Elsevier

Health & Place

Volume 18, Issue 2, March 2012, Pages 250-262
Health & Place

When urban taps run dry: Sachet water consumption and health effects in low income neighborhoods of Accra, Ghana

https://doi.org/10.1016/j.healthplace.2011.09.020Get rights and content

Abstract

Intraurban differentials in safe drinking water in developing cities have been exacerbated by rapid population growth that exceeds expansion of local water infrastructure. In Accra, Ghana, municipal water is rationed to meet demand, and the gap in water services is increasingly being filled by private water vendors selling packaged “sachet” water. Sachets extend drinking water coverage deeper into low-income areas and alleviate the need for safe water storage, potentially introducing a health benefit over stored tap water. We explore correlates of using sachets as the primary drinking water source for 2093 women in 37 census areas classified as slums by UN-Habitat, and links between sachet water and reported diarrhea episodes in a subset of 810 children under five. We find that neighborhood rationing exerts a strong effect on a household's likelihood of buying sachet water, and that sachet customers tend to be the poorest of the poor. Sachet use is also associated with higher levels of self-reported overall health in women, and lower likelihood of diarrhea in children. We conclude with implications for sachet regulation in Accra and other sub-Saharan cities facing drinking water shortages.

Highlights

► Half of low-income households in Accra, Ghana now use sachet water as their primary drinking water source. ► We examine the effect of municipal water rationing on sachet use and health effects in slum neighborhoods. ► Sachet-using households are generally the poorest of the poor with least access to basic services. ► Neighborhood rationing and select socio-demographic factors are predictive of sachet use. ► In a subset of children, lower maternal self-reported overall health and sachet avoidance are predictive of recent diarrhea.

Introduction

The United Nations annually coordinates World Water Day to focus attention on the importance of freshwater and sustainable management of freshwater resources. Despite global efforts, nearly one billion people still lack safe sources of drinking water, over a third of whom live in sub-Saharan Africa where progress has been particularly slow. While 97 percent of urban residents in developing nations had access to some improved drinking water source by 2006, over 137 million urban residents still lack improved drinking water. The Millennium Development Goal (MDG) targets for halving the population without sustainable access to safe water and basic sanitation, and for achieving a significant improvement to the lives of slum dwellers (Goal 7, targets 10 and 11) may not be met in sub-Saharan Africa (United Nations Development Programme, 2006) where over 60 percent of urban dwellers live in slum conditions (United Nations, 2008). In some urban areas, increased coverage of water and sanitation services has been outstripped by population growth and the number of unserved people may be increasing (International Development Committee, 2007, United Nations Development Programme, WHO/UNICEF, 2000). On any given day, almost half the people in the developing world are suffering from one or more of the main diseases associated with inadequate water and sanitation services (United Nations Millennium Project, 2005).

Ghana receives enough rainfall that no community should experience water shortages. Yet despite those abundant water resources, Ghana experiences chronic water shortages due to uneven distribution of rainfall, prolonged drought, and poor water resource management (Nsiah-Gyabaah, 2001). Drinking water sources are often polluted due to insufficient sanitation infrastructure and frequent cross-contamination with human and animal waste. The Ghana Water Company Ltd. (GWCL) has been unable to supply enough water to meet both household and commercial consumption demands; the resulting deficiency in water quantity and quality has slowed improvements to urban population health. The gap between population demand for clean water and its supply to urban residents is increasingly being met by private firms selling so-called sachet water, and our objective in this paper is to explore the link between health and the use of sachet water.

Ghana's municipal water history dates back to 1928 when the first pipes were laid in the former capital city, Cape Coast (see Dreschel and Van-Rooijen, 2008 for a detailed summary). Today Accra's public water services are supplied by two GWCL water treatment plants on the eastern and western peripheries (Kpong and Weija Waterworks, respectively) of the Accra Metropolitan Area, but the city has grown well beyond the plants' capacities. GWCL is unable to provide water to all of Accra due to production and distribution limits, continued population growth without urban planning, and non-revenue water (NRW) losses, which weaken the utility further. Subsequent water rationing and low quality ad hoc storage systems leave large portions of the population without adequate potable water. Although GWCL's service coverage is 80 percent, less than half of the citizens have a house or yard connection (Van-Rooijen et al., 2008), and less than 10 percent have a reliable in-house connection (Taylor et al., 2002). Most people are dependent upon water vendors when lacking a nearby connection or when rationing diverts water to higher-income neighborhoods. In Accra, where residents are already paying four times more for water by volume than New Yorkers, slum residents are paying vendors up to eight times the local public utility prices (United Nations Development Programme, 2006), and up to twenty times in dry periods (Taylor et al., 2002). Barriers to connecting to the water network, such as high capital costs and lack of property rights in informal settlements, exacerbate inequalities in water network access: connection rates in Accra average 90 percent in high-income areas and 16 percent in low-income settlements (Collignon and Vézina, 2000). The GWCL mandate to reduce NRW also widens inequalities, as the contracted operator Aqua Vitens Rand Limited (AVRL) is evaluated based on its ability to convert consumers into billable customers. Customers become more willing to pay when they receive more reliable water access, so billable customers tend to receive the best water rations and vice versa; rationing thus becomes intertwined in a self-perpetuating cycle of poverty and inability to pay for regular water service.

Water rationing began in Accra in the 1980s when water demand first exceeded supply, as Accra's water supply infrastructure has not been significantly expanded to accommodate population growth. Water rationing commenced as a stopgap measure to ensure that most residents of Accra would have access to some quantity of water. Initially rationing was instituted in the Accra-Tema Metropolitan Area by GWCL's thirteen water districts (administrative units responsible for maintenance, billing, and customer care), but it is currently implemented at smaller geographic units that are delineated from the water distribution network by district managers (see Fig. 1). GWCL water districts essentially compete for water, as district performance is assessed by total monthly customer billings for water services, which partly determines NRW. Willingness-to-pay and billability of customers is strongly influenced by the level of service and customer expectations, as previously demonstrated empirically (Hensher et al., 2005), but as Fig. 1 indicates, water service remains quite variable in Accra. The rationing regime operates on a graduated scale ranging from supply at certain hours of the day to a certain number of days per week. The over-arching water delivery strategy is determined by distribution and district managers with the help of the GWCL Geographic Information Systems (GIS) Office, and decisions are based on the pressure in the mains and the size and elevation of the neighborhoods involved. The interplay between household billability and local “infrastructure ecology” creates this geographic variability in water delivery, and sometimes creates spatial mismatches between supply and neighborhood demographics. Any societal effects of water rationing would therefore be expected to vary by neighborhood as well. The rationing program is generally only reviewed when water supply is affected by maintenance or expansion of either of the two water treatment facilities.

Rationing itself is a purely mechanical activity that involves the throttling of butterfly valves designated as “rationing valves.” Each district assigns a distribution supervisor to manually manage valves according to the rationing schedule, though there are several obstacles to proper implementation. Limited staff at the district level often results in slack supervision of distribution supervisors, and valve management is not always timely. Common power outages and maintenance activities adversely impact effective implementation of the rationing schedule by disrupting pumps and downstream water supply. Informal filling stations for private, packaged water are often unaccounted for in the rationing plan, and can adversely affect water pressure downstream in the distribution network. GWCL and individual water districts therefore often have to rely on customer complaints to normalize the schedule. There is also substantial political interference in this process, as every Member of Parliament lobbies to optimize water supply for constituents in order to gain electoral advantage. Despite these obstacles, the current rationing procedure remains the best known way to manage Accra's limited water resources. Future capital investments, perhaps fueled by new oil revenues in the Gulf of Guinea, may eventually drive the expansion of water production and distribution infrastructure to catch up with water demand. In the meantime GWCL is creating new hydraulic models of the water distribution network that integrate flow, pressure, elevation, and population data to create a more scientific rationing schedule and enable more equitable distribution of water.

Where lack of infrastructure and/or rationing have left a void, entrepreneurial water vendors have stepped in to sell water either straight from their tap (filling jerrycans, etc.), or packaged as sachets with varying degrees of filtration or disinfection. The booming sachet water industry diverts an unknown quantity of water from the municipal system, but effectively extends improved water coverage deeper into informal settlements and slums, and alleviates the need in those places for a method of safely storing drinking water.

Sachet water typically consists of 500 ml plastic bags of water that are heat-sealed on either end. Popularly referred to as “pure water,” sachets have gained public affinity due to low price (∼US$0.03), convenience, ubiquity, and the perception of higher quality versus tap water. Sachets are also notorious for constituting a major proportion of the plastic waste generated throughout the country, as consumers typically litter the plastic sleeves in streets and gutters due to lack of organized solid waste removal. Clogged gutters cause flooding during the rainy seasons, which leads to subsequent loss of property and localized bouts of water-borne illness. Despite the adverse environmental impact, sachet distribution has become an important channel of drinking water acquisition for much of Western Africa's urban poor, and particularly in Accra.

Previous research into the transformation of drinking water delivery in developing urban centers such as Accra has focused on commodification of water (McDonald and Ruiters, 2005) and private sector participation at the institutional level (Bakker et al., 2008, Nickson, 1997). There has been little study of how privatized, packaged water such as sachets is changing the need for and attention to safe storage practices. The health benefits of safe storage and higher-quality drinking water are well known (Clasen and Cairncross, 2004, Wright et al., 2004), as are socio-demographic and behavioral correlates of water quality (McGarvey et al., 2008) and child diarrhea (Boadi and Kuitunen, 2005) in Ghana, but the mass shift toward packaged ready-to-drink water may effectively eliminate storage and cross-contamination risks. This potential unintended consequence has been ignored by policy experts, as the word sachet itself does not appear in the United Nations' recent 440-page Human Development Report focusing on global water crises (United Nations Development Programme, 2006).

This paper explores socio-economic predictors of sachet water use in some of Accra's poorest communities, the link between sachets and the GWCL water rationing program, and the serendipitous health benefit derived from sachet water. We present data on primary drinking water sources and expenditures for households in Accra's low-income neighborhoods from a Housing and Well-being Survey (HAWS) that are contextualized by in-depth interviews from several households. The literature on water privatization and water storage, and Accra's uneven growth in sachet consumption in response to GWCL NRW priorities suggest that the poorest in Accra may be pressed to buy sachet water despite its higher per-unit cost, yet may also derive some health benefit from drinking higher-quality water. We expect that the trend of higher sachet consumption seen broadly across Accra will especially be present within lower socio-economic slices of the population. Socio-economic status is operationalized by household measures such as quality of housing, access to basic services, and core daily expenditures. Because GWCL water rationing is enforced at the water district level, we expect that a household's drinking water options are significantly influenced by the degree of neighborhood rationing after controlling for individual and household differences. Because the risks for transmission of water-borne illness vary considerably with individual and household behavior, we expect an individual's neighborhood to have less influence on illness, operationalized as the number of reported diarrhea cases in children under five years of age, than household factors.

The specific hypotheses tested are (1) urban slum residents enduring lower socioeconomic living standards are more likely to consume sachets, (2) slum residents experiencing greater water rationing in their neighborhood are more likely to choose sachets, and (3) children under five in sachet-using households are less likely to experience diarrhea in the previous two weeks. We also comment on the downside of the sachet phenomenon, including concerns about the waste created by empty sachets, and the issue of whether the existence of sachet (i.e. privatized) water undermines the demand for major water infrastructure improvements throughout the city.

Section snippets

Methods

This research draws upon primary data collected in 2009–2010 as part of the Housing and Welfare Study (HAWS) of Accra, Ghana. The HAWS survey is a representative household survey conducted by the Harvard School of Public Health and University of Ghana with assistance from San Diego State University. The sampling frame was modeled after a 2003 UN-Habitat study that focused on slum neighborhoods as a supplement to the 2003 Ghana Demographic and Health Survey (DHS). UN-Habitat operationally

Sachet water and poverty

Table 1 presents the individual and household characteristics of women from the HAWS interviews, stratified by their primary source of drinking water, and Table 2 presents the overall mean EA-level characteristics. At the individual level, just less than half, 47 percent, use sachets as their primary drinking water source. These women are 3–4 years younger on average and more likely to be of Ga/Dangbe or Mole/Dagbani ethnicity; they are significantly less likely to be of Fante or Ewe ethnicity.

Discussion and conclusions

The sachet water phenomenon represents a massive shift of the drinking water landscape in Western Africa, particularly among the urban poor. This is, to our knowledge, the first paper to explore the distribution and potential health effects of sachet consumption. While population-based surveys such as the Demographic and Health Survey indicate that sachet use is primarily a trend among low-income residents, this study utilizes a recent data set to examine the variability within Accra's slums

Acknowledgments

This research was funded in part by Grant number R01 HD054906 from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (“Health, Poverty and Place in Accra, Ghana,” John R. Weeks, Project Director/Principal Investigator). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of Child Health and Human Development or the National Institutes of Health. Additional funding was provided

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