care from medical staff and helped communities understand what should be delivered. This mutual understanding has eased tensions between staff and patients, clarifying issues from opening times to service levels. They have even made sure a local law was changed to control when medicine deliveries occur so they are always able to audit them.
As a lynch pin between the health centre and local authorities, the committee’s reports and activities feed into the chain that ultimately demands better resourcing for these facilities at a district level. The human right to health is recognised internationally, and by working side-by-side with these groups, we help progress that conversation so they can demand resourcing, accountability and transparency from duty bearers.
When clean water and toilets arrive, lives will be saved
But the HCMC team’s job won’t be over when clean water arrives. They know they’ll need to keep working to make sure the new facilities are maintained. Indeed, they’ll be instrumental in educating patients in how to use them. The women, they said, will then be able to "tell the difference between the health facility and home".
The showers will be flowing, in place of dry dusty cubicles. They hope to stop women sleeping on the floor. They’ll also be able to ensure life-saving infection prevention control procedures are in place, and the HCMC’s vision is that women will take this vital advice home with them. All these improvements will mean women will want to come to the health centre, rather than risk a home birth; the changes will motivate women to comply with the law, and will save their lives.
A vision for the future
And so change begins. But where would you start if you couldn’t get past the first hurdle – clean water, decent toilets and good hygiene? With all three, people can lead safer, more dignified lives. Women can give birth in a hygienic place and the staff who care for them can minimise risks to their patients and themselves.
When these three vital services are in place, the HCMC will focus on the next target. In fact, they already have a list: a bigger hospital to serve the large catchment area; an ambulance so staff can respond better to emergencies; a communications system so there is easier contact with the district hospital; and a solar power source so they aren’t caught out in power cuts. Their momentum will change what has become normal.
“HCMCs are integral to the success of our project work in healthcare,” Kawanga said. “These communities are remote. Their insight helps us understand what is needed and to give us the balance we need, alongside other authorities, to design an effective, sustainable project. We can’t go into a community to work without working with them. They challenge established practices and keep asking important questions throughout.”
As the rain starts to fall, and the noise on the tin roof forces a pause in our conversation, I’m left holding the thought that what I’ve seen tonight is as exciting as seeing water flowing from a new borehole. This group is the embodiment of what we talk about when we describe changing normal. They don’t accept what has become normal here at Chikwewo, and neither do we.
Lis Parham is Senior Partnership Communications Officer at WaterAid UK.
We are still fundraising for this project, Deliver Life to Mothers, Girls and Children in the Southern Region of Malawi. If you are a major donor, trust or foundation, please get in touch with our Philanthropy and Trusts team to see how you can lend your support to this life-changing project. Visit our Philanthropy and Trusts web pages, or email [email protected]