A guide for
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A guide for communities and
community health workers
Water, Engineering and Development Centre
Loughborough University, Loughborough, England
Bilharziasis Laboratory, Charlottenlund, Denmark
Protection of the Human Environment
World Health Organization, Geneva, Switzerland
United Nations Children's Fund
Protection of the Human Environment
World Health Organization, Geneva, Switzerland
Water, Engineering and Development Centre
Loughborough University, Loughborough, England
Centre for Applied Psychology
University of Leicester, Leicester, England
World Health Organization
WHO Library Cataloguing-in-Publication Data
Healthy villages : a guide for communities and community health workers / Guy Howard with Glaus
Bogh . . . [et al.]
1. Rural health services - handbooks 2. Community health services - handbooks 3. Community health
aides - handbooks I. Bogh, Glaus Il.Title
ISBN 92 4 154553 4 (NLM Classification: WA 390)
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World Health Organization 2002
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Chapter 1. Introduction 1
1.1 What is a healthy village? 2
1.2 Structure of the guide 3
1.3 Using the guide and setting priorities 3
Chapter 2. Achieving good health 7
2.1 Factors that influence health 7
2.1.1 Environment 7
2.1.2 Awareness of health issues 9
2.1.3 Personal hygiene 9
2.1.4 Health care 10
2.1.5 Faecal-oral diseases 10
2.1.6 Vector-borne diseases 10
2.2 Identifying health problems and establishing priorities 11
2.2.1 Assessing community perceptions about health 12
2.2.2 Identifying causes of health problems 16
2.3 Using the information 18
Chapters. Water 19
3.1 Providing community water supplies 19
3.2 Types of water sources 22
3.2.1 Protected springs 22
3.2.2 Dug wells 24
3.2.3 Boreholes 25
3.2.4 Piped water supply 27
3.2.5 Rainwater harvesting 29
3.2.6 Ponds, lakes and water treatment 30
HEALTHY VILLAGES: A GUIDE FOR COMMUNITIES AND COMMUNITY HEALTH WORKERS
3.3 Household water treatment 30
3.3.1 Boiling 31
3.3.2 Canvas filters 31
3.3.3 Candle filters 31
3.3.4 Disinfection 31
3.3.5 Settling 32
3.4 Safe handling of water 32
3.5 Monitoring water quality 33
3.5.1 Microbial quality 33
3.5.2 Sanitary inspection 34
3.5.3 Chemical quality 34
3.6 Managing community water resources 35
3.6.1 Preventing over-pumping of ground water 35
3.6.2 Water conservation 35
3.6.3 Managing water for agriculture 36
Chapter 4. Excreta disposal 38
4.1 Technologies for excreta disposal 38
4.1.1 Cartage 39
4.1.2 Pit latrines 40
4.1.3 Septic tanks 43
4.1.4 Aquaprivies 44
4.1.5 Sewerage systems 44
4.2 Sewage treatment and reuse 45
4.2.1 Stabilization ponds 45
4.2.2 Wastewater and sludge reuse 46
Chapter 5. Drainage 48
5.1 Problems caused by poor drainage 48
5.2 Methods for improving drainage 49
5.2.1 Stormwater drains 49
5.2.2 Sullage disposal methods 50
5.2.3 Combined drains 51
5.2.4 Buried drains and combined sewers 51
Chapter 6. Solid waste management and chemical safety 52
6.1 Strategies for solid waste management: minimizing
waste and recycling 52
6.2 Managing solid waste in households 53
6.2.1 Composting 53
6.2.2 Turning organic waste into fuel 53
6.3 Managing solid waste in the community 54
6.3.1 Communal refuse pit 54
6.3.2 Communal collection 54
6.4 Managing special solid wastes 55
6.4.1 Health care solid wastes 55
6.4.2 Slaughterhouse solid wastes 56
6.4.3 Industrial solid wastes 56
6.5 Chemical safety 57
6.5.1 Storage of toxic chemicals 57
6.5.2 Handling toxic chemicals 58
6.5.3 Chemicals in the home 59
6.5.4 Disposal of toxic chemicals 60
Chapter 7. Housing quality 61
7.1 Ventilation 61
7.2 Lighting 62
7.3 Disease vectors in the home 62
7.4 Overcrowding in homes 63
Chapter 8. Personal, domestic and community hygiene 65
8.1 Personal and domestic hygiene 65
8.1.1 Hand washing 65
8.1.2 Bathing 66
8.1.3 Laundering 68
8.2 Community hygiene 68
8.2.1 Markets 68
8.2.2 Animal rearing 69
8.3 Food hygiene 70
8.3.1 Food preparation in the home 70
8.3.2 Eating-houses 71
8.3.3 Street food-vendors 72
8.3.4 Promoting nutrition 73
Chapter 9. Promoting hygiene 74
9.1 Assessing hygiene practices 74
9.2 Planning hygiene promotion projects 75
9.3 Implementing hygiene promotion projects 76
9.3.1 Building community capacity 76
9.3.2 Organizing groups and committees 76
9.3.3 Situation analysis 77
9.3.4 Communication and education 77
9.4 Monitoring and evaluating hygiene projects 78
9.4.1 Deciding what information is needed 79
HEALTHY VILLAGES: A GUIDE FOR COMMUNITIES AND COMMUNITY HEALTH WORKERS
9.4.2 Selecting project investigators 80
9.4.3 Selecting tools for collecting information 80
9.4.4 Reviewing project findings 81
9.4.5 Feedback and dissemination of findings 81
Chapter 10. Providing health care 82
10.1 Establishing community health care programmes 84
10.2 Factors that influence the type of health care that
people seek 85
10.3 Encouraging and sustaining the use of health services 86
10.4 Immunization of children 86
10.4.1 Overcoming barriers to immunization 87
10.4.2 Making immunization safe 89
10.5 Groups with special health care needs 90
10.5.1 Pregnant women and infants 90
10.5.2 The elderly 91
10.6 Risky behaviour 91
10.6.1 Changing risky behaviour 92
10.6.2 Health education 93
10.7 Mental health problems, learning difficulties and epilepsy 94
10.7.1 Mental health problems 94
10.7.2 Learning difficulties 95
10.7.3 Epilepsy 95
10.7.4 Social inclusion 95
Chapter 11. Establishing committees for implementing
Healthy Villages programmes 97
11.1 The role of local community committees in Healthy
Villages programmes 98
11.1.1 Composition of a Healthy Villages committee 98
11.1.2 Transparency and accountability 99
11.2 The role of local government committees in Healthy
Villages programmes 99
11.2.1 Funding and accountability 100
11.2.2 Technical advice and support 100
11.3 The role of national committees and coordinators in
Healthy Villages programmes 101
Annex 1. Organizations supporting Healthy Villages initiatives 103
Annex 2. Books and manuals providing further advice 106
Document aims and target audience
This guide was developed to support the Healthy Villages approach for
improving the health of rural communities. It provides local community
leaders with a model of the type of information they may need to consider
in their roles as current or prospective managers of a Healthy Villages project.
Community leaders include not only elected officials, but also the health staff,
respected elders and others who work to improve the health of rural com-
munities. We outline the type of information that Healthy Villages managers
could provide to their communities, as well as the basis for developing ma-
terial that is specific to regions or to entire countries. Because this guide was
designed to be used in many different countries, it is likely that modifications
will be required at local levels to ensure that local conditions and practices
are taken into account.
It is recognized that many excellent locally-developed solutions for village
health problems are already being practised. This guide is not intended as a
global prescription for promoting improved health in rural communities, but
rather as source material from which readers can develop local solutions to
local problems. The purpose of this guide, therefore, is to provide a model of
the type of information and approaches for promoting healthier villages that
readers can use when implementing village-level activities.
The Healthy Villages project
Many countries are developing stronger partnerships between the health
sector and local government organizations to promote local "settings" initia-
tives for health. A Healthy Villages project assists in this by putting concepts
such as hygiene education, environmental health, health promotion and envi-
ronmental protection into action in rural communities. A Healthy Villages
project enables a village to mobilize the human and financial resources
needed to address many health and quality-of-life issues. The process works
viii HEALTHY VILLAGES: A GUIDE FOR COMMUNITIES AND COMMUNITY HEALTH WORKERS
as a communication strategy that develops political and popular health
awareness and support for health issues.
Settings are major social structures that provide ways of reaching defined
populations. Each setting in a village has a unique set of members, authori-
ties, rules and participating organizations, each with interests in different
aspects of the village life. For example, work settings include agriculture and
small-scale industry; other settings include the food-market, the housing
setting or the school setting. Generally, these structures are organized for pur-
poses other than health. Interactions are frequent and sustained in these set-
tings and are characterized by patterns of formal and informal membership
and communication. These qualities create efficiencies in time and resources
for health education programming, and offer more access and greater poten-
tial for social influence.
Villages are often defined in terms of arbitrary administrative definitions.
A village may be a small group of people living in a settlement who practise
subsistence agriculture, with no specialization or division of labour, and who
are isolated from national development agencies. A village may also be a large
and differentiated conurbation where some people work in agriculture, some
work in small-scale industries and others provide education, health care,
administration and a variety of services. This guide is directed towards the
larger and more differentiated village. It is also recognized that many villages
do not operate independently from cities, in that cities require sustained inter-
action with rural communities for their food and natural resources (includ-
ing land for waste disposal). Often, too, the district agencies that set policy
and administer the villages are located in cities. Under these circumstances,
a Healthy Villages programme has a greater chance of success if the linked
city is participating in a similar type of programme for cities a Healthy
Cities Programme 1 and if the district-level staff implement Healthy Villages
as part of the health policy for all the towns and villages in the district.
1 Werna E et al. Healthy city projects in developing countries: an international approach to local
problems. London, Earthscan, 1998.
The preparation of this guide was coordinated by the Water, Sanitation and
Health programme, Protection of the Human Environment Department, of
the World Health Organization in support of the Healthy Villages Pro-
gramme. Its preparation was initiated and led by Annette Priiss.
The authors gratefully acknowledge the contributions of the participants
in the following two expert consultations organized by WHO's Regional
Office for the Eastern Mediterranean:
Regional Consultation on the development of technical guidelines and
integrated environmental management norms for Healthy Villages,
Tabriz, Islamic Republic of Iran, June 1998
Inter-regional Consultation on Healthy Villages, Damascus, Syria,
The authors would also like to thank the staff from WHO Headquarters and
WHO Regional Office for the Eastern Mediterranean for their comments on
the content and style of the guide. In particular thanks go to Kumars Khosh-
Chashm for his support.
Finally, the authors would like to acknowledge the editorial work of Kevin
Many factors determine the health both of individuals and of the commu-
nities in which they live. These factors include income, social relationships,
access to and use of basic services such as water supply and sanitation, the
quality of available health services, individual responsibility and the quality
of the environment. Consequently, public health interventions designed to
reduce the risk of ill-health and promote feelings of well-being in a commu-
nity must consider many social and environmental factors. These factors will
vary in importance between communities, because of differences in the
current services, facilities, priorities and needs of the communities, and
because communities change over time. If health interventions are needed in
several areas, they may need to be prioritized before they are implemented.
Several programmes, such as primary health care or the Basic Development
Needs programme, 1 address the factors that influence the health and well-
being of communities. Advice on these programmes is available from a
number of sources (see Annexes 1 and 2).
This guide focuses on the different health interventions that support the
development of healthy communities. Many of the interventions require
outside support to the communities, such as from local and national
governments and nongovernmental organizations (NGOs). However, the
communities themselves also play an important role in identifying problems,
defining solutions and setting priorities. Often, communities will also need
to participate directly in implementing solutions and in sustaining the
improvements made. Indeed, many interventions require commitments
from individual community members and households, in addition to com-
mitments from the broader community. Frequently, the most important
element in promoting health is to ensure that everyone has access to
1 Abdullatif AA. Basic development needs approach in the Eastern Mediterranean Region.
Mediterranean Health Journal, 1999, 5:168-176.
HEALTHY VILLAGES: A GUIDE FOR COMMUNITIES AND COMMUNITY HEALTH WORKERS
Characteristics of a healthy community
The physical environment is clean and safe.
The environment meets everyone's basic needs.
The environment promotes social harmony and actively involves everyone.
There is an understanding of the local health and environment issues.
The community participates in identifying local solutions to local problems.
Community members have access to varied experiences, interaction and
The health services are accessible and appropriate.
The historical and cultural heritage is promoted and celebrated.
There is a diverse and innovative economy.
There is a sustainable use of available resources for all.
The purposes of this guide are:
To help community leaders and people who work with rural com-
munities identify problems that affect health.
To outline possible solutions to these problems.
To help in the setting of priorities that will lead to a healthier
During the development of the draft version of this guide many workshops
and discussions were held with public health practitioners. Based on these
discussions, it is expected that health department officials will find the
guide a valuable tool for their community health work, and may translate
it into local languages or make adaptations to suit local circumstances and
conditions. The guide is not exhaustive, however; it does not cover interven-
tions for every situation, nor are the descriptions of interventions detailed.
Instead, it is designed to provide information to communities that will enable
them to start the process of problem solving. More information about imple-
menting programmes can be obtained from the organizations and documents
listed in the annexes at the end of the guide.
1.1 What is a healthy village?
It is impossible to define precisely what is "healthy'' for all communities,
because this will depend on the perceptions of community members as to
whether their village is a "good" place to live. However, a village or rural
CHAPTER 1. INTRODUCTION
community can be considered healthy when rates of infectious diseases are
low, when community members have access to basic services and health care
that meet their needs, and when the community lives in a state of reasonable
harmony. Examples of unhealthy and healthy villages are illustrated in
Figures 1.1 and 1.2; however, these pictures show extremes and most com-
munities will fall somewhere between the two.
1.2 Structure of the guide
The guide follows a simple format and deals with various interventions.
Checklists are provided to help community leaders to assess their problems
and evaluate the importance of different interventions.
An initial section looks at how good health is defined and how to identify
gaps in the social and physical environment that would hinder the promo-
tion of good health in villages. The importance of technology in improving
health is then discussed, including means for providing a safe water supply
and good sanitation, for safely disposing of waste and chemicals, and for pro-
viding good drainage. The importance of sustaining technologies is also
emphasized, because simply installing infrastructure, such as a well or a bore-
hole, will not improve community health if it is allowed to become nonfunc-
tional. The importance of personal and community hygiene in promoting
health is also outlined, since good hygiene practices are as important as tech-
nology for improving health.
The provision of health care and the ways in which communities can
access or demand improved health care services are then discussed. This
section also examines the health needs of special groups, such as pregnant
women, the elderly and people with mental health problems. A final section
describes the role of local governments in supporting improvements in rural
1.3 Using the guide and setting priorities
The guide is designed to help rural community members and health workers
make informed decisions about interventions for their community health
problems, by providing information about how to improve different aspects
of health. Further information may be also required, such as on the detailed
workings of different pit latrines, before final decisions can be made as to the
best intervention. However, raising the awareness of community members
about the different options for intervention should increase their participa-
tion in the decision-making process and help them to select solutions that are
appropriate for their community. Although this guide provides a framework
for decision-making and should help rural communities to improve the
HEALTHY VILLAGES: A GUIDE FOR COMMUNITIES AND COMMUNITY HEALTH WORKERS
CHAPTER 1. INTRODUCTION
HEALTHY VILLAGES: A GUIDE FOR COMMUNITIES AND COMMUNITY HEALTH WORKERS
health and well-being of community members, it does not replace local
professionals, who will have a more detailed understanding and knowledge
of the communities they work in. To improve community health, it may also
be necessary to coordinate intervention activities with service bodies such as
When considering interventions, it is important to bear in mind the current
conditions in a community, as well as the community priorities. For example,
a community may be prone to flooding, and have poor sanitation and an
inadequate water supply. The community will need to determine which pro-
blems are most urgent and which can be dealt with later, and then decide
on the interventions for dealing with the most pressing issues. The whole
community, and not just a powerful few, should be involved in this decision-
making process. Women, in particular, should be given a proper say in
improving their village, as they may be most affected by the health problems
caused by an unhealthy environment. Whenever possible, a number of
interventions should be undertaken at the same time, since this may resolve
health problems more quickly and cost-effectively. However, realizing these
goals may require a substantial commitment of time and resources from
the community, so a balance must be struck between working to improve
the village environment and the needs of families to grow food and earn
Achieving good health
According to the World Health Organization (WHO) good health is not
merely the absence of disease; it is also a reflection of the social and mental
well-being of people in a community. Thus, to achieve the WHO goal of pro-
viding health for all, improvements in a community should aim not simply
to reduce disease, but also to reduce social tensions and mental ill-health to
2.1 Factors that influence health
Many factors influence health and some may have both good and bad influ-
ences. For example, surface water bodies can be beneficial as they can supply
water for domestic and agricultural work, may be used for fishing and re-
creation, and can create a pleasant environment. However, they can also be
breeding areas for insects and snails that transmit diseases such as malaria,
dengue fever and schistosomiasis. Pollution of water bodies by humans also
increases the risks to health. Factors that influence health can be grouped as
The awareness of individuals and communities about health.
The linkages between these factors and health are discussed more fully below
(see also Figure 2.1).
The environment includes both the physical environment we live in and
the social fabric of the community, and both significantly influence health.
The physical environment plays an important role in many ways. A clean
HEALTHY VILLAGES: A GUIDE FOR COMMUNITIES AND COMMUNITY HEALTH WORKERS
Figure 2. 1 Linkages between factors that affect health
environment helps prevent the spread of disease and may reduce depression.
For example, safe and adequate water supplies, sanitation, drainage and solid
waste disposal all benefit health by removing disease vectors from human
contact. Dirty environments, by contrast, encourage the spread of disease and
may adversely influence the mental and emotional well-being of individuals.
CHAPTER 2. ACHIEVING GOOD HEALTH
Industry and traffic also adversely affect health by polluting the air, water
and soil, and by causing accidents.
Equally important are the home and social environments. When the home
environment is dirty, disease may still spread even if the rest of the village is
clean; and where houses are of poor quality, with poor ventilatioji and light-
ing, other health problems may result, such as premature eyesight failure
or respiratory diseases. The social environment also has a major impact
on health. If people are marginalized because of gender, income status or
ethnic /religious affiliation, they are more likely to be prone to anxiety and
depression and to suffer mental ill-health. In particular, the status of women
in the community is important. In communities where women are discrimi-
nated against, they are more likely to suffer both physical and mental ill-
health. By contrast, in communities that are harmonious, accept differences
and promote resolution of conflict through dialogue, the people are usually
2.1.2 Awareness of health issues
The awareness of individuals about health is fundamental to promoting a
healthier village. If people do not understand the causes of ill-health and how
they can improve their health they cannot make decisions about investing
resources and time to improve their village, or about lobbying for outside
assistance. Such awareness should be developed in all areas that influence
health because the different influences are often interrelated. Unless people
accept that they need an improved environment, better personal hygiene and
better access to adequate health care, investments aimed at improving health
may have only limited impact. It is also essential that community members
are aware that improvements in their environment or hygiene need to be
sustained to achieve long-term improvements in their health. Both com-
munity leaders and governments play important roles in developing this
2.1.3 Personal hygiene
Personal hygiene is essential both for improving health and for sustaining
the benefits of interventions. For example, if injuries and minor cuts are
not kept clean, they may become infected and lead to further health prob-
lems. And even though water supplies and sanitation facilities may be
constructed in a community, unless people use these facilities properly and
wash their hands after defecation, store water safely, bathe, and clean clothes
and utensils properly, diseases caused by poor water and sanitation may still
1 HEALTHY VILLAGES: A GUIDE FOR COMMUNITIES AND COMMUNITY HEALTH WORKERS
2.1.4 Health care
All people suffer from disease at some point in their lives and may need to
seek medical advice and treatment. Small children in particular may be prone
to illnesses that require treatment and there are several infectious diseases for
which immunization is recommended (which should be carried out or super-
vised by trained medical staff). In all cases, the health outcomes are pro-
foundly affected by whether health care facilities are available to the people.
Community leaders should therefore lobby national and regional service
providers to locate health care facilities as close to communities as possible
and preferably within the community itself.
2.1.5 Faecal-oral diseases
Many diseases are caused by food, water and hands that are contaminated
by disease-causing organisms or "pathogens" that come from faeces. The dis-
eases caused by these pathogens are called faecal-oral diseases because faecal
material is ingested. These diseases, which include dysentery, cholera, giar-
diasis, typhoid and intestinal worm infections, are responsible for much sick-
ness and many deaths each year. Many of these illnesses and deaths occur
unnecessarily, since the faecal-oral routes of disease transmission are among
the most easily blocked. There are several faecal-oral routes of transmission
(Figure 2.2). For example, many infectious diseases are spread through poorly
prepared and stored food, and many epidemics start with the consumption
of poor quality food, or from drinking contaminated water. Good quality
drinking-water and good personal hygiene in food preparation and hand-
ling are therefore of utmost importance in preventing the spread of these
2.1.6 Vector-borne diseases
Diseases transmitted by vectors such as mosquitoes (malaria) and sandflies
(leishmaniasis) and those with intermediate hosts in fresh water such as snails
(schistosomiasis) place a heavy burden on rural communities in the tropics
and subtropics. They are closely linked to the characteristics of the local
ecology (e.g. standing water or irrigation systems), human behaviour (water
contact patterns) and socioeconomic status (capacity to maintain a clean envi-
ronment). Since the flight range of most disease-carrying insects is relatively
limited and the transmission of schistosomiasis is restricted to water contact
points, communities can make substantial contributions towards making
villages healthier by managing their environment; by using simple vector
control procedures; and by cleaning the village and its surroundings. In many
CHAPTER 2. ACHIEVING GOOD HEALTH
Figure 2.2 Faecal-oral routes of disease transmission
instances these procedures can be incorporated into daily village routines, for
example by modifying agricultural practices.
2.2 Identifying health problems and establishing priorities
To improve the health of people in a community a number of problems may
need to be resolved. While it is better to address these problems in an inte-
grated way, it may be necessary to establish priorities and deal with the most
pressing issues immediately. This situation could arise, for example, if com-
munities or service providers have limited resources and can tackle only a
few problems at a time. Community members may also have different per-
ceptions of the main problems: people living in low-lying areas prone to
flooding may feel that drainage is the major problem to be resolved, whereas
those living in higher areas may be more concerned with water supply. If
external bodies alone are responsible for prioritizing the issues, the priorities
may not reflect community concerns and there may be a more limited sense
of community ownership of a project.
Two questionnaires are provided in this guide that allow community
members to identify major health issues in their community and establish
1 2 HEALTHY VILLAGES: A GUIDE FOR COMMUNITIES AND COMMUNITY HEALTH WORKERS
health priorities. However, to ensure that community priorities are under-
stood and that needs are met, it is essential to involve the different stake-
holders in a community. Women and men, rich and poor, children and the
elderly, and different ethnic and religious groups may all have different
health priorities, and while it may not be possible to accommodate every
view, the final list of priorities should reflect what most people believe are
important health issues. To identify health problems in a community, com-
munity members should try to answer the questions listed below and then
discuss the most pressing issues. During the discussion community members
can try to list (ot rank) the problems identified in order of importance.
Identifying community health issues
Is diarrhoea common among children?
Are worm infections common?
Are respiratory (breathing) problems common?
Are eyesight problems common, particularly among women?
Are malaria or other vector-borne diseases common?
Do many people have fevers?
Have there been recent outbreaks of disease that affected many people in your
Are children undernourished? Do they look thin or lack energy?
Are there health workers or facilities (clinics or health centres) in the community?
Do any children or adults have a mental health problem (e.g. psychosis)?
What are the major health problems identified by community members? List them
in order of importance.
2.2.1 Assessing community perceptions about health
To help identify the most important health problems in a community,
the perceptions of community members about health should be assessed.
It is important that all sections of the community are involved in these
assessments. Different methods for achieving this goal are discussed
One way to find out what people think is to use a community questionnaire.
Because questionnaires may be answered by many people (sometimes, every
CHAPTER 2. ACHIEVING GOOD HEALTH 1 3
household in the community) they can provide good information about the
perceptions of community members towards health problems and health
priorities. However, questionnaires have limitations. Frequently, it may be
difficult for community members to devise their own questionnaires and the
information collected may require sophisticated analysis. As a_ result, it is
likely that nongovernmental organizations (NGOs) or local government
staff will administer the questionnaires, rather than community members.
Nevertheless, the community should always ask for feedback on the findings.
Because the questions must be defined before the information is collected,
the information will be limited to these issues. Questionnaires may not
therefore be flexible enough to include other issues of importance to the
Because of the limitations of questionnaires, a number of other techniques
have been developed. They are often grouped together and referred to as a
participatory rural (or rapid) appraisal. The techniques allow the community
itself to develop areas for discussion, rather than using questionnaire
responses to define the topics. These techniques are sometimes used with
questionnaires: by asking the same question in different ways during com-
munity discussions, issues raised by questionnaire respondents can be
verified. More information about the techniques can be found in the docu-
ments listed in Annex 2. They are briefly discussed below to provide an idea
of how such techniques may be used.
Participatory approaches cover a range of techniques, including key infor-
mant interviews, group discussions and observations. Although these tech-
niques are often used by trained staff, they can also be used by community
leaders to assess the perceptions of community members about health issues.
When using these techniques it is important to balance the need to discuss
all issues of community concern with the need to remain focused on the prin-
cipal objective assessment of community health priorities.
Key informant interviews are discussions with key people within a com-
munity who have a special interest in, or responsibility for, improving health.
Key informants include women's leaders, youth leaders, religious leaders and
health workers. The interviews are usually structured, in that the interviewer
has the objective of obtaining information on key health issues. Rather
than directly asking prepared questions, however, the interviewer can instead
prepare topic guides to ensure that the principal areas of interest are covered
during the course of discussions. The objective of each interview should be
clearly defined and the community members best placed to provide answers
should be identified.
1 4 HEALTHY VILLAGES: A GUIDE FOR COMMUNITIES AND COMMUNITY HEALTH WORKERS
Example topic guide
Uganda: focus group discussion on water usage
To determine which sources of water are used for consumption.
What water sources are available to the community?
Which local water sources do people commonly use?
What are the water sources used for?
What influences decisions to use the sources?
A focus group discussion is a technique that brings together groups of people
to discuss a particular issue, often in an informal setting as illustrated in
Figures 2.3 and 2.4. The role of the group facilitator is to help the group to
identify key issues related to the topic under discussion, while allowing suf-
ficient flexibility to cover all aspects of the topic to everyone's satisfaction. To
help foster agreement about the key issues, it is better to establish a goal or
objective that the whole group agrees with from the outset. For example, the
goal may be to decide which problems are most important to resolve. Some-
times people may give responses that are not relevant, or that appear silly or
amusing to the other group members. It is important that people do not feel
they are being ridiculed for their views. This can be accomplished by saying,
for example, "That is a good point, but maybe we need to discuss the rele-
vance of this."
Problems may arise during group discussions which can lead to biased
answers or dissatisfaction among group members. For example, the discus-
sion may be dominated by a few individuals who express their point of view
forcefully and prevent others from fully participating. Lack of contribution
by some members may also be a problem and it may be necessary to directly
ask such individuals what they think about a particular issue. However, care
should be taken not to appear too aggressive or insistent since some people
find it hard to talk in front of others. One approach that may help everyone
to feel comfortable during discussion is to select individuals from specific
groups, such as women or young people, rather than include a mix of people
in the discussion. To overcome problems in group discussions, it is important
to set ground rules at the outset of the discussion which all members agree
to abide by. If this is not done, the discussion may become heated, some
people may dominate the group and others may feel disappointed with the
CHAPTER 2. ACHIEVING GOOD HEALTH
Figure 2.3 Focus group discussions
Figure 2.4 Small community discussions
1 6 HEALTHY VILLAGES: A GUIDE FOR COMMUNITIES AND COMMUNITY HEALTH WORKERS
Ground rules for focus group discussions
There are no right or wrong answers, just different opinions.
Everyone has the right to express their opinion and should not be penalized if the
group feels the opinion is not relevant or interesting.
Only one person at a time should talk; when someone wants to contribute they
should raise their hand.
No one person should dominate the discussion all should be allowed to
Different sections of the community may have different opinions about which
problems are most important. To reflect this, different groups in the commu-
nity can prepare a map that locates the most important problems. The map
can then be used as a discussion tool with the groups to help community
members decide which activities should be undertaken to improve the health
of the overall community.
Key points for collecting information from a community
All sections of the community should have input into the process. Priorities estab-
lished by only a few people may not cover all needs adequately.
Decide from the start how the information will be used. This should be developed
with the whole community.
Make sure the information is reliable.
2.2.2 Identifying causes of health problems
Once the major health problems in a community have been identified, the
underlying causes need to be examined so that priorities for action can
be ranked. For example, diarrhoea in a community may be caused by
poor-quality water, by unhygienic food, or by a lack of sanitation, and the
type of intervention required will depend on the nature of the underly-
ing cause. To help identify the principal causes of ill-health in a community
and the most important areas to improve, community members can complete
the following questionnaire and discuss the findings with the whole
CHAPTER 2. ACHIEVING GOOD HEALTH 1 7
Identifying causes of community health problems
What types of water supply does the community have?
Is the water source protected and/or treated?
How much water is collected by households?
Is the water always available?
Does everyone have access to water?
Does the community know the quality of the water?
Are there special places for bathing and laundry?
Do households have some form of sanitation?
What types of sanitation are there?
Are there separate facilities for women (in areas where mixed facilities are
Is solid waste disposed of, or does waste build up in the village?
How is solid waste disposed of?
Are there stagnant or standing bodies of water in the community?
Is there a system of drainage in homes and for the community?
Is there a market in the community?
Is the market area cleaned every day?
Is the market dirty?
Is meat sold at the market?
Is the meat always fresh?
Are market vendors careful with personal hygiene and do they keep their hands
Does the market have water supply and sanitation facilities?
Are chemicals used or stored in the community?
How are they stored?
How are chemicals disposed of?
Do houses in the community have many windows?
What cooking fuel is used in the community?
Where do people cook in the community?
What materials are used for house construction?
Are mosquitoes, flies and other insects common in the community?
Are rats and other vermin common?
Are cattle or other domestic animals kept close to homes?
Are the same bodies of water used for washing, laundering and receiving human
and animal wastes?
What are the major problems? List them in order of importance to the community.
1 8 HEALTHY VILLAGES: A GUIDE FOR COMMUNITIES AND COMMUNITY HEALTH WORKERS
2.3 Using the information
Whichever techniques are used it is essential that the information obtained
reflects broad opinion in the community, is reliable and can be translated into
action. Once the major causes of ill-health have been identified by the com-
munity and the necessary interventions agreed upon, the resources required
must be identified. If the community lacks the necessary resources, repre-
sentatives of the local government and NGOs can be contacted to discuss how
best to carry out the improvements. It may be possible to prepare a proposal
that identifies the work the community would like to undertake, how much
the improvements would cost and the contributions community members
themselves can make.
The time and money required to keep improved facilities working should
also be considered, because benefits may be short-lived if the community
cannot afford to maintain improvements. It is important therefore to discuss
with community members, local governments and NGOs the long-term
requirements of improvements and whether they are affordable. This will
help community members to select options most suited to community needs
Water is critical to life, but it is also a limited resource and several interrelated
factors are decreasing its availability. These factors include climate changes,
increasing demand, lowered water tables and environmental degradation.
There is also the growing threat of international and intercommunity disputes
over water supplies. It is important, therefore, that communities manage their
water resources better and supply water for specific uses.
For most people, it is not a problem to obtain the minimum amount
of water necessary to sustain life. Rather, problems relate to the quantities of
water required for different activities (resource allocation) and the quality of
the water available (source suitability). Many places with water shortages
actually receive abundant rainfall and community-based initiatives could
alleviate water scarcity. Such initiatives may incorporate traditional
approaches and include water management and conservation measures;
sustainable rates of extraction; sustainable crop production; catchment
protection; rainwater harvesting; and soil conservation.
3.1 Providing community water supplies
To promote community health an easily accessible water supply should be
available that provides sufficient safe water to meet community needs.
Household water needs can be estimated by questioning community mem-
bers about their daily water use. If this is not possible, a minimum water need
can be calculated by assuming that the average person uses 25 litres per day
for drinking, cooking and personal hygiene. More water will be needed for
laundry, but this may be available from other sources such as rivers or ponds.
To ensure that the water is potable, either the water supply should be pro-
tected or the water should be treated before use. Low-risk water supplies for
drinking and other domestic uses can be provided to communities in many
ways. Often, unprotected water sources, such as springs, traditional wells and
ponds, can be improved and this may be preferable to constructing com-
pletely new supplies. However, unprotected sources are open to contamina-
20 HEALTHY VILLAGES: A GUIDE FOR COMMUNITIES AND COMMUNITY HEALTH WORKERS
tion and pose a potential health risk. Community hygiene programmes
should therefore promote the use of protected drinking-water sources.
Characteristics of low-risk water sources
The water source is fully enclosed or protected (capped) and no surface water can
run directly into it.
People do not step into the water while collecting it.
Latrines are located as far away as possible from the water source and preferably
not on higher ground. If there are community concerns about this, expert advice
should be sought.
Solid waste pits, animal excreta and other pollution sources are located as far as
possible from the water source.
There is no stagnant water within 5 metres of the water source.
If wells are used, the collection buckets are kept clean and off the ground, or a
handpump is used.
When resources are limited, it may be necessary to decide whether greater
emphasis should be placed on the quality of the water, or on its availability.
Where sufficient safe water for all is not immediately available, intermediate
steps should target the provision of larger quantities of lower-quality water.
Deciding on an acceptable level of contamination is difficult and depends on
the willingness of community members to pay increased costs for better
water, as well as on their willingness to treat water within the home. If
payment is required for water use, it must be affordable to the whole com-
munity. In any case, water with high levels of contamination, particularly
with faeces, should never be used. Local health officials should be consulted
about the quality of water provided and the level of health risk.
Many rural water supply programmes aim to develop water sources that
can be fully managed by users, with only limited additional support from
local government. While this can make a sense of community ownership more
achievable, it also requires communities to make long-term commitments,
such as maintenance of improved water sources, and even to contribute finan-
cially towards their construction. If this is not done, the water supply may
deteriorate as shown in Figure 3.1. This means that it is important to involve
communities during all stages of development of the improved water sources,
from initial planning and implementation to long-term management. Com-
munity members should be actively involved in selecting the type of water
supply they receive and have access to information that allows them to make
informed decisions. However, discussions must be balanced and should also
Fi g u re 3 . 1 Unhealthy practice (water supply is damaged)
consider what the supporting agency considers feasible, not simply what the
community desires. On the other hand, solutions chosen solely by outside
agencies are more likely to fail.
From the outset it is also essential that community members are fully
aware of the short- and long-term implications of their choices, for while it is
relatively easy to build an improved water supply, sustaining it is often a
major problem. For example, boreholes with handpumps are often recom-
mended to communities, but this technology requires relatively expensive
maintenance, and access to spare parts and tools is essential. In one country,
spares for handpumps were available only in the capital city, a two- or three-
day journey for remote communities. As a result, the handpumps were likely
to fail in a very short time and the investment would have been wasted.
Checklist for communities considering water supply improvements
Have community members been fully consulted about the type of water supply?
Have community members had previous experiences with water supply improve-
ments and have these been relayed to the relevant agency?
How will the water supply be managed to ensure that it is reasonably accessible
to everyone in the community?
How will initial costs be paid and is the community expected to provide labour?
Will labour be provided free or will the community have to raise funds to cover
22 HEALTHY VILLAGES: A GUIDE FOR COMMUNITIES AND COMMUNITY HEALTH WORKERS
What are the long-term financial implications of the choice of water supply?
Can the community afford to pay expected operation and maintenance costs?
What spare parts are required and how often should they be replaced?
Who sells these spares and where are they obtained?
What tools are required and where can they be obtained?
Who will be trained to operate and maintain the water supply?
What skills should operators have and what training will they receive?
What long-termjsupport can the community expect from the government and other
If major repairs are required, whom should you contact and who will pay?
Will the quality of the water be tested?
How often will testing be done and how will the information be communicated to
3.2 Types of water sources
3.2.1 Protected springs
A spring is where underground water flows to the surface. Springs may occur
when the water table meets the ground surface; these are called gravity
springs. Other times water is forced to the surface because the water-
carrying layer meets an impermeable layer (gravity overflow springs or
contact springs). In some cases, ground water is held under pressure and
springs come to the surface because of a natural break in the rock, or because
a shallow excavation is made (artesian springs).
Springs can make very good water supplies provided that they are prop-
erly protected against contamination. If springs are found above the village,
they can feed a pipe system for providing water close to homes. When a
spring is at the same, or lower, level than the village, it can still be protected,
but greater care is needed and it is unlikely that water will flow through the
pipe system by gravity. The first step in deciding whether a spring should be
protected is to determine whether it provides enough water for the expected
number of users. This is easily done by measuring the time it takes for the
spring to fill a bucket of known volume.
CHAPTER 3. WATER 23
Estimating whether a water source has sufficient flow rate
A spring fills a 20-litre bucket in 6 seconds, corresponding to a flow rate of 3.3
litres per second (20/6 = 3.3).
In 24 hours, this spring would provide 285000 litres (3.3 x 60 x 60 x 24).
If each person uses 25 litres per day, the spring will supply the daily needs of
1 1 400 people (285000/25).
NB: a storage tank may be needed so that water flowing from the spring at night
can be stored and used during the day, instead of running to waste.
To protect a spring, a retaining wall or box is constructed around the "eye"
of the spring, where the water emerges from the ground. The area behind the
wall or box is backfilled with sand and stones to filter water as it enters the
box and help remove contamination in the groundwater. The backfill area is
capped with clay and grass is planted on top.
The whole area should be fenced and a ditch dug above the spring to
prevent surface water from eroding the backfill area and contaminating the
spring. The collection area should be covered with concrete and sufficient
space left beneath the outlet pipe for people to place jerry cans and buckets.
A lined drain should be constructed to carry spilled water away from the
spring. The water could be used for laundry, to feed an animal-watering
trough or for irrigating a garden. In other situations spilled water may be
drained to a soak-away pit or to the nearest surface water body. To prevent
mosquito breeding, water from the spring should not be allowed to form
pools. An example of a well-protected spring is shown in Figure 3.2.
As discussed earlier, all water supplies need to be maintained. Although
protected springs require very little maintenance, far less than a borehole
with handpump, the following basic checks should be carried out every 1-3
Examples of basic checks for protected springs
Does the water change colour after rain?
Has a water-quality test been carried out recently?
Did the community receive the results of the test?
Is the area behind the retaining wall losing the grass cover?
Does the retaining wall show signs of damage?
Can this be repaired locally?
Does the uphill ditch need clearing?
Does the downhill ditch need clearing?
HEALTHY VILLAGES: A GUIDE FOR COMMUNITIES AND COMMUNITY HEALTH WORKERS
Does the fence need repair?
Does the grass behind the retaining wall need cutting?
Do the outlets leak?
3.2.2 Dug wells
Dug wells are usually shallow wells dug by hand, although some may be quite
deep, and they are often lined with bricks. However, unless artesian water is
tapped, many dug wells go dry or have very little water in dry periods because
it is difficult to sink wells below the water table without using more sophisti-
cated techniques. In some arid areas, dug wells have traditionally been con-
structed in sandy riverbeds. Where flooding is rare, such wells can be
improved to provide dry-season water sources. To protect the well from river
Figure 3.2 Collecting water from a protected spring
CHAPTER 3. WATER 25
damage during the rainy seasons the well opening can be covered with a con-
crete slab and a concrete barrier built upstream from the well. In sandy
riverbeds with water-resistant bedrock beneath, walls can be constructed
under the sand to create sand dams. These collect the river water and can
ensure that nearby wells are productive for longer periods in the dry season.
The shaft of an improved dug well has a concrete lining above the dry-
season water table and a series of concrete rings (caissons) sunk below this
level to ensure a year-round supply of water. The lining acts both to protect
the shaft from collapse and to prevent surface water from infiltrating into the
well at shallow depths. The top of the well (the wellhead) is built up by
at least 30cm and an apron is cast around it to prevent surface water from
entering the well directly Usually a permanent cover is put over the well and
water is drawn by a handpump or windlass and bucket. People should not
use their own bucket to draw water from the well as this may contaminate
the water in the well. A communal rope and bucket attached to the well can
be used to draw water, but the bucket and rope should be kept off the ground.
One way to do this is to put a hook inside the well and always store the bucket
on it. Once a dug well is completed it should be cleaned with chlorine and
the pump installed.
The advantage of improved dug wells is that they can be deepened and,
if the handpump or windlass fails, water can still be collected, although care
should be taken not to contaminate the water by using individual buckets.
However, dug wells are more likely to go dry in prolonged dry periods, or if
large volumes of water are pumped from nearby deep boreholes, and they
are easily contaminated. Nevertheless, they provide a low-cost water supply
and communities can be actively involved in their construction. Abandoned
wells should be closed to avoid polluting groundwater.
Boreholes are narrow holes drilled into the ground that tap into groundwa-
ter. Boreholes can be drilled using motorized rigs operated by trained staff,
but this is expensive. Boreholes can also be drilled by hand using an augur,
or by forcing water into the ground under pressure ("jetting"). If a community
is involved in the actual sinking of the borehole, it is likely to use auguring
or jetting because these are less expensive methods, but it is not possible to
sink deep boreholes with these methods. Depending on the depth of the
groundwater, a handpump may be required to bring the water to the surface.
The practical limit for most handpumps is 45 metres; beyond this a motor-
ized pump (diesel-, electric-, wind- or solar-powered) may be required.
As the borehole is drilled, a lining of plastic, steel or iron is sunk to protect
the hole from collapse. The lining has slots in the bottom section to allow
HEALTHY VILLAGES: A GUIDE FOR COMMUNITIES AND COMMUNITY HEALTH WORKERS
water to enter the borehole and gravel is placed around the bottom of the
lining to improve flow and provide filtration. The top few metres around the
borehole should be sealed using concrete, and a concrete apron is cast around
the top of the borehole to prevent surface water from flowing into the lined
shaft. A stand is usually cast into the apron to provide a stable base for the
pump. Once the borehole is completed it should be cleaned with chlorine and
the pump installed.
Boreholes with handpumps are often provided to villages, with the
community being given responsibility for operation and maintenance. An
example is shown in Figure 3.3. Unfortunately, many boreholes world-
wide are no longer working because simple repairs have not been carried
out. Consequently, if a borehole is drilled in a village, it is important that
maintenance costs and activities can be met by the community. This may
require additional training in financial management to ensure that funds
can be raised for maintenance. In addition, it is particularly important to
make sure that all required spares can be purchased within a reasonable
distance from the village. For major repairs beyond the skills of the com-
munity, clear information as to how these repairs will be carried out
should be requested from the relevant agency. If the agency is unable or
unwilling to provide this information, the community may not wish to
commit to working with the agency, since failure of the project may not be
Figure 3.3 Handpump on a borehole
CHAPTER 3. WATER 27
seen as the fault of the agency, and may bar the community from future
Boreholes usually provide good quality water, but the water sometimes
contains harmful chemicals, such as fluoride and arsenic, or nuisance chem-
icals such as iron. Although a village would not be expected^ to carry out
chemical analysis, community members should request that tests be carried
out by the government agency or development partner, and the results
fully discussed with the community. In villages with existing boreholes, com-
munity members should share their experiences with agency representatives
before more boreholes are drilled. This will help both parties to make better
decisions about the water supply.
Factors to consider when selecting a borehole water supply
What training will be provided for maintaining the pump?
What tools and materials are required for maintenance?
What tools and materials are provided by the outside agency?
What tools and materials must be purchased by the community?
How much do these tools and materials cost?
Where can spare parts be purchased?
How much do spare parts cost?
How often do spares need to be purchased and what is their shelf-life?
3.2.4 Piped water supply
Many villages may have piped water systems that supply communal taps or
yard taps. These piped water systems are often small and rely on community
management, and many use untreated ground water sources. Small piped
water systems are usually fed by gravity, either from protected springs or
from surface water above the village, although some may be supplied from
boreholes fitted with motorized pumps. Most piped water supplies include
storage tanks so that water is always available, even when demand is heav-
iest. Such tanks are usually necessary because the rate of water use at peak
times of the day (often early morning and early evening) is greater than the
average rate of use throughout the day. The tanks also provide emergency
storage in the event of a breakdown. When planning a piped system, com-
munity members should consider carefully where to locate the taps, so that
everyone has relatively easy access. However, the design of piped systems
can be quite complicated and it may not be possible to place taps where
people would prefer.
HEALTHY VILLAGES: A GUIDE FOR COMMUNITIES AND COMMUNITY HEALTH WORKERS
Figure 3.4 Single standpost with surround
As with boreholes and handpumps, piped systems require regular main-
tenance. Pipe leaks need to be repaired rapidly to prevent water loss, and to
prevent surface water from entering the pipes and contaminating the supply.
Also, communal taps are likely to be used heavily and users may not be as
careful as they would with their own taps. As a result, the taps are more likely
to break and will need frequent replacement. One way of dealing with these
issues is to give someone in the community responsibility for checking com-
munal taps and making repairs. To prevent the accumulation of stagnant
water around community taps, which could become mosquito breeding sites,
community members could build a concrete "apron" at the base of the taps
and include a drain and a soakage pit. An example of a standpost is shown
in Figure 3.4.
Another problem with piped systems is that users do not consider the
impact of how much water they use, and may not think it is important to turn
off the tap after use. When there is a lot of water, this may not have negative
consequences. However, where the amount of water available is limited, if
CHAPTER 3. WATER 29
users at the high end of the system leave taps running, users lower down may
suffer shortages or intermittent service. This can force them to use less safe
sources of water. Moreover, if the pipes are dry or have very low flow rates,
surface water may enter the pipes and contaminate the piped water. Users of
piped water systems should thus be aware of the impact of their water use
on others and good water use should be promoted. This could be supported
through village regulations or by-laws that penalize people who persistently
abuse the system.
3.2.5 Rainwater harvesting
Although rainwater can be a good source of water for drinking and domes-
tic use, it may be seasonal, and it is often difficult for a community to rely on
rainwater alone. Collecting sufficient rainwater for an entire community also
requires relatively large roofs and tanks, and the supply may still not be suf-
ficient. Instead, rainwater is usually collected by households for their own
use. If the rainwater is to be used for drinking it is better to collect it from a
roof, rather than from a ground catchment where it may become contami-
nated. Ground catchments are more appropriate for agricultural use.
Using roofs to collect rainwater is relatively easy and a lot of water can
be collected. For example, 50mm of rainfall on a 4m 2 roof yields 200 litres
of water. All that is required are gutters around the roof that discharge
into a collection tank. The roofing material is important and hard surfaces,
such as iron sheets or tiles, allow more rain to be collected than softer surfaces
such as thatch and grass, which absorb water. Hard surfaces are also easier to
keep clean and are less likely to have insects and animals living in them.
Any roof used to collect rainwater for human consumption must be thor-
oughly cleaned at the start of the rainy period. Birds and animals may leave
faeces on the roof and these can be a source of pathogens. There should be a
system for diverting the flow of water in gutters away from the tank, so that
the first rains (which are more likely to pick up contamination from the roof)
are not collected. A small filter may be added to the top of the collection tank
as an added protection. The tank should also be cleaned every year and any
silt or algal matter removed. After cleaning and before use, the tank should
be scrubbed using a chlorine solution (bleach).
Water should be drawn from a tap at the base of the tank, rather than with
a bucket, which may contaminate the water. It is better not to bury the col-
lection tank, even partially, since contaminated water from the soil can enter
the tank. Covering the tank is also essential for preventing contamination of
the water and for reducing opportunities for disease vectors to breed.
30 HEALTHY VILLAGES: A GUIDE FOR COMMUNITIES AND COMMUNITY HEALTH WORKERS
3.2.6 Ponds, lakes and water treatment
Ponds and lakes have traditionally been used as sources of drinking-water.
Although they are easily contaminated, the water quality can be improved
by careful use. For example, if platform steps or ramps are constructed at the
water edge, people can be encouraged not to walk into the pond or lake when
collecting water. This rapidly stops the discharge of guinea-worm eggs into
the water, thus interrupting transmission. Preventing urination and defeca-
tion close to or in the pond may reduce schistosomiasis. Even so, dirt
deposited on these structures can enter the pond, especially when it rains.
Pumps mounted on the banks of ponds can also supply water to people away
from the pond, but these may be difficult to maintain. Alternatively, a pro-
tected intake with a layer of sand as filter can be constructed in the pond or
lake and be connected to a handpump. Whichever method is used, however,
domestic water drawn from ponds and lakes must always be treated before
consumption. Although water treatment can be complicated, communities do
operate and maintain simple water- treatment plants. Some simple technolo-
gies are robust and have been community-managed in Latin America and
parts of Asia. They are usually based on several filtration stages and tend not
to use expensive chemicals and dosing equipment.
Pond or lake water is easily contaminated and should be treated with a
disinfectant as a minimum. The most commonly used disinfectant is chlorine,
although others can be used. Chlorine can be added as a solution of calcium
hypochlorite, as chlorine gas or as other chlorine compounds. Achieving the
correct ratio of chlorine and water is complicated, however; using too little
chlorine will not kill the pathogens, while using too much will make the water
Some treatment systems, called package plants, come ready constructed.
Package plants have been promoted on the basis of their low operational
requirements; however, when package plants fail they usually require spe-
cialist repairs and equipment beyond the means of a small community. This
should be taken into consideration when deciding whether to use a package
3.3 Household water treatment
Sometimes the best option for improving water quality is to treat water in the
home, by boiling, filtering, chlorinating or leaving the water to settle. These
options are discussed in more detail in the following sections.
CHAPTER 3. WATER 31
Bringing water to a rolling boil will destroy pathogens in the water and make
it safe to drink. Boiled water tastes "flat", but if it is left for a few hours in a
partly filled, covered container, it will absorb air and lose its flat taste.
3.3.2 Canvas filters
Canvas bags are the simplest type of home filter. The bag is filled with water
and the water collected as it seeps out of the bag. This makes the water cleaner
and, although it does not remove all pathogens, is particularly useful for
removing Cyclops containing guinea- worm eggs. Bags that have been spe-
cially treated to prevent them from rotting are available.
3.3.3 Candle filters
Candle filters are hollow, porous ceramic cartridges. Although they do not
filter out all pathogens, they should remove the larger ones such as protozoa,
worms and bacteria (but not viruses). Ceramic candles need careful mainte-
nance and should be cleaned and boiled at least once a week, even if they are
not clogged. If a candle filter becomes clogged, it should be scrubbed under
running water with a stiff brush free of soap, grease or oil. To reduce the risk
that water will pass through a candle without being filtered, such as through
a small crack, candle filters should be regularly inspected and replaced if nec-
essary. In some countries it is common to both filter and boil water. Where
this is done, the water should be filtered first and then boiled. Some filters
incorporate silver into the candle, but this does not disinfect the water and
the candle acts simply as a normal filter.
One method of treating water in households is to add chlorine. This will kill
most bacteria and some viruses. Since the taste of chlorine disappears when
water is left in open containers, a very small lump of bleaching powder or
one drop of household bleach can be added to a 20-litre water container and
the mix left to stand for at least 30 minutes. After this time, if a faint smell of
chlorine can be detected in the water, it should be low-risk and palatable to
drink. Chlorine should only be added to clear water otherwise it will be
absorbed by the dirt in the water. Moreover, chlorine that has been stored for
some time will lose potency. The use of disinfectants as a household treat-
ment system has been successfully implemented in Latin America and Asia.
Other disinfection systems have been developed for treating household
water, particularly the use of solar radiation. There are some simple methods
32 HEALTHY VILLAGES: A GUIDE FOR COMMUNITIES AND COMMUNITY HEALTH WORKERS
of solar disinfection (e.g. SODIS), which can effectively treat water, although
this may take longer than chlorine disinfection.
Household water treatment
In Bolivia, household water treatment was introduced into two communities where
water quality was generally poor. The treatment used mixed oxidants (including
chlorine) and a container fitted with a tap. After the treatment was introduced, faecal
contamination of water samples was reduced by over 90% and the incidence of diar-
rhoea dropped by almost 50%. Similar improvements have been observed in other
countries, such as Bangladesh, demonstrating that household treatments can be
Source: Quick RE et al. Diarrhoea prevention in Bolivia through point-of-use water treatment and safe storage:
a promising new strategy. Epidemiology and Infection, 1999 122:83-90.
Where water is cloudy or muddy, a simple treatment is to allow particulates
in the water to settle overnight. Clear water at the top of the container is then
poured into a clean container. Adding certain chemicals can help settling,
such as a pinch of aluminium sulfate (alum), or powder from the ground
seeds of Moringa oleifera (horseradish tree) and Moringa stenopetala, sprinkled
onto the water surface.
It should be stressed that settling does NOT remove all pathogens, silt or
clay. The settling of particles may reduce pathogens but some will remain,
and water should be boiled or disinfected before it is consumed.
3.4 Safe handling of water
Frequently, water collected from a communal point and transported back to
houses for use becomes contaminated because of poor handling. Community
members should therefore be aware of the risks of contaminating the water
and how it can be prevented.
All water containers should be clean, especially inside. It is always best
to clean the insides of storage containers with either detergent or chlorine.
Leaving a capful of bleach in a sealed plastic or metal container full of water
for 30 minutes will kill most pathogens. If detergent or chlorine is not avail-
able, the insides of clay pots can be cleaned with ash. Plastic or metal con-
tainers should be cleaned weekly by putting clean sand and water inside
them and shaking for a few minutes. The top of the water container should
be covered to stop dust and other contaminants falling into the drinking-
water. It is best for water to be poured from the container to prevent contact
CHAPTER 3. WATER
with dirty fingers and hands. An example of a good storage container is
shown in Figure 3.5.
When scoops are used to take water out of the storage container they
should be clean and kept inside the water storage jar. They should never be
placed on the floor.
3.5 Monitoring water quality
Water of poor microbial quality can have a significant impact on the health
of community members by causing disease and contributing to the spread of
epidemics. Water quality should therefore be monitored on a regular basis.
Ideally, it should be tested by staff working with local and national govern-
ment in support of the Healthy Villages programme. The community should
request that such support is given by the local authorities, particularly if it
suspected that the community water supply is contaminated. The test results
should be provided to the community and if any problems arise, the com-
munity should request recommendations for solutions.
3.5.1 Microbial quality
The major concern of microbiological testing is whether faeces have contam-
inated the water supply, as most of the infectious water-related diseases,
such as cholera and dysentery, are caused by faecal contamination. Although
these diseases can also be transmitted through poor hygiene and inadequate
Figure 3.5 Household storage container
34 HEALTHY VILLAGES: A GUIDE FOR COMMUNITIES AND COMMUNITY HEALTH WORKERS
sanitation, control of drinking-water quality is one of the main ways of pre-
venting their spread.
Using surveillance to promote better management of water quality
Environmental health staff from local councils in Uganda used water quality tests as
a way of working with communities to identify problems. The staff took water samples
from sources and households, and then left the water testing kit overnight so that
community members could perform the tests themselves. The next day the results
were discussed with community members. The discussions were always lively and
the approach helped to improve both the management of protected springs and
water handling and hygiene practices. Discussing the results of water quality tests
with communities was an effective way of promoting improvements.
The principal method of assessing the microbial quality of water is to test
for bacteria whose presence indicates that faeces may be in the water. An
analysis of the test results is usually beyond the resources of communities
and will be carried out by health or water officials. However, community
members can request that officials regularly test the water supply and inform
the community of the results and recommendations. Some kits have been
developed for community use, but the results of these tests should be
analysed with caution.
3.5.2 Sanitary inspection
An analysis of water quality usually also includes a sanitary inspection. This
is a visual assessment of the water supply, using standard forms to record
information, to see whether faecal pollution exists and whether such pollu-
tion could reach the water source. Sanitary inspections can be undertaken
by communities on a regular basis as part of operation and maintenance,
and forms have been developed in several countries to help communities
undertake these inspections. Many of the risks to the water supply relate to
improper operation and maintenance activities in the area around the water
source, and sanitary inspection can be used to ensure that these tasks are
carried out to keep the water supplies safe. Examples of sanitary inspection
forms for community use are available in a number of the documents listed
in Annex 2.
3.5.3 Chemical quality
It may also be necessary to test community water supplies for harmful
chemicals. Certain chemicals, such as fluoride, nitrate and arsenic, represent
a health risk, whereas others, for example iron, manganese and sulfate, may
CHAPTER 3. WATER 35
cause consumers to reject the water because it is unpleasant to drink or stains
clothes and causes other problems. Testing is usually done by health or water
officials, but community members can play a key role by demanding that such
analyses are carried out, and by informing officials of any developments that
may cause contamination of the water supply When a water supply is first
developed, a full water quality analysis should be carried out. TRe commu-
nity should request feedback regarding this analysis and ask for guidance
concerning the suitability of the water source for drinking.
3.6 Managing community water resources
Communities need to conserve water resources for future generations; ways
in which this can be accomplished are discussed in the following sections.
3.6.1 Preventing over-pumping of groundwater
Communities should discuss with outside agencies the short- and long-term
impacts of water supply improvement on water resources. For example,
sinking too many tubewells for irrigation may cause serious depletion of
water held underground and even cause water sources to dry up. This can
also lead to deteriorating water quality: as the water table falls, domestic tube-
wells must be sunk deeper into underground water that may contain harmful
chemicals such as fluoride or arsenic. Because community members are the
principal stakeholders of local water resources, they should always ask
planning agencies to assess the longer-term effects of water pumping on the
environment and should be actively involved in evaluating the risks.
3.6.2 Water conservation
Although it is important that people use enough water for good hygiene,
in areas where water is scarce it is also important not to waste water. Piped
water supplies are particularly vulnerable to wastage; if they are not prop-
erly managed, the community as a whole may suffer water shortages and
people will have to wait longer to collect water. Most piped water systems
leak and need to be checked regularly and repaired as soon as faults are dis-
covered. Taps should also be turned off immediately after use and children
discouraged from playing with taps.
Questions to ask in areas prone to water shortages
Does the main water source dry up?
If so, where will water be collected?
36 HEALTHY VILLAGES: A GUIDE FOR COMMUNITIES AND COMMUNITY HEALTH WORKERS
How far away are alternative sources of water and how long does it take to collect
Who collects the water and how often do they have to go to the source?
How much water do families collect each day?
Does the source provide sufficient water?
Are there problems with water quality?
Would rain failure next season bring a drought?
What would be the effect on pasture, vegetation and crops?
What would be the traditional response to drought?
3.6.3 Managing water for agriculture
Farmers can protect their lands by building small stone dykes or growing
hedges along the edges of fields. These prevent rainwater from running down
slopes too fast and reduce erosion. Some of the rainwater infiltrates the soil,
and crops near the dykes have a higher survival rate in times of water stress
and produce yields about 40% higher than crops further from the dykes. The
amount of water that goes into the ground water is also higher in these areas.
The introduction or expansion of irrigated agriculture will cause impor-
tant changes in the local hydrology, land use patterns and ecology. Such
changes may introduce new health risks into the area, although there are
ways to manage these risks. Some examples of health risks and how they may
be managed are listed below.
When irrigation is permanently introduced into arid areas, habitats for
disease vectors, such as the malaria-carrying anopheline mosquitoes,
can also be created. This is particularly a problem in low-lying areas
where drainage is poor and pools of stagnant water appear. Also, if the
local drinking-water wells become saline, the community may use irri-
gation channels as a source of drinking-water, increasing the risk of diar-
rhoeal disease, of schistosomiasis (from contact with the water) and of
exposure to agrochemical residues. To help counter these risks, the com-
munity can take measures such as maintaining proper drainage, ensur-
ing water systems are well-maintained and filling ground depressions.
Water storage facilities are an essential part of many irrigation systems,
but small dams /reservoirs and tanks can pose health risks by acting as
breeding habitats for disease vectors, and as foci for transmitting schis-
tosomiasis and guinea- worm infections. Options for a Healthy Village
approach include fencing off reservoirs, varying the water reservoir
levels, removing weeds and flushing the surrounding areas.
Mosquitoes often breed in areas flooded for rice production, but the
CHAPTER 3. WATER 37
breeding cycle can be interrupted by alternately flooding and drying
the rice plots (as opposed to continuous flooding). A well-designed
regime will also save water and may even increase rice yield.
Irrigation water demands can be reduced by recycling treated waste-
water. Recycled wastewater can be used productively to irrigate fruit,
such as papaya and banana, or for irrigating vegetable gardens. Euca-
lyptus and papyrus should be avoided, since they are "water-hungry"
plants. Safe use of wastewater is discussed further in section 4.2.
Safe disposal of excreta, so that it does not contaminate the environment,
water, food or hands, is essential for ensuring a healthy environment and for
protecting personal health. This can be accomplished in many ways, some
requiring water, others requiring little or none. Regardless of method, the
safe disposal of human faeces is one of the principal ways of breaking the
faecal-oral disease transmission cycle. Sanitation is therefore a critical barrier
to disease transmission.
Plans for locating sanitation facilities, and for treating and removing
waste, must consider cultural issues, particularly as sanitation is usually
focused on the household. Excreta disposal may be a difficult subject for a
community to discuss: it may be taboo, or people may not like to discuss
issues they regard as personal and unclean. In some cases, people may feel
that sanitation facilities are not appropriate for children, or that children's
faeces are not harmful. In others, separate facilities may be required for men
and women, and it may be necessary to locate the facilities so that no one can
be seen entering the latrine building. If the disposal facilities smell and are a
breeding ground for flies, people may not use them.
Health improvement comes from the proper use of sanitation facilities, not
simply their physical presence, and they may be abandoned if the level of
service does not meet the social and cultural needs of community members
at an affordable cost, as shown in Figure 4.1. Within a community, several
different sanitation options may be required, with varying levels of conveni-
ence and cost (sometimes called a sanitation ladder). The advantage of this
approach is that it allows households to progressively upgrade sanitation
facilities over time.
4.1 Technologies for excreta disposal
Technologies for excreta disposal, with illustrations, are briefly discussed
below. More detailed information is provided in the references cited in
CHAPTER 4. EXCRETA DISPOSAL
Fi g u re 4.1 Disused latrine
Cartage is the most basic form of excreta disposal faeces are collected in a
container and disposed of daily. An example is the bucket latrine, in which
household wastes are collected in buckets under a hole in the floor of a
specific room. Each day, the bucket is emptied into a larger container and the
contents disposed of. Bucket latrines should not be promoted because they
pose health risks to both users and collectors and may spread disease. If
cartage is considered for your community, a vault latrine (a latrine where
wastes are stored in a sealed container) that is mechanically emptied on a
regular basis is a better choice.
40 HEALTHY VILLAGES: A GUIDE FOR COMMUNITIES AND COMMUNITY HEALTH WORKERS
4.1.2 Pit latrines
In most pit latrine systems, faecal matter is stored in a pit and left to decom-
pose. Unless specifically designed, pit latrines do not require periodic emp-
tying; once a pit is full it is sealed and a new pit dug. If faecal matter is left
to decompose in dry conditions for at least two years, the contents can be
safely emptied manually and the pit reused. Indeed, some pit latrines are
designed to allow faecal matter to compost and be reused in agriculture.
Other designs use two alternating pits, reducing the need for new pits. Some
pit designs are meant to be completely dry, while some use small quantities
of water. Ventilation to remove odours and flies is incorporated into certain
designs, while others are very basic and use traditional materials and
approaches. As with all sanitation designs, it is important to know what com-
munity members want and can pay for before embarking on construction. An
example of an improved pit latrine is shown in Figure 4.2.
The sanplat is the cheapest and most basic pit latrine. It is a small concrete
platform (usually 60 cm x 60 cm or smaller), laid on top of logs or other sup-
porting material traditionally used to cover the pit. The purpose of the sanplat
is to provide a sanitary (san) platform (plat) which can be easily cleaned to
limit the presence of helminths such as hookworm. Once the pit is full, the
sanplat can easily be moved. However, the sanplat design does not overcome
problems with odours or flies and may not be acceptable to some community
members. The sanplat is best used when there is very little money for improv-
ing sanitation and where odours and flies will be tolerated.
The VIP latrine
The VIP (ventilated improved pit) latrine is designed to overcome some of
the problems with traditional latrine designs, but it is more expensive than a
sanplat. It has a vent pipe from the pit to above the roof of the building as
shown in Figures 4.3 and 4.4. When air flows across the top of the vent pipe,
air is drawn up the pipe from the pit and fresh air is drawn into the pit from
the building. Offensive odours from the pit thus pass through the vent pipe
and do not enter the building. The location of VIP latrines is important: unless
a clear flow of air is maintained across the top of the vent, the ventilation
system may not be effective. VIP latrines should therefore be located away
from trees or high buildings that may limit airflow. A dark vent pipe also
helps the air to rise. The top of the pipe is usually covered with mosquito
meshing. If the inside of the building is kept partially dark, the flies will be
attracted to light at the top of the pipe, where they will be trapped and die.
CHAPTER 4. EXCRETA DISPOSAL
Figure 4.2 Improved pit latrine
When the VIP latrine is constructed and used properly, it provides great
improvements in fly and odour control, but may not eliminate either
A VIP latrine is designed to work as a dry system, with any liquid in the
content infiltrating into the surrounding soil. Although some liquid inevitably
will enter the pit, it should be minimized. For example, it would not be appro-
priate to dispose of household wastewater into the pit as this may prevent
decomposition of the contents. VIP latrines are most appropriate where
people do not use water for cleaning themselves after defecating, but use solid
materials such as paper, corncobs or leaves.
HEALTHY VILLAGES: A GUIDE FOR COMMUNITIES AND COMMUNITY HEALTH WORKERS
Figure 4.3 Twin pit latrine
Figure 4.4 VIP latrine
CHAPTER 4. EXCRETA DISPOSAL 43
VIP latrines may be designed with single or double pits. Double pits may
be used, for example, when cultural taboos prohibit the mixing of male and
female faeces. Twin pits may also be used to facilitate emptying and com-
posting. When one pit is full, the other can be emptied and reused. The pit
of a VIP latrine is usually located directly beneath the slab to prevent fouling
of the chute, which would lead to odour and fly problems, and require regular
The VIP latrine is more expensive than either traditional designs or the
sanplat and this should be borne in mind when considering its use. In some
areas, traditional latrines or sanplat latrines can be improved by providing
ventilation. However, it likely that traditional floor materials will allow light
to enter the pit, which will make fly control more difficult. Installing a vent
pipe on an existing latrine may damage it. When considering a VIP latrine as
an improvement on existing sanitation, it is important to be aware that this
may require the construction of a new latrine, not simply the upgrading of
an existing one.
A pour-flush latrine is a type of pit latrine where small volumes of water
(commonly 1-3 litres) are used to flush faeces into the pit. They are most
appropriate where people use water to clean themselves after defecating
(e.g. in Muslim cultures) and where people have access to reliable water
supplies close to the home. Solid materials should not be disposed of into
pour-flush latrines, as this could block the pipe and even cause it to break.
A pour-flush latrine has a small collection pan set in a slab. Wastes are dis-
posed of through a section of pipe bent into a U shape (a U-bend) to maintain
a water seal for reducing fly and odour problems. A vent pipe may also be
added to the pit to help with fly and odour problems. The pit of a pour-flush
latrine may be located directly beneath the slab or set to one side, but offset
pits may require more water to prevent blockages. The pit is usually connected
to a soakaway to allow liquids to infiltrate the soil, leaving solid waste to
decompose. Pour-flush latrines can also be designed to be connected to small-
bore sewers at a later date. As with VIP latrines, twin pits may be used.
4.1 3 Septic tanks
A septic tank is a form of on-site sanitation that provides the convenience of
a sewerage system. It is usually linked to flush toilets and can receive domes-
tic wastewater (or sullage). Since flush toilets tend to use large amounts of
water, septic tanks are usually appropriate only for households with water
piped into the home. The tank is offset from the house and linked to the toilet
44 HEALTHY VILLAGES: A GUIDE FOR COMMUNITIES AND COMMUNITY HEALTH WORKERS
and domestic wastewater by a short drain. It is designed to hold solids and
is linked to a soakaway to dispose of liquid waste (effluent).
Septic tanks generally require relatively large amounts of land and peri-
odic emptying by vacuum tankers. This is often expensive and the trucks
will need easy access to the tank. Septic tanks thus tend to be high-cost
solutions for improving sanitation. They are commonly used only by com-
munities whose members have access to water supply within the home,
have land available and who can afford the cost of emptying the tanks. Com-
munal septic tanks may be feasible if a large number of households close to
the tank can be- connected with very short lengths of sewer pipe. For such a
system to work, however, each household needs sufficient water to flush
faeces into the septic tank effectively. This approach will probably be effec-
tive only when water is supplied to at least one tap on each plot.
An aquaprivy is similar to a septic tank; it can be connected to flush toilets
and take most household wastewater. It consists of a large tank with a water
seal formed by a simple down pipe into the tank to prevent odour and fly
problems. Its drawback is that water must be added each day to maintain the
water seal, and this is often difficult to do unless water is piped into the home.
The tank is connected to a soakaway to dispose of effluent. Unlike a septic
tank, the aquaprivy tank is located directly below the house, but it, too,
requires periodic emptying and must be accessible to a vacuum tanker.
Aquaprivies are expensive and do not offer any real advantages over
4.1.5 Sewerage systems
Sewerage systems are designed to collect excreta and domestic wastewater
and transport them away from homes to a treatment and /or disposal point.
All sewerage systems require water for flushing waste away. Conventional
sewerage is a high-cost sanitation option; it is usually deep-laid and must be
maintained by professional staff. Such a system is thus appropriate only
where funds are available for operation and maintenance by trained staff. All
sewerage systems should be linked to a treatment plant, as the raw faeces
they carry represent a public health risk
Modified sewerage systems are also designed to transport waste away
from the home, but work on different principles from conventional sewerage
systems. They do not require high- volume flush toilets, but do need signifi-
cant amounts of water for flushing. At least one tap on each plot or property
is therefore essential. Small-bore sewers are designed to carry only effluent,
CHAPTER 4. EXCRETA DISPOSAL 45
and each home requires an interceptor tank to collect and store solid mate-
rial, which must be regularly emptied by mechanical means.
Shallow sewers are larger-diameter sewers that carry both solid and liquid
wastes. They differ from conventional sewers in that solids deposited in the
pipes are resuspended when water builds up behind the blockage. To ensure
that enough water is available to move the solids, all household wastewater
should be disposed of into the sewer.
While both of these modified sewerage systems have problems, they have
been successfully managed by communities and have far lower water require-
ments than conventional sewers. The modified technologies may be appro-
priate in larger villages that have water supplies close to, or within, the
4.2 Sewage treatment and reuse
All wastes in sewerage or septic tank systems require treatment before dis-
posal, so that surface water and groundwater sources are not contaminated
and communities are not exposed to health risks from untreated sewage.
This can be accomplished either through high-cost conventional treatment
systems, or through a series of waste stabilization ponds (or lagoons).
421 Stabilization ponds
Waste stabilization ponds require more land, but are cheaper and easier to
operate and maintain, and need fewer trained staff than other treatment
systems. The final water from waste stabilization ponds can be very good if
the ponds are properly maintained. Without proper maintenance, however,
the quality of the final effluent may be poor and pose a risk to health if it is
used for irrigation.
In usual configurations, sewage flows through a series of ponds where the
solid and liquid wastes undergo natural breakdown processes, including
microbial activity Usually, at least two ponds are used, and more commonly
three. If the sludge (the solid part of the waste) from septic tanks is to be
treated in a waste stabilization pond, it should go into a special pond at the
start of the series because it is potentially highly toxic. Subsequent ponds treat
effluent (the liquid part of the waste). Wastewater in stabilization ponds tends
to have a high organic content and can serve as breeding sites for Culex mos-
quitoes that transmit lymphatic filariasis and other infections. The ponds
should therefore be sited well away from human habitation, at least beyond
the flying distance of the mosquitoes (over a kilometre with wind assistance).
46 HEALTHY VILLAGES: A GUIDE FOR COMMUNITIES AND COMMUNITY HEALTH WORKERS
4.2.2 Wastewater and sludge reuse
As society uses more water, the demand on natural water resources becomes
ever greater. Some of the demands for water, particularly for agriculture and
fish breeding, can be met by reusing properly treated effluent, since the water
quality requirements for these purposes are not as high as for drinking-water.
Treated wastewater can also be used to recharge groundwater resources,
although this will be usually be undertaken as part of a national ground-
water management strategy.
Benefits of reusing treated sewage effluent and sludge
It reduces the costs of abstracting irrigation water.
It reduces demand on valuable water resources.
It reduces the costs to farmers of expensive inorganic fertilizers.
It stabilizes soils, maintains good organic content, and improves the long-term pro-
ductivity of the soil.
It promotes better use of water resources.
It decreases pollution by reducing the waste load discharged into water bodies.
The use of untreated wastewater in agriculture or aquaculture poses high
health risks to farmers and consumers alike, and only the reuse of treated
wastewater should be promoted. The treated wastes should not contain
pathogens (bacteria, viruses, helminths or protozoa), because these could con-
taminate products and infect consumers, or be accidentally ingested by
farmers during handling. Properly operated sewage-treatment plants should
produce treated effluent of good enough quality for use in irrigation or fish-
breeding ponds. If treated wastewater is to be reused, the community should
ask the operator of the sewage-treatment plant or the local health body to
carry out regular monitoring to ensure that the effluent is safe.
Solid waste from pit latrines and sewage-treatment plants can also be a
valuable resource for farmers as an organic fertilizer and soil conditioner, pro-
vided that it has been allowed to properly decompose and contains no
pathogens. It is particularly important to ensure that roundworm (Ascaris)
eggs are no longer infective. Normally, it takes two years for the waste in a
pit latrine to decompose, but longer if the pit is wet. Some composting pit
latrines (e.g. the Viet Nam latrine) accelerate the decomposition of sludge and
inactivation of roundworm eggs by increasing the temperature in the sludge
pile. Before your community reuses sludge, however, health officials should
be consulted about the minimum time for sludge decomposition. If possible,
CHAPTER 4. EXCRETA DISPOSAL 47
the quality of the sludge should occasionally be tested. However, testing for
microorganisms such as protozoa and helminths is expensive, and it may be
more effective to use retention time to judge whether the sludge will be safe
While the microbial quality of treated effluent and sludge_is the major
health concern, chemical contamination is also a consideration. In particular,
wastewater reuse may increase the nitrate and chloride content of the soil.
Nitrate has been linked to the "blue-baby" syndrome that can be fatal in
infants. Although chloride is not a health concern, it can increase water salin-
ity and affect soil fertility. If community members suspect that a water source
is contaminated with chemicals, they should seek the advice of local health
and environment officials and request that periodic monitoring of wastewater
quality be carried out.
When wastewater is reused, care should be taken to separate domestic
effluent from industrial effluent, since the industrial effluent may contain
chemicals harmful to health or the environment, such as heavy metals. If
industrial sewage is mixed with domestic sewage, it is therefore not advis-
able to reuse the wastewater. Food products fertilized with such wastewater
may pose a health risk to consumers, and the repeated application of solid or
liquid wastes may cause chemical build-up in soils, leading to long-term
problems for water resources.
5.1 Problems caused by poor drainage
Removing stormwater and household wastewater (sometimes called
"sullage") is an important environmental health intervention for reducing
disease. Poorly drained stormwater forms stagnant pools that provide breed-
ing sites for disease vectors. Because of this, some diseases are more common
in the wet season than the dry season. Household wastewater may also
contain pathogens that can pollute groundwater sources, increasing the risk
of diseases such as lymphatic filariasis. Poor drainage can lead to flooding,
resulting in property loss, and people may even be forced to move to escape
floodwaters. Flooding may also damage water supply infrastructure and con-
taminate domestic water sources.
Drainage and public health
In areas where drainage and sanitation are poor, water runs over the ground during
rainstorms, picks up faeces and contaminates water sources. This contributes sig-
nificantly to the spread of diseases such as typhoid and cholera, and may increase
the likelihood of contracting worm infections from soil contaminated by faeces.
Flooding itself may displace populations and lead to further health problems.
Source: Kolsky P. Storm drainage: an intermediate guide to the low-cost evaluation of system performance.
London, Intermediate Technology Publications, 1998.
Drains from irrigated fields should also be properly designed and main-
tained, since the introduction or improvement of irrigation is often associated
with an increase in the numbers of people with schistosomiasis. This is par-
ticularly true where earth drains are used and the water supply and sanita-
tion are inadequate. Lining and properly grading the drains, removing
aquatic weeds and constructing self-draining structures are all important
measures for reducing health and environmental risks.
CHAPTER 5. DRAINAGE
5.2 Methods for improving drainage
Designing and constructing drainage systems require expert advice from
engineers to make sure that water flows away quickly and smoothly and is
disposed of in a surface watercourse or soakaway. Drainage installed by one
community should not create problems for other communities~downstream /
nor should it affect ecologically important sites. Environmental considera-
tions should be given adequate attention: long-term changes to the environ-
ment may lead to greater health problems in the future.
5.2.1 Stormwater drains
The detailed design of stormwater drains should be carried out by engineers
and take into account climatic and hydrological data. These data may be
scarce, or may not cover the community where work is to be carried out. In
such cases, the community can help by describing where major flood prob-
lems occur in the village and providing information about previous floods.
Stormwater drains should be designed to collect water from all parts of the
community and lead it to a main drain, which then discharges into a local
river (Figure 5.1). The size of the drains should be calculated according to the
amount of water they would be expected to carry in a storm. More extreme
floods occur relatively infrequently; to provide a safety margin, the maximum
Figure 5. 1 Stormwater drain through a village
50 HEALTHY VILLAGES: A GUIDE FOR COMMUNITIES AND COMMUNITY HEALTH WORKERS
flow of water is usually calculated on the basis of floods expected to occur
once every 10 or more years. If drains are designed to carry only the amount
of water expected from an annual flood, they will not be able to cope with
the flow of water from heavier floods, which may occur as often as every 2-3
years. This may make flooding problems worse and increase the health risks.
Stormwater drains are best constructed using a concrete lining. Earth
drains are more likely to become clogged and overgrown, and cause prob-
lems with stormwater flow during minor floods. This can lead to the forma-
tion of stagnant pools and result in breeding sites for disease vectors, such as
mosquitoes, increasing the risk of malaria, and snails, increasing the risk of
schistosomiasis. The drains must also be properly maintained and cleaned: it
is common to find that new drains become dumps for solid waste or even
sewage because of inadequate maintenance. The community should therefore
establish how often drains are to be cleaned and who will be responsible for
the maintenance. Often, the best solution is for community members them-
selves to take responsibility.
Community participation in maintaining drains
It is often essential that community members participate in maintaining drains. In
Indonesia, for example, residents agreed to clean the drains in front of their houses
every day and this was inspected twice a week. Community members responded
well to friendly inspectors who provided support for clearing the drains. Maintaining
the drains soon became part of the daily routine for responsible community members.
Source: Surface water drainage for low-income communities. Geneva, World Health Organization, 1991
5.2.2 Sullage disposal methods
Every household generates sullage. For instance, it has been estimated that
each person generates 15-20 litres per day when collecting water from a
standpipe. Sullage may be disposed of either at home, using on-site methods,
or through the drainage system. When sullage is disposed of at home a soak-
away pit can be constructed. Alternatively, sullage can be used to irrigate
small gardens, thus improving the crop yield and nutrition, and this should
be promoted if possible. However, sullage can be reused this way only if it
contains little or no detergent, which may damage crops.
If a soakaway is used, the pit should be located away from the house and
away from water sources. Ideally, there should be a minimum of 30 metres
between the soakaway pit and the nearest water source, but this distance may
need to be increased if houses are uphill of water sources. It is not recom-
mended that sullage be disposed of in pit latrines, since this may interfere
CHAPTER 5. DRAINAGE 51
with the breakdown of excreta within the pit, and may overload latrine soak-
away s where pour-flush latrines are used. When the household is connected
to a form of sewerage, sullage can be disposed off in the toilet or latrine.
Indeed, for some sewerage systems (such as shallow sewerage or conven-
tional sewerage) disposal of sullage in this way ensures better functioning of
523 Combined drains
Combined drains are designed to carry both stormwater and sullage. Unless
a combined drain is well designed and maintained, however, sullage will pool
within the drain and form insect breeding sites. These problems can be over-
come by using a system with a small insert drain that carries the sullage into
a larger drain for carrying stormwater. As with all drainage systems, it is
essential that the drains are properly operated and maintained, and that
refuse is cleared from the drains.
5.2.4 Buried drains and combined sewers
Drains may also be incorporated into sewerage systems and be buried. This
is more appropriate for urban areas, but can be considered in rural areas if
the village roads are paved and if flood flows are significant. Buried drains
have inlet chambers at regular intervals, usually along roadsides, that allow
the entry of stormwater. The drains then lead directly either to a watercourse
or to a sewage- treatment works. When drains flow directly into sewage-
treatment works, care must be taken not to overload the works. The storm-
water should always flow either into a stabilization pond, or into a storage
pool constructed to take stormwater flows above a certain volume.
Solid waste management and
To keep the household and village environment clean and to reduce health
risks, solid waste (refuse) should be disposed of properly. Untreated refuse is
unsightly and smelly and degrades both the quality of the environment and
the quality of life in the community. It also provides a breeding ground for
disease vectors, such as mosquitoes, flies and rats. If waste is not properly
disposed of, animals can bring it close to the home and children can come
into contact with disease vectors and pathogens. To be effective, solid waste
disposal programmes require action at both household and community
levels if only a few households dispose of waste properly, the village envi-
ronment may remain dirty and contaminated. Community members should
decide how important solid waste management is and determine the best
ways to achieve waste-management goals.
61 Strategies for solid waste management: minimizing waste
Key strategies for improving solid waste management and disposal are to
minimize the waste generated by households, and to recycle waste whenever
possible. To minimize waste, it is important that both the households and the
community at large make a conscious decision to reduce the amount of waste
they produce and actively participate in recycling. This may involve carrying
food and other purchases in reusable bags, such as cloth bags, rather than
using plastic bags. Minimizing waste may also entail sorting and recycling
waste, which is discussed in more detail below and illustrated in Figure 6.1.
Solid wastes should be sorted for recycling, and for burying or burning.
Recycling includes composting organic wastes, and reusing plastic and
glass products as well as construction debris. It can offer both cost-saving
and economic opportunities for communities. One way a community could
generate additional revenue, for example, would be to sell paper waste to
industries that use old paper in their manufacturing processes. Paper wastes
can also be compacted into dense fuel briquettes and used for cooking to
CHAPTER 6. SOLID WASTE MANAGEMENT AND CHEMICAL SAFETY
Figure 6.1 Separated wastes
supplement firewood. This would also help reduce deforestation, which
itself can adversely affect soil fertility and the quality of water sources. If
used tyres are not recycled the best option may be to bury them, since burning
produces toxic fumes. They should not be left as waste, because they can
fill with rainwater and become breeding sites for insects that carry serious
6.2 Managing solid waste in households
Some low-cost methods for managing household solid waste are summarized
below. More information may be available from local government staff, or
from agencies such as NGOs and donor organizations.
Fruit and vegetable waste, animal dung and even leaves from trees can break
down to form a valuable soil conditioner and fertilizer (compost). Household
vegetable waste, for example, can be composted in a suitable container. After
a few months the contents can be removed and used as fertilizer. An example
of a household composting container is shown in Figure 6.2. A more sophis-
ticated option is to use timber and chicken wire to construct a ventilated con-
tainer that promotes composting. Again, vegetable waste is disposed of in the
container until it is full, or until the compost is required.
6.2.2 Turning organic waste into fuel
Vegetable waste, including vegetable peelings and dried weeds, can be
chopped up and compressed into small bricks and dried in the sun. Animal
dung, too, can be spread thinly on the ground and dried in the sun. Once
dried, the waste can be stored and used to replace charcoal or wood as a
HEALTHY VILLAGES: A GUIDE FOR COMMUNITIES AND COMMUNITY HEALTH WORKERS
Figure 6.2 Household composting container
6.3 Managing solid waste in the community
Certain wastes are preferably managed at a community level. Some house-
hold items do not decompose and can cause injury if not properly disposed
of. For example, neither glass nor plastics can be used in composting, and
plastic gives off poisonous fumes when burned. Bones and metal items do
decompose, but the process is very slow; batteries contain toxic chemicals.
Bones, metal objects and broken glass can also be thrown into a latrine pit,
but only if the pit is not going to be reused.
6.3.1 Communal refuse pit
A communal refuse pit is simply a pit dug near the community compound
and filled with general refuse. The pit should not be located close to a water
source, because toxic chemicals could leach into the water.
The disposal site itself should be fenced off to prevent access by scaveng-
ing animals. At the end of the day, new waste should be covered with a layer
of clean soil 0.1 metre deep. When the pit is full, the waste should be covered
with a final layer of soil to prevent flies from breeding.
6.3.2 Communal collection
Householders may transport their solid waste to the disposal site or com-
munal collection may be organized. Communities themselves can organize
waste collection, for example by purchasing a suitable vehicle and charging
households for the service. If this is done, however, it is essential that the com-
CHAPTER 6. SOLID WASTE MANAGEMENT AND CHEMICAL SAFETY 55
munity members who perform the service are provided with protective
equipment and are trained to handle waste safely. This type of approach
provides employment and income to community households, improves the
environment and reduces health risks.
Communal collection points are particularly important at places such as
markets and bus stations, where large numbers of people congregate and food
is prepared, sold and eaten. Communal containers, such as empty oil drums,
skips or concrete bunkers, can be located strategically, so that solid waste is
collected at a single site. If communal concrete bunkers are constructed, they
should have holes at the base to encourage drainage away from the bunkers,
but care must be taken not to cause contamination of either groundwater or
surface water sources. Ideally, water from the waste bunkers should flow into
the drainage system and be treated before it enters a river or stream.
It is preferable that vegetable waste is not disposed of in communal col-
lection points unless these are emptied on a daily basis. Vegetable matter
decomposes rapidly, is often very smelly and may cause significant contam-
ination of groundwater sources.
All waste from communal collection points should be collected several
times a week and taken to a designated disposal site. It can be transported in
boxes, or by handcarts, animal carts, bicycles with box containers, tractors
with trailers and skip-trucks. The waste should preferably be collected by
staff wearing protective clothing and masks, who are trained in safe disposal
6.4 Managing special solid wastes
Some solid wastes require special handling and their disposal should be
carried out only by trained staff with proper clothing and equipment. Such
wastes represent a special health risk and their proper disposal is essential
for protecting health in the community. These wastes and their management
are discussed in sections 6.4.1-6.4.3.
6.41 Health care solid wastes
Health care wastes can be generated both by medical facilities and by
activities at home, such as changing bandages. Often, these wastes contain
infectious pathogens; ideally they should be incinerated or safely buried
immediately. Incineration can be carried out at a health centre or clinic, and
it is preferable to use purpose-built incinerators with chimneys. However,
simple home or community incinerators can be made from oil drums. If incin-
eration is not an option, an alternative is to put bandages or other waste
56 HEALTHY VILLAGES: A GUIDE FOR COMMUNITIES AND COMMUNITY HEALTH WORKERS
into a strong disinfectant. The person who does this must wear gloves. They
should also wash their hands immediately after handling the waste, even
though gloves were used. When bandages are to be reused, they should be
thoroughly disinfected in strong bleach. If health care wastes are buried, they
should be disposed of in a pit that restricts the access of people and animals.
The pit should be built in the medical facility compound and should be sur-
rounded by a fence; each layer of waste should be immediately covered with
a layer of dirt. The pit should also be properly lined to prevent contamina-
tion of groundwater.
If needles must be used at home, for example because a person is a dia-
betic, they should be disinfected and disposed of properly. Used plastic
syringes or their needles should never be reused, as this can cause serious
illness. The needles should be blunted before disposal, to prevent them from
becoming a hazard to others, and then burned or buried.
6.4.2 Slaughterhouse solid wastes
Slaughterhouse wastes contain decaying animal carcasses, blood and faecal
matter, and they are a significant source of pathogens and bad odours. These
wastes may also pollute water supplies. As slaughterhouse wastes represent
a particular hazard, their collection and disposal should be carried out by
trained staff and the wastes disposed of in properly maintained sites. If there
are slaughterhouses in a community, community members should ensure that
the local health authorities inspect the premises to ensure that proper proce-
dures are followed.
6.4.3 Industrial solid wastes
Industrial wastes contain toxic chemicals that pose health risks and pollute
the environment. While most industries will be located in towns, some small-
scale industries, such as tanneries and mining operations, may be located in
Tannery wastes, in particular, contain highly toxic metal compounds
that cause both short- and long-term health problems. If water sources are
polluted with tannery wastes, they may be unusable for many years, re-
sulting in higher costs for drinking-water and adversely impacting health.
If small-scale tanneries are located in a village, environmental protec-
tion agencies should be consulted about ways of reducing the risk of
Small-scale mining operations also use and produce toxic chemicals, such
as mercury, and arsenic. These chemicals represent a serious health risk to the
population, and if mining is carried out in a community, community members
CHAPTER 6. SOLID WASTE MANAGEMENT AND CHEMICAL SAFETY 57
should seek advice on how to dispose of toxic chemicals properly. While it
may not be possible for the community itself to set up disposal and treatment
areas for industrial wastes, it is important that community members recog-
nize the hazards of these wastes and request support to ensure that they are
properly disposed of.
6.5 Chemical safety
Toxic chemicals are frequently used within a village and within homes. Pes-
ticides, dips and inorganic fertilizers, for example, are used in agriculture,
and toxic chemicals are commonly used in the repair of vehicles. In the home,
chemicals are used as cleaning agents. Many of these chemicals are highly
toxic and care should be taken to store, use and dispose of them safely. In
particular, the manufacturers' instructions on use, storage and disposal
should be carefully followed; these are usually marked on the packaging. If
they are not, or if they are in a foreign language, advice on disposal should
be sought from the suppliers, or the product should be avoided. If chemicals
are past their " sell-by " date they should be avoided.
6.5.1 Storage of toxic chemicals
All chemicals should be kept in a safe place and out of the reach of children,
for example by storing them in a locked cupboard. When chemicals are stored
in houses, workshops or stores, individuals should be aware of the dangers
posed by the chemicals, and poisonous chemicals should be clearly marked
with a danger symbol recognizable by all community members. Chemical
stores should remain locked when not in use and keys given only to indi-
viduals who must use the chemicals. Chemical stores should also be well
ventilated, as many chemicals give off toxic fumes. With chlorine products,
for example, there must be ventilation at the bottom of the building because
chlorine is heavier than air and chlorine gas will accumulate at floor level.
Local health and environment staff can be consulted about the safe storage
and ventilation of chemicals.
For safety reasons, chemical stores should have a shower or washing
system so that users can wash themselves immediately in the event of a toxic
chemical spill. One option is to keep a full barrel of water close to the store
for this purpose. When chemicals give off toxic fumes, breathing apparatus
may also be required for people entering the store. Chemical stores should be
located away from water sources to avoid the possibility of toxic chemicals
infiltrating the soil and contaminating drinking-water supplies. Poorly stored
agricultural chemicals in particular, such as fertilizers and pesticides, can get
into the groundwater.
HEALTHY VILLAGES: A GUIDE FOR COMMUNITIES AND COMMUNITY HEALTH WORKERS
Figure 6.3 Unhealthy use of agricultural chemicals
6.5.2 Handling toxic chemicals
All chemicals should be handled with great care. Most are toxic at some
level and even though short-term exposure may not be particularly harmful,
long-term exposure can cause serious health problems. For example, organo-
phosphates in sheep dips can lead to heart and breathing problems, and
to mental health problems. Consequently, agricultural workers should be
trained in the use of chemicals. Training is usually carried out by agricultural
extension workers and will normally include such topics as use of protective
clothing, gloves and breathing apparatus. An example of bad practice in han-
dling agricultural chemicals is shown in Figure 6.3. If there are any doubts
regarding the safe handling and use of agricultural chemicals, workers should
seek advice from local agricultural staff, otherwise the community may be
exposed to serious health risks. If a toxic spill occurs, it should be contained
as far as possible and the appropriate local or national environmental agency
CHAPTER 6. SOLID WASTE MANAGEMENT AND CHEMICAL SAFETY
6.5.3 Chemicals in the home
Many households use chemical cleaning products that can be harmful if not
handled and stored correctly. Gloves and other protective wear should be
worn when chemicals such as bleach are used, even if they are diluted. Fumes
should not be inhaled, nor should the chemicals be allowed to writer the eyes
or mouth, since many household chemicals are poisonous in sufficient
amounts. Children are more likely to suffer accidents than adults, and chem-
icals should be stored in locked cupboards, out of reach of children as shown
in Figure 6.4. If a chemical accident occurs in the home, medical advice should
be sought immediately. With some chemicals, if detoxification is not carried
out right away, death or permanent injury can result.
When insecticides are used in the home to control mosquitoes, flies and
other insects, manufacturers' instructions must be followed and the products
kept out of the reach of children. In a Healthy Village approach, however,
Figure 6.4 Keeping household chemicals secure
60 HEALTHY VILLAGES: A GUIDE FOR COMMUNITIES AND COMMUNITY HEALTH WORKERS
communities should be informed about alternative and more sustainable
ways of insect control, such as draining insect breeding sites, screening
houses, using impregnated mosquito nets and introducing fish that feed on
6.5.4 Disposal of toxic chemicals
Proper disposal of toxic chemicals requires responsibility and action at both
household and community levels. In households where home chemicals are
not safely disposed of, it is not simply the health of family members that is
jeopardized; the health of all community members is placed at risk. Old
chemicals should not be indiscriminately dumped in the environment, as this
can pollute both soil and water, and the chemicals may give off toxic fumes.
If it is suspected that toxic chemicals are being illegally dumped in a com-
munity, the local agency responsible for waste management or for the envi-
ronment should be contacted immediately and community members should
insist that preventive action be taken.
Chemicals should be disposed of according to manufacturers' guidance
and if they have passed their "sell-by" date they should be collected by
trained staff and disposed of at special sites. If there is any doubt about
how to dispose of chemicals, local health and environment officials should be
Good-quality housing is a key element for ensuring a healthy village. Poor
housing can lead to many health problems, and is associated with infectious
diseases (such as tuberculosis), stress and depression. Everyone should there-
fore have access to good-quality housing and a pleasant home environment
that makes them happy and content. Specific aspects of housing quality are
described in the following sections.
Problems associated with poor housing
Cramped and crowded conditions give rise to poor hygiene by providing places
for vermin to breed and transmit diseases via fleas, ticks and other vectors.
Poor household hygiene leads to food and water contamination within the home.
Poor indoor air quality leads to respiratory problems and inadequate lighting leads
to eyesight problems.
Stress is higher for individuals living in poor housing and poverty.
Adequate home ventilation is particularly important where wood, charcoal
and dung are used for cooking or heating, since these fuels give off smoke
that contains harmful chemicals and particulate matter. This can lead to res-
piratory problems, such as bronchitis and asthma, and make tuberculosis
transmission easier. Women and small children are particularly at risk from
poor ventilation if they spend long periods within the home or in cooking
areas. Where cooking is done indoors, it is essential that smoke and fumes be
removed from the house quickly and efficiently. Ventilation may be improved
by constructing houses with a sufficient number of windows, particularly in
cooking areas. Alternatively, houses can be constructed using bricks with
holes drilled through them ("air-bricks"), which allow fresh air to circulate
within the house.
HEALTHY VILLAGES: A GUIDE FOR COMMUNITIES AND COMMUNITY HEALTH WORKERS
Figure 7.1 House with good ventilation and light
Poor indoor lighting can have many harmful effects on health and well-being.
A poorly lit working environment in the home can lead to eyesight problems,
for example. This is a particular concern for women working in indoor
cooking areas. Poor lighting within the home can also make people feel
more depressed. These problems can be remedied by adding windows to the
house to increase the amount of natural light, which is much stronger than
light from candles or lamps, as shown in Figure 7.1. In communities where it
is important that privacy within the home is maintained, windows can be
located where it is difficult for people to see into the house, or constructed
with a mesh or lattice work which allows light to enter while guarding
privacy. Increasing natural light is also important for home cleanliness: if a
house is dark, it is more difficult to see dust and dirt and thus more difficult
to clean properly.
7.3 Disease vectors in the home
Unless homes are kept clean and steps taken to prevent insects from
entering, the homes can become infested with disease vectors. In eastern
CHAPTER 7. HOUSING QUALITY
Figure 7 2 Example of a house with unhygienic practices
Mediterranean areas, for example, sandflies thrive in the dirt inside houses
and transmit leishmaniasis; and in Central and South America, triatomid
bugs live in the cracks of walls and in thatched roofs and transmit American
trypanosomiasis (Chagas disease). Insect disease vectors can be reduced by
keeping food covered and properly disposing of waste. If mosquitoes or flies
are a problem, windows and doors should be covered with mesh screens and
kept shut at night, and mosquito nets placed over beds. Cleanliness within
and around home areas significantly reduces the risk of disease transmission.
Examples of bad and good household hygiene are shown in Figures 7.2 and
7.4 Overcrowding in homes
Overcrowding in homes causes ill-health because it makes disease transmis-
sion easier and because the lack of private space causes stress. Overcrowd-
ing is related to socioeconomic level, and the poor often have little choice but
to live in cramped conditions. In principle, increasing the number of rooms
in a house should improve the health of the people who live there, but increas-
ing house size is often difficult. Careful planning of family size can also help
to reduce overcrowding. If community members feel that overcrowding is a
HEALTHY VILLAGES: A GUIDE FOR COMMUNITIES AND COMMUNITY HEALTH WORKERS
Figure 7.3 Example of a house with hygienic practices
problem, they can take the initiative and press landlords to provide more
space for tenants at affordable prices. This may necessitate working with
local government and pressure groups to ensure that the housing laws
and tenancy agreements are revised, and that everyone has access to houses
adequate for their family size.
Personal, domestic and
Good hygiene is an important barrier to many infectious diseases, including
the faecal-oral diseases, and it promotes better health and well-being.
To achieve the greatest health benefits, improvements in hygiene should be
made concurrently with improvements in the water supply and sanitation,
and be integrated with other interventions, such as improving nutrition and
increasing incomes. The next sections discuss how to improve personal and
community hygiene practices that help to prevent the spread of faecal-oral
If wastewater is not disposed of effectively it can serve as a breeding
ground for mosquitoes. People may also slip and fall in muddy puddles, and
children may play in them and risk waterborne illness.
8.1 Personal and domestic hygiene
Proper handwashing is one of the most effective ways of preventing the
spread of diarrhoeal diseases. Pathogens cannot be seen on hands, and water
alone is not always sufficient to remove them. Soap and wood ash are both
cleansing and disinfecting agents when used with water and can be used to
kill pathogens on hands and utensils. The most important times that hands
should be washed with soap and water are:
After cleaning a child who has defecated.
Before eating or handling food.
Promoting good personal hygiene often requires that community members
are mobilized towards this goal and awareness is raised about how to achieve
it. It is important that hygiene education programmes do more than simply
tell people that if they do not wash their hands they will become sick because
of pathogens they cannot see. This rarely works. Instead, education pro-
grammes should try different methods to maximize community participation
66 HEALTHY VILLAGES: A GUIDE FOR COMMUNITIES AND COMMUNITY HEALTH WORKERS
in the programmes and to encourage people to promote good hygiene. Some
methods for promoting hygiene and health are discussed in the next chapter.
To encourage handwashing to become part of the daily routine, suitable
facilities must be located near to places such as latrines and kitchens, where
they will be needed. If running water is available, the facilities should include
a tap and a sink as well as soap. Hands may also be washed at a tap stand
as shown in Figures 8.1 and 8.2. If running water is not available, an oil can
or bucket fitted with a tap is a simple way of providing handwashing facili-
ties; the larger the container, the less frequently it will need filling. Some con-
tainers are mounted on stands with a ledge for soap. A leaking container (such
as a tin can with holes in its base) can also be used to scoop water from the
water storage container and provide a stream of running water for hand-
washing. Another approach involves a suspended container that, when
tipped, pours water onto the hands of the user. The system can easily be
made from plastic cooking oil containers. Soap itself can be kept clean by sus-
pending it above the ground on a string.
Regular bathing and laundering are important for cleanliness and good per-
sonal appearance. They also prevent hygiene-related diseases such as scabies,
ringworm, trachoma, conjunctivitis and louse-borne typhus. Educational and
promotional activities can encourage bathing and laundering, but increasing
the number of washing facilities and locating them conveniently may be more
effective. Bathing with soap is an important means of preventing the trans-
mission of trachoma an illness that can cause blindness and other eyesight
problems. Children's faces in particular should be washed regularly and thor-
oughly. If a child has trachoma, a special towel or tissue should be used to
wipe or dry the child's face; the towel should never be used for other chil-
dren because of the risk of transmitting the disease. Ideally, programmes that
promote bathing should be combined with a programme to reduce the
numbers of flies, which spread trachoma and other diseases, and to improve
For people to bathe thoroughly they must use sufficient water, but it may
be difficult to promote the use of more water for washing if water supplies
are distant and water must be collected by hand. Moreover, many traditional
bathing practices do not use water efficiently and ensuring cleanliness may
be difficult. By modifying existing practices, such as by encouraging the use
of water containers with taps, it may be possible to improve the efficiency of
water use. Community shower units, with separate facilities for men and
women, can also become income-generating enterprises in larger villages, but
the facilities require careful maintenance and must be conveniently located.
Operators should also allay concerns about voyeurism, which may be
CHAPTERS. PERSONAL, DOMESTIC AND COMMUNITY HYGIENE
Figure 8.1 Handwashing using a tap
Figure 8.2 Handwashing at a standpost
68 HEALTHY VILLAGES: A GUIDE FOR COMMUNITIES AND COMMUNITY HEALTH WORKERS
particularly important to women. Such problems are best resolved through
discussion within the community.
To promote laundering of clothes and bedding, laundry slabs or sinks can be
constructed near water points. They should be large enough to wash bedding
and other bulky items and be situated so that water drains away from the
laundry area and away from the water source. Locating laundry places in
natural water bodies, streams and irrigation canals is best avoided if possi-
ble, since this practice can contribute to the transmission of schistosomiasis.
8.2 Community hygiene
Some health measures can be undertaken only by the community as a
whole; these include water source protection, proper disposal of solid waste
and excreta, wastewater drainage, controlling animal rearing and market
hygiene. Some of these issues have been described in earlier sections.
Individual community members play an important role in community
hygiene, and have a responsibility to their neighbours and to the community
to promote good health and a clean environment. For example, everyone in
the village must keep their houses and compounds clean, because one dirty
house can affect many conscientious neighbours and contribute to the spread
of disease. Community leaders can promote cleanliness in the home by reg-
ularly checking on village households and by using by-laws to encourage
Markets often represent a health hazard because foodstuffs may not be stored
properly and because the markets may lack basic services, such as water
supply, sanitation, solid waste disposal and drainage. Ideally, markets should
have several taps to provide traders and customers with ready access to safe
water for drinking and washing. Many vegetable and fruit sellers regularly
sprinkle their produce with water, and it is important that they have access
to clean water for this. The sanitation facilities should also be appropriate for
the number of people who will visit the market, with separate facilities for
men and women. Water and sanitation facilities for a market are often rela-
tively easy to support by charging a small user fee, or by using part of the
market fee to pay for such services. If people are charged a fee to use the facil-
ities, discounts can be offered to traders who already support the facilities
through their market fee.
CHAPTER 8. PERSONAL, DOMESTIC AND COMMUNITY HYGIENE 69
Foodstuffs sold at the market should be inspected daily by health officials.
This is particularly important for meat and fish, which should be inspected
before sale to ensure that they have been prepared according to national
regulations and that they do not contain pathogens or other contaminants.
Markets usually generate a lot of solid waste and it is importanJMthat it is dis-
posed of properly, to prevent vermin such as rats and insects from feeding
and breeding among it. The layout of market stalls should thus allow easy
access for vehicles that collect waste and clean the area. Solid waste should
be collected and disposed of daily, and preferably more often. Strategically
located waste bins (often concrete bunkers) can make this more effective.
Market areas should also be properly drained to prevent flooding and insect
Successful refuse collection in west Africa
In one west African market, refuse collection was effective because there were
enough disposal points, and because the market was closed for a short time each
day to allow waste to be collected and the market to be cleaned. This made the
market safer and more attractive to customers.
Markets function most effectively when they have legal status, with market
fees and supervision, preferably by health officials based at the market. Well-
run markets tend to have strong traders' associations and good links between
market associations and local service providers. Market traders can have a
strong voice in improving conditions, since they generate significant income
for communities and provide essential food distribution services. Traders'
associations can set up standards for the market, can successfully manage
water and sanitation facilities, and can organize regular waste collection. If
markets are held regularly, community members should seek advice and
support from local health staff on issues such as setting up an association,
establishing trading standards and penalties for contravention, and on lob-
bying for service provision. As markets grow, the management of services
often gets easier because the growing number of fees collected provides more
income for services.
8.2.2 Animal rearing
In many communities animal rearing is a means of generating food high in
protein content and nutritional value, and for generating additional income.
Animals can also provide many other products, such as leather and fuel, that
improve the quality of life. However, if it is not practised safely, animal
70 HEALTHY VILLAGES: A GUIDE FOR COMMUNITIES AND COMMUNITY HEALTH WORKERS
rearing can have negative effects on the health of the community. Animals
should always be kept away from households, particularly cooking areas and
drinking-water sources, since their excreta contain pathogens that can conta-
minate food and water. Preferably, animals should be kept in compounds at
least 100 metres from water sources and 10 metres from houses. Animal waste
should be disposed of properly, away from homes and water sources, or be
used as a fertilizer. It is also best that animals are slaughtered away from
households and water sources, since the offal and wastes may introduce con-
tamination. Slaughtering must be carried out by qualified individuals who
follow the country laws governing slaughter practices..
Some disease vectors prefer animal hosts to humans. Pigs, for example,
can be reservoirs of Japanese encephalitis, dogs can be reservoirs of leishma-
niasis, and some mosquitoes prefer to feed on cattle rather than humans.
Placing animal shelters between mosquito breeding places and the village
may therefore provide some protection against malaria transmission.
8.3 Food hygiene
Contaminated food represents one of the greatest health risks to a population
and is a leading cause of disease outbreaks and transmission. Food that is
kept too long can go bad and contain toxic chemicals or pathogens, and food-
stuffs that are eaten raw, such as fruits or vegetables, can become contami-
nated by dirty hands, unclean water or flies. Improperly prepared food can
also cause chemical poisoning: cassava leaf that has not been properly
pounded and cooked, for example, may contain dangerous levels of cyanide.
To promote good health, therefore, food should be properly stored and pre-
pared. Ways in which communities can prevent health risks from food are
discussed in the following sections.
831 Food preparation in the home
As most food is likely to be prepared in the home, it is important that fami-
lies understand the principles of basic hygiene and know how to prepare food
safely. Before preparing food, hands should be washed with soap or ash. Raw
fruit and vegetables should not be eaten unless they are first peeled or washed
with clean water. It is also important to cook food properly, particularly meat.
Both cattle and pigs host tapeworms that can be transferred to humans
through improperly cooked meat; for this reason, raw meat should never be
eaten. Eggs, too, must be cooked properly before eating, since they may
contain salmonella, a virulent pathogen. The kitchen itself should be kept
clean and waste food disposed of carefully to avoid attracting vermin, such
as rats and mice, that may transmit disease. Keeping food preparation sur-
CHAPTER 8. PERSONAL, DOMESTIC AND COMMUNITY HYGIENE
faces clean is critical, because harmful organisms can grow on these surfaces
and contaminate food.
Fresh meat should be cooked and eaten on the same day, unless it can be
stored in a refrigerator; if not, it should be thrown away. Cooked food should
be eaten while it is still hot and should not be left to stand at room tempera-
ture for long periods of time, since this provides a good environment for
pathogens to grow. Food that is ready to eat should be covered as shown in
Figure 8.3 to keep off flies and should be thrown away if not eaten within
12-16 hours. If food must be stored after cooking, it should be kept covered
and in a cool place, such as a refrigerator. If a refrigerator is not available,
food can be stored on ice blocks or in a preservative such as pickling vinegar
or salt. Food that is already prepared, or food that is to be eaten raw, must
not come into contact with raw meat as this may contain pathogens that can
contaminate the other foods (particularly if slaughtering was not carried out
In many rural communities food is bought and consumed at eating-houses
(cafes, restaurants or cantinas). If basic health and safety rules for storing,
preparing and handling food are not followed in the eating-houses, these
places will represent a health hazard for the customers and may cause serious
disease outbreaks. The most important aspects of food hygiene in these
establishments relate to sanitation, water supply and personal cleanliness:
Figure 8.3 Storing food properly
72 HEALTHY VILLAGES: A GUIDE FOR COMMUNITIES AND COMMUNITY HEALTH WORKERS
Eating-houses should have clean water for washing and drinking, and
separate sanitation facilities, away from the kitchen area, for customers,
cooks and food-handlers.
The staff should have clean uniforms each day and have regular medical
Food should be freshly prepared daily and any that is spilled or not
used should be disposed of.
The kitchens and eating areas must be kept clean and free of vermin
Eating-houses should also be well-ventilated, with adequate lighting,
and have procedures for dealing with fires and accidents. For example,
the eating area should not be too crowded, to allow customers easy exit
in the event of a fire.
Most countries have legislation covering eating-houses and their operation.
As a rule, eating-houses require official approval before they can operate and
are subject to regular checks. These checks are likely to be increased in times
of epidemics. The community should recognize that eating-houses must be
properly run and maintained to ensure that they do not become a source of
disease. Eating-houses should be periodically checked, for example by health
officials, to make sure that the establishments do not pose health risks. If a
community member suspects an eating-house of posing a health hazard,
he/she should request an inspection by the appropriate local health
8.3.3 Street food-vendors
Street food-vendors are common in urban and periurban areas, but they
also operate in rural areas, particularly if there is a market or community
fair with bars and other drinking establishments. Although people enjoy
food from these vendors, in many cases the food is of poor quality and it
represents a serious health risk. A study in one African city, for example,
found that 98% of the street vendors had faecal contamination on their hands
and food, a situation that is likely to be the same for food vendors in other
cities and villages. In part, this is because the street vendors have little or
no access to safe water supplies or sanitation facilities, and they commonly
cook and handle food with dirty hands. Raw foodstuffs, too, cannot be
kept in safe storage places and are easily contaminated by vermin and insects.
Moreover, the street vendors often keep cooked food at ambient (environ-
mental) temperatures for prolonged periods of time and may heat the food
only slightly before serving. All these factors may make the food from street
CHAPTER 8. PERSONAL, DOMESTIC AND COMMUNITY HYGIENE 73
Where street food-vendors are legal, they should be regulated by the health
authorities. Often they are not legal, however, and in these cases steps should
be taken to promote their safe management of food and, where necessary, to
prevent them from selling their food. This may be difficult if the demand for
street food is high, and it may be necessary to work closely with local health
authorities. Street vendors should be encouraged to locate close to water points
and sanitation facilities where they can keep hands and food clean. Commu-
nity members can also work with vendors to ensure that food is prepared and
eaten immediately, rather than being kept unrefrigerated for long periods.
8.3.4 Promoting nutrition
A healthy and well-balanced diet is essential for good health. When there is
not enough food, or if the diet does not contain the right balance of food-
stuffs, people become more prone to illness and may become undernourished
or malnourished. Children, in particular, are vulnerable to poor nutrition.
Undernourishment and malnourishment can lower their resistance and make
them more likely to suffer from infectious diseases. Often, children will eat
only small amounts of food if it is spicy, even if it is nutritious, and it is impor-
tant to make children's food less spicy than adult food. Also, because their
stomachs are small, children can eat only small portions and need to be fed
more frequently than healthy adults. It is also important that children are fed
not just foods high in starch or carbohydrate (for instance rice or cassava).
Although these foods can quickly make a child feel full, he or she may become
malnourished if other key foodstuffs are not eaten. A well-balanced diet
usually has a mixture of food with protein (for example beans, peas, meat,
fish or eggs), carbohydrates (such as maize, potatoes, cassava, rice and many
other staple foods), vitamins (such as vegetables, fish, fruits or milk), and
some fats or oils (such as cooking oil). Sometimes not all these foods are avail-
able and it is important that community members ask health workers how to
make best use of available foods for a balanced diet.
In many situations, nutrition can be improved by changing agricultural or
gardening practices. Often, even small plots of land can provide nutritious
food provided that the right crops are grown. Health workers or agricultural
extension workers can be asked for advice about which crops to grow to
provide community members with well-balanced diets. It is not possible here
to give a full discussion of the nutritional value of foods, or of what consti-
tutes a well-balanced diet. This is an enormous subject and is covered in more
detail in materials developed by other programmes and organizations.
However, it is important that communities request advice and support for
improving nutrition. Many organizations that provide advice and support to
nutrition programmes are listed in Annex 1.
The goal of hygiene promotion is to help people to understand and develop
good hygiene practices, so as to prevent disease and promote positive atti-
tudes towards cleanliness. Several community development activities can be
used to achieve this goal, including education and learning programmes,
encouraging community management of environmental health facilities,
and social mobilization and organization. Hygiene promotion is not simply
a matter of providing information. It is more a dialogue with communities
about hygiene and related health problems, to encourage improved hygiene
practices. Some key steps for establishing a hygiene promotion project,
possibly with support from an outside agency, are listed in the text box below.
Establishing a hygiene promotion project
Evaluate whether current hygiene practices are good/safe.
Plan which good hygiene practices to promote.
Implement a health promotion programme that meets community needs and is
understandable by everyone.
Monitor and evaluate the programme to see whether it is meeting targets.
9.1 Assessing hygiene practices
To assess whether good hygiene is practised by your community, some of the
methods discussed in section 2.2 can be used. It is particularly important to
identify behaviours that spread pathogens. The following are the riskiest
The unsafe disposal of faeces.
Not washing hands with soap after defecating.
The unsafe collection and storage of water.
CHAPTER 9. PROMOTING HYGIENE 75
Key questions for assessing hygiene
What "risky" practices are widespread in the community?
How many people employ risky practices and who are they?
Which risky practices can be altered?
What motivates those who currently use "safe" practices?
Who influences them?
What communication channels are available?
Which communication channels are trusted for hygiene messages?
9.2 Planning hygiene promotion projects
The entire community should be involved in a hygiene promotion project,
but this is likely to mean that different groups within the community
will have different perceptions and priorities. Women's priorities are partic-
ularly important, since women usually ensure that good hygiene is practised
in the home. It is crucial to take these different priorities into account
and make realistic plans. By consulting all community members, it is possi-
ble to identify priorities and achieve solutions more relevant to the whole
When identifying community members to carry out hygiene education,
it is important to consider the amount of time they will spend on promotional
activities and how they will be compensated. The duties and skills required
by prospective promoters should also be clearly identified. Existing health
staff and teachers may be appropriate as hygiene education providers, but
they may not have the time to commit to additional activities or have the
skills to carry out activities on sensitive subjects. Other community members
may perform hygiene education activities well, but may require training. In
such cases, local government bodies and other agencies should be contacted
to provide the necessary training and support. Usually, the most effective
skills in a promoter are an ability to communicate well with the target group
and an understanding of constraints that cause people not to adopt safe prac-
tices. People who cannot read or write should not be excluded as promoters
if these skills are not required, since that may exclude older women who are
respected in the community and have plenty of life experience.
There is no hard-and-fast rule for the ratio of hygiene promoters to com-
munity members, but it is generally considered that one community promoter
can adequately cover about 1000 community members, provided that it is
easy to move between households. Community promoters can be supervised
by an outside agency or by local government officials, but the community
76 HEALTHY VILLAGES: A GUIDE FOR COMMUNITIES AND COMMUNITY HEALTH WORKERS
itself should also be involved to ensure that the programme is effective and
responsive to local needs.
9.3 Implementing hygiene promotion projects
Flexibility is essential when implementing a hygiene promotion project.
Different community members may need different information and support,
and the project as a whole may need to change as it develops.
9.3.1 Building community capacity
To promote hygiene within a community it is not enough simply to provide
messages about hygiene; the capacity of the community to analyse situations
and initiate changes must also be improved. In this sense, hygiene promotion
is comparable to community development activities. Building community
capacity may involve:
Operating and maintaining water and sanitation facilities.
Organizing and supporting community groups and committees.
Helping communities to analyse their current hygiene and sanitation.
Negotiating agreements and settlements between development
Encouraging the private sector to develop water, sanitation and hygiene
9.3.2 Organizing groups and committees
Groups and committees, such as water and sanitation user groups, may be
required to perform hygiene-related tasks, and it may be difficult to involve
all members of the community in these groups. Women, for example, may
not be able to serve on water and sanitation committees, yet fulfilling their
needs is of paramount importance to the work of the committees. In some
cases, hygiene promotion staff may be able to encourage the representation
of women on committees, but it may be more appropriate to have separate
committees for women. When these are established, however, there must be
a link to the overall community committee responsible for managing the
water and sanitation facilities, so that women's opinions influence manage-
ment. The women may require special training to develop their confidence
and communication skills and to effectively represent women's interests on
CHAPTER 9. PROMOTING HYGIENE 77
9.3.3 Situation analysis
Before a project with a community is started, information about the current
hygiene situation should be collected and analysed. This will help to guide
project activities and provide a baseline against which changes can be mea-
sured. The information collected from a project will also form_the basis of
other hygiene promotion activities. Situation analysis should not be under-
taken by hygiene promotion staff alone, but should involve the entire com-
munity, both during the project and afterwards. Hygiene promotion staff can
share findings with the community, and help community members to analyse
information and identify solutions to problems.
9.3.4 Communication and education
Communication and education activities include selecting appropriate
hygiene messages; identifying the target groups for those messages; identi-
fying effective communication methods; preparing communication materials;
and communicating the messages. Selecting the appropriate hygiene mes-
sages and identifying target audiences require an analysis of information
collected from the community. Mothers are often designated as the primary
target audience, since they are usually the main caregivers for young children
and are most influential in a family setting. While targeting mothers may be
useful for influencing change at household level, there is also a need to
involve the immediate family and other people who influence women's
Accessing target audiences
Who are the members of each target group?
Where are they?
How many of them are there?
What languages do they speak?
Who listens to the radio or watches television regularly?
What proportion can read?
Do they read newspapers?
To which organizations and groups do they belong?
Which channels of communication do they like and trust?
78 HEALTHY VILLAGES: A GUIDE FOR COMMUNITIES AND COMMUNITY HEALTH WORKERS
Figure 9.1 Health education group
Hygiene education messages can be communicated in different ways, includ-
ing posters, drama and storytelling, mass media messages, group discussions
(Figure 9.1) and home visits. Some methods, such as the use of mass media
and posters, communicate messages to large numbers of people. Other
approaches emphasize the need to work with small groups, through meet-
ings and household visits. No single method is always effective, however.
Most health education works best when interventions are made at different
levels and use a mixture of awareness-raising tools, and when they focus on
individual activities, such as "child-to-child" programmes or home visits by
health educators. Getting households and community members involved in
learning about hygiene is often crucial for improving hygiene practices and
reducing the risks to health. The messages should be understandable by the
target audience. This can be accomplished by first testing educational mate-
rials on small pilot groups. More information on hygiene communication and
education can be obtained from the agencies and materials listed in Annexes
1 and 2.
9.4 Monitoring and evaluating hygiene projects
Regular review of hygiene education projects by community members
ensures that issues important to the community are covered. Reviews can
evaluate whether community members are uncertain or confused about
hygiene messages and whether they need further hygiene information. The
results of reviews also provide feedback to hygiene educators for improving
the programmes. Community members should decide on the frequency with
which hygiene education activities are evaluated. Meetings could be held
every 1-2 weeks, with assessment based on agreed goals set at each meeting,
or less frequently (every 3-6 months) with more lengthy discussions at each
CHAPTER 9. PROMOTING HYGIENE 79
meeting. When outside donors have provided funds, they may have their
own requirements for monitoring and evaluating the information collected,
so it is important that the community members are clear about how such
evaluations will be performed and what role the community will play.
Try to decide what information is needed. This may require reaching a consensus
with all concerned individuals and organizations, a process that may involve
Identify who will carry out the investigations. This, too, can be a lengthy process
and depends on the availability and willingness of individuals to help.
Select tools for collecting information. (Who has the information, what form is it in
and who will collect it?)
Organize logistic arrangements. Try to make sure that everyone involved in the
project is contacted and provided with necessary information in a timely manner.
The staff or community members undertaking the evaluation may need guidance
on how they should collect information and how they should respond to evaluation
Review findings with investigators. This may need to be coordinated by a
committee of representatives from different stakeholder groups.
Provide feedback to all stakeholders about investigators' findings. Different reports
will probably be needed for different stakeholders.
941 Deciding what information is needed
Developing a framework of questions is the first step in monitoring and eval-
uating a hygiene education programme, and the framework should include
a measurement of what has happened and how it has happened. Some of the
most common questions to consider are:
Appropriateness. Are project activities the right ones? Do they provide
solutions to the most important problems?
Effectiveness. How well are the different activities carried out?
Costs. What does the project cost? What contributions come from the
community and are they acceptable?
Participation. Who attends project activity meetings? Are all groups
represented in planning, implementing and evaluating the activities?
Sustainability. Can activities be sustained on a continuing basis? If
external agencies provide funds, can the community sustain activities
after funding has ceased?
Unintended outcomes. Are there outcomes (positive or negative) that
were not intended?
80 HEALTHY VILLAGES: A GUIDE FOR COMMUNITIES AND COMMUNITY HEALTH WORKERS
9.4.2 Selecting project investigators
The community should be actively involved in any assessment, including
the collection and review of information, and should identify individuals
within the community to carry out the assessment. Individuals from external
support agencies may also assist in the evaluation, which could bring new
perspectives to the project and facilitate the collection and review of infor-
mation. Selecting community members to undertake the assessment requires
careful planning; to ensure that assessment results are reliable it is usually
best to involve a mix of community members. This mix can include commu-
nity members Involved in the health education project, as well as those
who are not actively involved but who have a good understanding of project
943 Selecting tools for collecting information
The type of monitoring and evaluation tools chosen will depend on the type
of information to be collected. This section describes some of the tools
Assessment tools can be used at various points during the project to deter-
mine whether interventions are improving community hygiene. Focus group
discussions, for example, can be useful for revealing community views and
for solving problems that arise during discussions. For more quantitative
assessments, questionnaires can be used to record activities and behaviours.
The assessment tools should be carefully selected so that the collected infor-
mation is appropriate to the purposes of the evaluation.
By using self-monitoring forms, households can monitor their own hygiene
practices, or can monitor the incidence of an illness over time. The forms can
then be collected and discussed with householders, either individually or as
part of a group discussion. Health educators can also monitor their own activ-
ities using self-monitoring forms and they should meet regularly to discuss
problems and successes. Self-monitoring forms should be easily understand-
able by users and by individuals who collect and analyse the information.
CHAPTER 9. PROMOTING HYGIENE 81
Trainers' assessment forms
Training sessions should be regularly assessed to maintain their quality.
Again, the trainers 7 assessment forms should be easily understandable by
everyone who collects and analyses the information. One way of assessing
participants' attitudes towards a training course is to ask them td write down
on a flip-chart one positive thing and one negative thing about the course.
For those unable to write, a series of pictures representing feelings could be
provided and the participants asked to mark those that best represent their
own feelings about the training course.
9.4.4 Reviewing project findings
A review committee can be set up to manage the progress of the project and
to discuss the implications of its findings; a hygiene committee, for example,
could act as the reviewers. From the outset, committee members should be
aware of the amount of time that the committee work will entail and under-
stand the purpose of the evaluations. If the evaluation is important mainly
to a donor or funding organization, the information collected may need to
be representative of the community as a whole and its relevance for improv-
ing community hygiene clearly stated against the project goals. However,
it may also be important for the evaluation to be used as a means of discussing
the direction of the programme and of identifying how the effectiveness
could be improved. If the evaluation is geared more towards the community,
it can be used to generate further debate about the importance of the hygiene
promotion programme and how it can be enhanced by the community itself.
945 Feedback and dissemination of findings
Information gathered during monitoring and evaluation activities should be
shared with the wider community and other interested parties. This is best
accomplished by holding group discussions with different sections of the
community. Feedback can also be accomplished by posting notices at meeting
places, or by presenting the information in the form of a drama. Written infor-
mation should be summarized in no more than a couple of pages and illus-
trated with graphs, figures, pictograms and pictures. If information is shared
with the community and other concerned people, discussions about progress
can lead to new project targets or even to different types of projects.
Providing health care
In any community, people become ill and require access to health care facili-
ties and treatment. The problem may be physical, such as diarrhoea, fever or
injury, or mental, e.g. psychosis, epilepsy or a learning difficulty Women have
special needs related to pregnancy and childbirth, and children require
immunization against common diseases. Regardless of the nature of the
health issue, the health outcomes depend to a large degree on individuals'
ability to access health care services. Unfortunately, health services are often
planned without consulting the community members who use and pay for
such services, particularly in rural areas. To counter this, and to meet com-
munity demands for accessible, affordable services, community members
should be actively involved in their planning. Health centres should attract
the community (see Figure 10.1).
The way in which people deal with illness is also an important factor in
health care. Most people initially treat ill-health within the home and seek
outside help only when the problem continues or becomes severe. Such help
may not necessarily come from qualified medical personnel; it can also come
from local pharmacists or medicine sellers, traditional healers, religious
leaders and friends. Often, seeking medical advice from qualified personnel
is the last resort. This can happen for many reasons, such as that an individ-
ual does not consider the problem to be severe or "medical" in nature, or that
the value of medical advice is not appreciated. Sometimes, there is simply
mistrust of the medical profession.
Consequently, when planning health care interventions, it is important
first to understand current health practices, as well as community needs:
which health care services are available, what type of service the community
wants and where health facilities should be located. This can be achieved
through community discussions using participatory learning techniques with
different community groups defined by age, gender, wealth and ethnic /reli-
gious affiliation. The purpose is to generate a reliable picture of community
needs and ensure that the services provided will be equitable, accessible and
CHAPTER 10. PROVIDING HEALTH CARE
Figure 10.1 Rural health centre
Providing health care services
Health care facilities (rural clinics, health centres) should be within easy walking
distance of the community, particularly for women and children.
Outreach or primary health care workers, such as health visitors and pro-
moters, can be valuable front-line community health workers if they are provided
with adequate training and support, particularly if they come from the community
Other health service providers (pharmacists, medicine sellers, traditional healers)
can provide additional health advice and care if they are given adequate training
and support, and are supervised by medical staff.
Referral systems between different levels of health care (primary, secondary and
tertiary) should be clear and comprehensible to both users and providers. The
reasons for referrals are often unclear to the users, which can provoke anxiety and
lead to non-attendance. In addition, many primary- and secondary-level health
care workers may not understand how to refer a patient to higher levels of service,
or may not recognize symptoms of more severe illness, which leads to dangerous
delays in referral.
84 HEALTHY VILLAGES: A GUIDE FOR COMMUNITIES AND COMMUNITY HEALTH WORKERS
10.1 Establishing community health care programmes
When community health care services are established, it is essential that the
primary health care be effective and efficient. Community members can lobby
local service providers to put primary health care workers in the community,
as well as identify community members who could be trained to provide
health advice. Other people who can provide health advice to the commu-
nity, such as pharmacists or medicine sellers, birth attendants and traditional
healers, should also be identified. Local service providers can be lobbied to
provide additional training and support for these people if necessary. To be
effective, health care workers should be acceptable to different community
groups and have unrestricted access to the population. Women, for example,
may not consider male health care workers to be acceptable for certain issues,
and vice versa. Primary health care workers should also have sufficient
knowledge and support to recognize illnesses that are beyond their ability to
treat, and be able to refer patients to higher-level health care facilities for
expert advice and treatment.
The role of pharmacists and medicine sellers in malaria treatment
In south Asia, WHO has promoted the use of local pharmacists and medicine sellers
to provide treatment for malaria. They have been trained to recognize malaria symp-
toms, to prescribe the correct drug dosages, and to advise patients on whether they
should seek expert advice. The programme has proved popular with communities,
and with the medicine sellers and pharmacists, and it has reduced the burden on
over-stretched health services.
The following questionnaire can help community members to determine
whether current health services are adequate. If the community lacks ade-
quate access to health services, a strategy for improving the services should
be developed and presented to local service providers. Presenting a concrete
plan for improving health services, rather than simply complaining that they
are inadequate, will enable service providers to plan the necessary services
Are current health services adequate?
Where is the nearest health centre to the community? Can women and children
walk to it within one hour?
Do trained health workers visit the community? What treatment and health advice
can they offer?
CHAPTER 10. PROVIDING HEALTH CARE 85
Do health workers provide health education by visiting households and schools, or
by attending community meetings?
Is there a pharmacist or medicine seller in the community or in a nearby com-
munity? What medicines can be obtained and what advice is provided? Do the
pharmacists or medicine sellers receive supervision or support? Do community
members consider them to be helpful in treating disease?
If community members become sick, do they have access to drugs and other
What sort of health service provision would the community like to have?
10.2 Factors that influence the type of health care that people seek
When people are sick many cultural and societal factors influence whether
and where they seek health care and from whom. For example, it may be dif-
ficult for women to approach male health workers for certain problems. On
the other hand, individuals in the community who are perceived as wise, or
likely to have the required information, may be trusted by most community
members. Too often, traditional ways of treating health problems are dis-
counted by people outside a community who try to impose "western" or
orthodox models of health care, with their emphasis on medication. However,
if the illness is ascribed to angry gods or bad spirits, for example, this
approach may not be perceived as effective and community members will be
unlikely to seek orthodox health care; indigenous healers or religious leaders
may be consulted instead.
The societal context of a disease, too, can affect whether people seek
medical advice. In communities where communicable diseases are common,
diarrhoea may not be viewed as a major problem unless it is severe. Frequent
mild cases of malaria may not lead the sufferer to seek medical assistance,
even though malaria can be a life- threatening disease. As a result, people
often do not seek treatment and continue to have poor health.
For many reasons, therefore, it is important to work with a community to
find out where individuals go for health advice and why. By understanding
what help can be provided by different health care workers and how differ-
ent people can work together, the best possible health care can be provided.
This can be accomplished either by formal discussions or in more informal
settings. By working with community members it will be possible to set up
a referral system that includes all community health providers and to ensure
that all providers have standard codes of practice.
86 HEALTHY VILLAGES: A GUIDE FOR COMMUNITIES AND COMMUNITY HEALTH WORKERS
Who provides community health advice?
Are there any traditional healers or birth attendants in the community?
What sort of advice do they provide?
Do any problems arise from using traditional healers?
Are there any health workers in the community?
What services do they offer?
Where do men mostly go to seek advice about their health or treatment?
Where do women usually go to seek advice about their health or treatment?
Where do families usually take their children when they are sick?
Are boys taken to different people from girls?
10.3 Encouraging and sustaining the use of health services
For the cultural and societal reasons discussed in section 10.2, it can be diffi-
cult to change the way people seek health advice. To accomplish change,
health care services must be easily available, since people are less likely to
use good health services if they are distant from the community. If the com-
munity has been actively involved in planning and selecting the health ser-
vices, it is also more likely that community members will use them. All
community members should therefore be involved in the planning process,
not simply community leaders. Community leaders may desire a certain level
of health service, but if the rest of the community feels the service does not
meet their needs, the result may be expensive services that are not used.
To sustain the use of health services, continuing campaigns in the commu-
nity and in schools may be required. Educational messages through posters
and the mass media can be part of larger campaigns within the community.
Regular community meetings can also be held between outreach workers,
influential people within the community, and community groups or house-
holds. A key strategy is to allow people to express their concerns about the
health services. It may be, for example, that families do not use the available
service because service providers have been rude or aggressive, or because the
facility is not open at convenient times. Service providers and communities
should therefore maintain a dialogue and find compromises that meet com-
munity demands but also reflect the capacity of the service.
10.4 Immunization of children
Vaccines are available for some major infectious childhood diseases, includ-
ing measles, poliomyelitis, tuberculosis, diphtheria, tetanus, whooping cough
CHAPTER 10. PROVIDING HEALTH CARE 87
(pertussis), mumps and rubella (German measles). However, all children
in a community should have the full course of immunization for these
diseases. If a child contracts a disease it is not just his or her health that is at
risk: there is a risk of an outbreak within the community, and these diseases
can be fatal or cause complications such as blindness, infertility, partial pa-
ralysis and stunting.
For the majority of the childhood diseases, it is most effective to immu-
nize children at a young age (preferably under 1 year), usually by means of
a series of injections or oral vaccines as shown in Figure 10.2. Most countries
make immunization programmes available to communities at no cost through
local health centres, although some may offer immunization services only on
certain days. In other cases, mobile teams visit communities on certain days
to carry out immunization. It is important that community members know
where and when immunization services are available.
10.4.1 Overcoming barriers to immunization
Immunization generally requires babies or young children to be injected and
many parents have fears about this. The fears result from several factors,
including a dislike of needles, and concerns about the transmission of
HIV /AIDS or other health problems arising from the use of contaminated
syringes and needles. Immunization injections can also cause reactions, such
as a mild fever or pain in the injection site, and make the child cry. Mothers
and families may thus be reluctant to follow the full course of immunization,
or even to begin immunization, if other families have had bad experiences.
However, such reactions are not harmful to the child and the full course must be taken
to ensure that the child is fully immunized. Many rural families may feel they do
not have the time to take children for immunization, particularly if immu-
nization services are available only during periods of intensive work on the
To overcome these barriers, immunization services should be available
at times convenient for community members. Community leaders and
health staff should also provide full information to families before immu-
nization is started and ensure that everyone has an opportunity to ask ques-
tions and voice concerns. If immunization is to be effective, all children
should complete the full course and obstacles to this must be overcome.
Community meetings with health staff should help in overcoming such
HEALTHY VILLAGES: A GUIDE FOR COMMUNITIES AND COMMUNITY HEALTH WORKERS
Figure 10.2 Nurse immunizing a child
Checklist for immunization
Are immunization services available at the local health centre?
When are these services offered and who provides them?
Are special arrangements required (e.g. do people have to make appointments;
are there restrictions on how many immunizations can be done in one day)?
If mobile teams offer immunization services, when will the services be available?
Where will the immunization sessions be held?
How many people can attend?
Who is responsible for providing the community with feedback from immunization
Has this information been provided?
While immunization should be carried out by trained health staff, the com-
munity itself has an important role to play in ensuring that this is done prop-
erly and that everyone has access to immunization services. It is important
that the community receives information about how many children were
immunized on each visit. A community health worker can be given respon-
sibility for identifying families that have limited access to services or that do
not use the services that are available. The health worker should then lobby
CHAPTER 10. PROVIDING HEALTH CARE 89
for improved access and work with the families to persuade them to use the
10.4.2 Making immunization safe
Immunizations are normally (and should be) carried out either at health
centres or by mobile immunization teams. Immunizations requiring an injec-
tion should be carried out by qualified medical personnel, such as doctors or
nurses; immunizations that are given orally (for instance poliomyelitis) can be
given by other health staff under the supervision of a doctor or senior nurse.
In all cases, the vaccines should be used before their expiration date. If dis-
posable syringes and needles are used for vaccinations they should be safely
discarded after use. A new type of safe, disposable syringe is now available,
called the AD (auto-disable) syringe, which is much safer because it locks after
a single use. Disposable syringes and needles are intended for a single use only
and are highly dangerous if they are used more than once. If sterilizable
syringes and needles are still used, they must be properly sterilized after each
use to avoid the transmission of pathogens such as HIV, viral hepatitis B and
hepatitis C. All used syringes and needles MUST be disposed of safely and not
be left on the ground or in waste bins in the village, since they represent an
extreme health risk, particularly for children who may find them and play
with them. Preferably, needles, syringes and other medical waste should be
taken away by trained staff and disposed of at properly designed facilities. If
no such facilities are available, the waste should be incinerated or buried in the
village but only if there is a secure site.
Several safety issues about which health staff need to reassure communi-
ties are listed in the text box below. Community members have a right to
know the answers to these questions they are important for establishing
confidence in immunization services.
Safety issues for immunization programmes
Do the people carrying out immunization have the necessary training?
Are nonmedical staff supervised?
Are the vaccines used by their expiry date? (Vaccines that have expired may lose
effectiveness or become dangerous.)
Are disposable needles used only once?
Are sterilizable syringes and needles properly sterilized between injections?
Are AD syringes available?
How will used syringes, needles and other waste be disposed of?
90 HEALTHY VILLAGES: A GUIDE FOR COMMUNITIES AND COMMUNITY HEALTH WORKERS
10.5 Groups with special health care needs
Certain groups within a community will have special health care needs
because they are more vulnerable to infectious or chronic noncommunicable
diseases than the general population. These groups include the very young,
the very old and pregnant women.
10.5.1 Pregnant women and infants
Local health care centres and village health care workers should provide
advice and specialist care to infants and pregnant women. For infants, regular
check-ups are necessary to ensure that they are not malnourished and are
gaining sufficient weight. Children are particularly susceptible to infectious
diseases that cause diarrhoea and extra care should be taken to ensure that
water and food for children are hygienic. Parents, and particularly mothers,
should actively encourage children at an early age to develop good hygiene
practices, such as using latrines and washing hands.
Key checks for pregnant women
Measure the growth and position of the baby.
Test blood pressure.
Test the urine for proteinuria.
Perform blood tests for diseases such as HIV, syphilis and malaria, and to assess
whether the mother is anaemic.
Screen for women who will be at high risk for health complications and refer them
to local hospitals for further checks and treatment. Those at high risk include
women pregnant with twins, women who have previously had a caesarean section
and women in their fifth (or greater) pregnancy.
Health care for pregnant women would usually be offered through a health
centre or mobile health team. Antenatal and postnatal care are both vital for
ensuring that mother and child remain healthy, and pregnant women should
visit their doctor regularly for health checks. If basic antenatal and postnatal
care are not available in a village, the community should lobby for such ser-
vices to be provided. In areas where malaria is endemic, pregnant women
should be given mosquito nets impregnated with insecticide as early in the
pregnancy as possible.
CHAPTER 10. PROVIDING HEALTH CARE 91
10.5.2 The elderly
As people age they become more susceptible to ill-health, both from infec-
tious diseases and from noncommunicable diseases, such as cancers or degen-
erative diseases. The risk of infectious disease is often increased by chronic
disease, particularly when treatment involves treatment with certain drugs
that can suppress the immune system and render it less effective. Some dis-
abilities in old age may result from an earlier lifestyle and work, or from mal-
nutrition and repeated infection in formative years. These disabilities can be
prevented only by healthier lifestyles at a younger age.
Key illnesses that affect older people include heart complaints, strokes, eye
problems (e.g. glaucoma), respiratory problems, deafness, arthritis, and prob-
lems with urinating and sleeping. If an elderly community member has eye
or heart problems, he or she should visit a health centre and obtain treatment
at an early stage of the disease. Many chronic health problems faced by the
elderly either require long-term medication or have significant potential for
recurrence. Planning for health care within the family and community may
therefore require careful budgeting. Furthermore, many older people are
sceptical of "western" or orthodox drug-based health care and it is important
to make sure that they take their medication regularly.
If a community has a significant number of older people, it should lobby
to ensure that the nearest health centre has someone with a particular inter-
est in the care of the elderly and runs regular clinics dedicated to older people.
Health education programmes that target the problems of the elderly and
provide information on healthy ageing are often an effective way to improve
the health and well-being of the elderly. Many older people also suffer from
depression or anxiety as their physical abilities (such as eyesight and hearing)
decline and they feel they are unable to contribute fully to the life of the home
and community. To counter this, they should be encouraged to retain an active
role in the community. While older people may not have the energy or
strength to perform all the roles they used to, this should not mean that they
are no longer asked to undertake important tasks. Indeed, their health and
well-being may depend on being actively involved within the community.
Developing a positive attitude towards ageing, among the young and old
alike, will help people to remain active in later life and develop better support
for the elderly.
10.6 Risky behaviour
Some people engage in behaviour that poses a high risk both to their health
and to the health of their family. For example, if a person has sex with mul-
tiple partners and does not use condoms there is a high risk of contracting
92 HEALTHY VILLAGES: A GUIDE FOR COMMUNITIES AND COMMUNITY HEALTH WORKERS
HIV /AIDS and other sexually transmitted diseases. If the person is married
or is in a relationship, he or she can then pass on the infection to their spouse
or usual partner. This can have devastating consequences: infection with HIV
can lead to the development of AIDS and to premature death, and other sex-
ually transmitted diseases can cause infertility, problems during childbirth
and stunting in babies.
Risky behaviour in a community
Do people in the community engage in high-risk sexual behaviour?
Do people in the community use drugs or drink too much alcohol?
Is information about these problems available in health centres, schools or com-
Is support available for people with drug or behavioural problems?
Are community health workers aware of the health risks associated with these
The abuse of substances such as alcohol, cigarettes and other legal and illegal
substances, to the extent that an individual becomes dependent upon them,
can also lead to severe physical health problems, such as liver dysfunction or
cancer, and may make the person more vulnerable to heart disease and other
health problems. Long-term use of such substances may lead to mental health
problems or worsen existing problems. Dependence on a substance can also
cause a person to neglect their normal social and family duties and take less
care of their appearance. In some cases, people dependent on substances
commit crimes in order to fund their habits.
10.6.1 Changing risky behaviour
People who engage in risky activities do so for many reasons, some of which
may relate to other problems in their life or in their society. People who abuse
substances or drink too much alcohol may do so not only to get a "buzz" or
"high" but also because they have problems in their personal or family life
or because they feel marginalized in their community. This behaviour can be
a means of trying to cope with these problems. People who engage in high-
risk behaviour do not always consider the impact of their behaviour on their
own health and well-being, or on the well-being of their families and
A first step in changing risky behaviour is to encourage people to talk
about the impact that their behaviour has on themselves and on their com-
CHAPTER 10. PROVIDING HEALTH CARE 93
munity. This requires that they have access to information and support.
Encouraging people to change risky behaviours takes effort and time, and
may require working with individuals, households and the whole commu-
nity. While it may be relatively easy to change a person's behaviour initially,
sustaining such changes can be much more difficult. If a person reverts to the
risky behaviour, it is important to continue to work with them ancThelp them
to stop the behaviour again.
One approach is to form a community support group with support from
counsellors or other health personnel. Those engaging in risky behaviour can
discuss the problems associated with their behaviour in terms of financial
cost, losing respect, disharmony in the home and difficult interactions with
neighbours. It is also important to identify the problems a person faces in
trying to change their behaviour and to discuss factors that might encourage
them to overcome these problems. This may require working with people to
develop strategies for dealing with personal and family problems, and
to develop other social and occupational activities in place of the risky
Many people will need ongoing support and encouragement not to go
back to risky behaviour. It is important not to penalize people who revert to
risky behaviour; they should be helped to understand why they went back
and encouraged to change. Such relapses can be used as a learning experi-
ence, helping the person to understand which situations trigger a return to
risky behaviour. Eliminating this behaviour completely may not be possible
and it may be more effective to keep it within limits that do not harm the
person or their family. For example, drinking could be reduced to non-
harmful levels. In some cases, the individual or community may need support
from medical personnel or mental health specialists. Sometimes, when a
person has become dependent on a substance, he or she will need medical
assistance to stop using the substance. This is sometimes called "detoxifica-
tion". Care should be taken to ensure that this process is properly supervised
as it can pose a risk to health.
10.6.2 Health education
In addition to working with people who engage in risky behaviour, it is
important to work with communities to develop strategies and knowledge
for preventing it. As with many health issues, prevention is much better than
trying to treat problems after they occur. Many of the techniques discussed
in the previous chapter can also be used to raise awareness about risky behav-
iours. The whole community should be encouraged to participate in defining
the impacts and problems associated with risky behaviours, and to discuss
how they can be reduced or prevented.
94 HEALTHY VILLAGES: A GUIDE FOR COMMUNITIES AND COMMUNITY HEALTH WORKERS
It is especially important that children have access to information about
the impact of risky behaviour on their health and on the well-being of their
community. In this respect, health education in schools is very important and
should be carried out in a way that allows children to openly discuss these
difficult problems. In many areas, encouraging less risky sexual practices
has proved to be an effective method for promoting better sexual health. In
addition to school programmes, health centres and clinics should also be
encouraged to provide information about the impact of risky behaviours. The
information should be communicated in terms that are easily understood by
the whole community, rather than in complicated medical terms, and com-
munity members should be provided with an opportunity to discuss issues
with health staff. It is important, however, that such messages are not too
harsh or strict. For instance, some consumption of alcohol may not be harmful
and discouraging all use may be neither necessary nor helpful. It is more
important to emphasize the need to keep consumption at levels that do not
represent a risk to the person's health.
10.7 Mental health problems, learning difficulties and epilepsy
1071 Mental health problems
Mental health problems are mental, emotional and behavioural difficulties
that disrupt relationships and may impair the ability of a person to play a
full and active role in the community. In some cases, mental health problems
result from brain diseases, while in other cases they may be reactions to
bad experiences. People with severe mental health problems often need
to be given drugs to treat symptoms, but these can have side-effects
that make people feel unwell or drowsy. As a result, some people stop taking
their prescribed medication and feel they can cope without it, which can
cause the illness to recur. People with mental health problems should there-
fore be encouraged to continue taking any medication that has been
An important way to help people with mental health problems is to
engage them in counselling or enrol them in mental health services. How-
ever, mental health specialists may not be easily accessible to community
members, since there are usually relatively few of them, and they work
at higher levels of service provision. To overcome this, community members
should lobby for access or referral to mental health specialists or other health
staff who can provide assistance, both in treating patients and in identifying
support for the individuals and families. Assistance does not necessarily
mean financial aid and often includes social support and health education.
To help them feel valued within the community, people with mental health
CHAPTER 10. PROVIDING HEALTH CARE 95
problems should be encouraged to take up employment and social
107.2 Learning difficulties
People with learning difficulties have limited intellectual capabilities and may
seem "slow 7 ', yet there are many ways in which they can play a meaningful
role in their community However, these people will often need support from
their community and will benefit from input from health care and other staff,
who can help them to develop their abilities and skills.
People with epilepsy suffer from fits that can be alarming to themselves, their
families and other community members. Epilepsy can be caused by head
injuries during infancy, or result from maternal infections such as meningitis
or syphilis. Epilepsy is not an infectious disease and there is no risk of catching it
from someone else. Epilepsy can be treated and controlled with suitable medi-
cation, and when people with epilepsy are stabilized on medication they can
play a full role in the community.
1074 Social inclusion
People with mental health problems, learning difficulties or epilepsy are often
stigmatized by the community because of ignorance about the nature of
mental illnesses. This only compounds the problem by making those suffer-
ing from the illnesses and their families feel like "outsiders", and can lead to
discrimination. Community members and health workers should work to
overcome stigmatization and value the sufferers as full and useful members
of the community. Often, this can be accomplished through education and by
providing support services for these individuals. Encouraging them to under-
take activities that are useful to the community, and that make them feel part
of their community, can reduce the level of stigma and increase social inclu-
sion. Schools should also include education about mental health to encour-
age greater understanding of the problems and of the ways in which sufferers
can be supported to enjoy a full and productive life. Addressing problems of
this nature with children often helps prevent stigmatization and other social
problems, which are usually fuelled by ignorance.
96 HEALTHY VILLAGES: A GUIDE FOR COMMUNITIES AND COMMUNITY HEALTH WORKERS
Community mental health
Are there people in the community suffering from mental health problems?
Are there people in the community suffering from learning difficulties?
Are there people in the community suffering from epilepsy?
Are community health workers trained to provide support to these people?
Does the community have access to mental health workers?
What is the attitude of the community towards people with mental health problems,
learning difficulties or epilepsy?
Are educational materials about mental health problems, learning difficulties or
epilepsy available to the community?
for implementing Healthy
This chapter describes how to establish committees for Healthy Villages pro-
grammes and discusses the key roles of committees in implementing the pro-
grammes. It also provides an overview of the local and national government
support that community leaders may expect when developing a Healthy Vil-
lages initiative. It is not meant as a definitive guide for government staff, as
this is covered elsewhere (see Annex 2).
Healthy Villages initiatives usually extend beyond a single community or
group of communities and are incorporated into provincial, district and
national plans. Healthy Villages programmes are also often linked to similar
programmes, such as Healthy Cities and Basic Development Needs. Each of
the different programmes greatly benefits from close association with other
programmes. For example, a Healthy Villages programme may be easier to
run if the local urban area is engaged in a Healthy Cities programme. Thus,
both national and local governments play key roles in supporting and devel-
oping Healthy Villages programmes.
Healthy Villages programmes in action
In the eastern Mediterranean region, Healthy Villages programmes have been
integrated into national plans for improving health. In Egypt, for example, the Healthy
Villages programme has been part of an integrated approach to rural develop-
ment. By 1999, the programme had covered 4405 villages and satellite settlements
in 1087 local administrative units. An estimated 36 million people (about 57% of the
population) have benefited from the programme. A total of 25450 projects
were implemented within five years in the economic, social and health sectors. A
key lesson is that it is possible to integrate environmental and health concerns in a
local development agenda and that this leads to greater stakeholder involvement.
98 HEALTHY VILLAGES: A GUIDE FOR COMMUNITIES AND COMMUNITY HEALTH WORKERS
11.1 The role of local community committees in Healthy Villages
Each village and community participating in a Healthy Villages programme
should establish a committee at the local level. Local committees are essen-
tial for broad approaches to health improvement that involve a wide range
of activities and individuals, such as the Healthy Villages programme. A com-
mittee can coordinate and support the different activities and provide lead-
ership for the community, and can serve as the community contact point with
local and national government staff involved in the Healthy Villages pro-
gramme. Local committees can also facilitate broad community participation
in the programme, something that may be difficult to achieve by outsiders.
Local committees are therefore crucial for promoting the Healthy Villages
approach in a community.
11.1.1 Composition of a Healthy Villages committee
The composition of a local committee is critical for a successful outcome.
Committee members should be influential people within the community who
are respected and who are able to represent the interests of all the different
community sections. If the committee reflects the narrow interests of only a
small group of people, confidence may be lost in the entire programme,
leading to failure. Ideally, the composition of the committee should reflect the
gender balance of the community. While it may not be possible to have com-
pletely equal gender representation, because of cultural and social norms,
women should be adequately represented to ensure that their concerns are
taken into account and dealt with sensitively. It is also helpful if staff from
the national or local government are members of the committee.
The importance of local committees in Healthy Villages programmes
Local village councils in the Islamic Republic of Iran have played key roles in the
successful implementation of integrated rural development programmes. The strong
role played by the local committees, supported with a legal mandate, has helped
rural development programmes meet the demands of the local populations and
deliver sustained improvements in public health.
The influential members of a community are not necessarily the people with
administrative responsibilities within the community. They can also be people
who are respected and act as opinion leaders, such as village chiefs, teachers,
religious leaders and ordinary community members. It is best that commit-
CHAPTER 11. IMPLEMENTING HEALTHY VILLAGES PROGRAMMES 99
tee members are elected by the community and have limited terms of office,
to ensure that serving on the committee does not become a burden to key
community members, or become a way for individuals to use the committee
for personal gain. As the committee is expected to be the principal imple-
menting body for the Healthy Villages programme, members must also have
time to allocate to the committee and other Healthy Villages activities. They
will also need to be accessible both to the community and to staff from local
government and other bodies that provide support to the Healthy Villages
11.1.2 Transparency and accountability
The committee should be accountable and transparent both to the commu-
nity and to external organizations, such as local government, NGOs or exter-
nal support agencies that may provide support. The committee should take
minutes of all meetings, record the decisions made and make sure that other
community members have access to this information. A regular feedback
mechanism to the broader community should also be established, along with
a forum for broader debate by the community about major activities and
issues. If the committee manages funds, accounts should be kept and made
available to other community members and external support agencies. To do
this, the committee should elect executive officers, such as a chairperson, trea-
surer and secretary, and meet regularly.
1 1 .2 The role of local government committees in Healthy Villages
Local governments usually have their own Healthy Villages committees
and coordinators who provide technical and administrative support to com-
munity committees overseeing Healthy Villages programmes. A key role
of local government committees is to provide new ideas and to make
communities aware of initiatives and successes in other communities par-
ticipating in Healthy Villages programmes, and provide the impetus for
communities to improve their own health and environment. For example,
local governments may support improvements to communities under their
jurisdiction by providing services and infrastructure. This may be paid for by
local government revenue, by grants and loans from central government, or
by raising funds from national and international support agencies. The deliv-
ery of many health services, such as immunization programmes or pro-
grammes that provide health centres and clinics, will be carried out by local
1 00 HEALTHY VILLAGES: A GUIDE FOR COMMUNITIES AND COMMUNITY HEALTH WORKERS
11.2.1 Funding and accountability
Often local governments have access to both conditional and unconditional
grants for improving services to their populations. These grants can be used
to support immunization programmes, for example, or provide funds for the
operation and maintenance of water supplies and latrine construction. To
retain access to these grants it is critical that local governments properly
account for the funds. In most cases, central governments, external support
agencies and NGOs are willing to provide continuing support to local gov-
ernments if the funds are spent in accordance with agreements between the
local governments and the finance providers and if all previously released
funds can be properly accounted for. One of the greatest barriers to local gov-
ernments accessing funds is an inability to properly account for money pre-
viously provided. This can result in local governments being blacklisted
by agencies or central government departments, and lead to frustration
within the local government and funding agencies over the inability to release
In many cases, the lack of accountability does not reflect misappropria-
tion of funds, but rather a lack of understanding of accounting procedures.
It is essential, therefore, that local governments request proper training and
support in accounting procedures, and ensure that their staff understand the
accounting requirements and can prepare and submit accountability forms in
the correct format.
11.2.2 Technical advice and support
In addition to providing infrastructure and services directly, local govern-
ments play an important role in other ways by providing support to com-
munities in terms of technical advice, health education, water quality
monitoring and management, lobbying for funds to support community-
based initiatives, and facilitating access to spare parts and tools. Often, they
can also support the development of health care provision within, or close to,
communities. These different types of support can provide opportunities for
educating community members on how to practise good hygiene, and how
to improve the operation and maintenance of water supplies. Local govern-
ments can also provide services that the community is unable to deliver, such
as periodic testing of wastewater quality, food inspection and food quality
CHAPTER 11. IMPLEMENTING HEALTHY VILLAGES PROGRAMMES 101
Partnerships between communities and local governments
In Morocco, the rural water supply programme (PAGER) has developed close rela-
tionships between local rural governments (communes) and communities. The com-
munes also provide a vital link to the national government. Rural water supplies have
been developed through a partnership between the communes andteaf communi-
ties, with the communes providing technical support and advice. However, initiation
of the process always comes from the local population.
Local government officials play a crucial role in providing technical advice
to communities. Many communities or households may wish to facilitate
better health by improving the environment, but do not know how to achieve
this. Local government staff can provide technical advice on a wide range of
activities, such as the design of sanitation, water supply, waste disposal and
drainage projects, and work with communities to define and implement
improvements that the community can afford and sustain. Local government
staff willing and able to answer questions from community members can
therefore assist in resolving many health problems.
Local government staff can also be the main implementers of health
education by providing health education directly through community
meetings, by providing posters, or by training and supporting local health
educators. The use of community health educators, drawn from the commu-
nity in which they live, can be a very successful approach if they are given
adequate technical and financial support from local government. Local
government staff also play a crucial role in helping communities to analyse
their environment and the risks to their health, and in helping them priori-
tize interventions. They can also help communities use the checklists included
in this document.
Finally, the local government can play a critical role in identifying the most
needy communities and households, and in directing external agencies
(whether large donors or NGOs) to those areas. This can ensure that all com-
munities, rather than just a few lucky ones, receive equitable support and
funds from Healthy Villages initiatives.
11.3 The role of national committees and coordinators in
Healthy Villages programmes
A Healthy Villages programme usually has a national committee and a coor-
dinator who are responsible for promoting and developing the programme
at a national level. National committees help to articulate policies that support
the development of Healthy Villages initiatives, and help to attract external
support when required. They may also provide training for local government
1 02 HEALTHY VILLAGES: A GUIDE FOR COMMUNITIES AND COMMUNITY HEALTH WORKERS
staff in techniques that are required to support Healthy Villages initiatives at
local levels, to evaluate progress and to ensure that experiences are shared.
To remain relevant, it is important that national committees remain in touch
with developments in communities with Healthy Villages programmes and
are aware of the reality of life in rural areas. They should also understand
how community members want to develop their village. National staff should
therefore make regular visits to villages participating in Healthy Villages pro-
grammes and listen to the views and concerns of local people.
The importance of national committees in promoting Healthy Villages programmes
To ensure that Healthy Villages programmes receive support, it is essential that there
are national level professionals who are committed to the development of the Healthy
Villages initiatives. In Egypt, the Islamic Republic of Iran, Jordan and the Syrian Arab
Republic, the role of national committees in developing materials and attracting
resources has been crucial. In all these countries, support from the highest levels of
governments has been secured because of the profile and performance of these
committees. A common factor across all these countries is that the national commit-
tees have maintained close contact with grassroots activities, thus ensuring that they
remain responsive to the needs of the rural population and are well-respected.
National committees and coordinators are often responsible for the devel-
opment of supporting materials that can be used by local Healthy Villages
committees when undertaking a range of interventions. These materials can
include overview guides for entire Healthy Villages programmes and con-
cepts, or pamphlets and manuals on specific subjects, such as protecting and
maintaining a water supply or improving sanitation and hygiene. Any mate-
rials developed should be properly tested before they are used and commu-
nities should be given opportunities to provide feedback on the usefulness of
the documents and on changes that may be required.
National committees and coordinators should also make sure that lessons
from different areas or countries with Healthy Villages programmes are
shared with key stakeholders, including community leaders. Building on suc-
cesses from other communities can be an important way for communities to
improve their own programmes and avoid the mistakes of others. Conse-
quently, community leaders should make sure that they know who the
national committees and coordinators are, where they are located and what
their roles are in developing a Healthy Villages programme. They should also
request information about activities in other areas of the country, as well as
those at the national level and in other countries.
Organizations supporting Healthy
Many organizations, some of which are listed below, provide support for
Healthy Villages projects at both local and national levels. Contact addresses
are given only for WHO offices. For most other agencies it will be more effec-
tive to contact the corresponding country offices directly.
A1.1 Government ministries
A1.2 World Health Organization
The first step in discussing a Healthy Villages project is to contact a WHO
office directly. WHO maintains offices in many countries, usually associated
with the Ministry of Health. Addresses for WHO headquarters and regional
offices are listed below. In most regional offices there are specific technical
departments that deal with issues such as environmental health and they may
be a valuable resource for information. Contact details for these departments
should be obtained from the WHO country or regional offices.
World Health Organization (WHO-HQ), 20 Avenue Appia, CH-1211
Geneva 27, Switzerland.
World Health Organization, Regional Office for Africa (AFRO), PO Box
No. 6, Brazzaville, Republic of Congo.
1 04 HEALTHY VILLAGES: A GUIDE FOR COMMUNITIES AND COMMUNITY HEALTH WORKERS
World Health Organization, Regional Office for the Americas /Pan
American Health Organization (AMRO/PAHO), 525 23rd Street, Wash-
ington, DC 20037, USA.
World Health Organization, Regional Office for the Eastern Mediter-
ranean (EMRO), WHO Post Office, Abdul Razzak Al Sanhouri Street,
Naser City, Cairo 11371, Egypt.
World Health Organization, Regional Office for Europe (EURO),
8 Scherfigsvej, DK-2100 Copenhagen 0, Denmark.
World Health Organization, Regional Office for South-East Asia
(SEARO)/World Health House, Indraprastha Estate, Mahatma Gandhi
Road, New Dehli 110002, India.
World Health Organization, Regional Office for the Western Pacific
Region (WPRO), PO Box 2932, 1099 Manila, Philippines.
A1.3 Other United Nations organizations
The following organizations often have a national office in countries:
United Nations Children's Fund (UNICEF).
United Nations Development Programme (UNDP).
United Nations Environment Programme (UNEP).
In addition, there are bilateral donor agencies (agencies that are the official
body for a single country), multilateral donor agencies (agencies that repre-
sent a group of countries, such as the European Union) and international
lending institutions, such as the World Bank, and these may also support a
Healthy Villages project.
A1.4 Nongovernmental organizations (NGOs)
Many NGOs may be able to provide technical or financial support to a
Healthy Villages programme. Information should be sought about which
NGOs (national or international) are active in a country, and whether they
would be willing to provide support. Some examples include:
African Medical Research Foundation (AMREF).
Action contra la Faim (ACF).
Federation of Red Cross and Red Crescent Societies.
Helen Keller Foundation.
International Rescue Committee (IRC).
ANNEX 1. ORGANIZATIONS SUPPORTING HEALTHY VILLAGES INITIATIVES 1 05
Medicins Sans Frontieres (MSF).
Save the Children Fund (SCF).
Books and manuals providing
Almedom AM, Blumenthal U, Manderson L. Hygiene evaluation procedures:
approaches and methods for assessing water- and sanitation-related hygiene
practices. London, International Nutrition Foundation for Developing
Byrne M, Bennett FJ. Community nursing in developing countries: a manual
for the community nurse, 2nd ed. Oxford, Oxford University Press,
Cairncross S, Feachem RG. Environmental health engineering in the tropics: an
introductory text, 2nd ed. Chichester, England, Wiley, 1993.
Boot MT. Just stir gently: the way to mix hygiene education with water supply
and sanitation. The Hague, Netherlands, IRC International Water and
Sanitation Centre, 1991 (IRC Technical Paper Series, No. 29).
Boot MT, Cairncross S, eds. Actions speak. The study of the hygiene behaviour in
water and sanitation projects. The Hague, Netherlands, IRC International
Water and Sanitation Centre, 1993.
Ferron S, Morgan J, O'Reilly M. Hygiene promotion: a practical manual for
relief and development. London, Intermediate Technology Publications,
Franceys R, Pickford J, Reed R. A guide to the development of on-site sanitation.
Geneva, World Health Organization, 1992.
Guidelines for drinking-water quality. Vol. 1: Recommendations, 2nd ed. Geneva,
World Health Organization, 1993.
Guidelines for drinking-water quality. Vol. 3: Surveillance and control of community
supplies, 2nd ed. Geneva, World Health Organization, 1997.
Hofkes EH, ed. Small community water supplies. Chichester, England, Wiley,
ANNEX 2. BOOKS AND MANUALS PROVIDING FURTHER ADVICE 107
Howard G. Water quality surveillance a practical guide. Loughborough,
England, Water Engineering and Development Centre, Loughborough
Hubley J. Communicating health: an action guide to health education and health
promotion. London, Macmillan, 1993.
Jordan TD. A handbook of gravity-flow water systems for small communities.
London, Intermediate Technology Publications, 1984.
Kolsky P. Storm drainage: an engineering guide to the low-cost evaluation of si/stem
performance. London, Intermediate Technology Publications, 1998.
Mara D, Cairncross S. Guidelines for the safe use ofwastewater and excreta in agri-
culture and aquaculture: measures for public health protection. Geneva, World
Health Organization, 1989.
Mariotti SP, Pruss A. Preventing trachoma a guide for environmental sanitation
and improved hygiene: the SAFE strategy. Geneva, World Health Organiza-
tion, 2000 (document WHO/PBD/GET/00.7/Rev.l).
Morgan P. Rural water supplies and sanitation: a text from Zimbabwe's Blair
Research Laboratory. London, Macmillan, 1990.
Pacey A, Cullis A. Rainwater harvesting: the collection of rainfall and runoff in
rural areas. London, Intermediate Technology Publications, 1986.
PHAST step-by-step guide: a particitory approach for the control of diarrhoeal
disease. Geneva, World Health Organization, 1998 (Participatory Hygiene
and Sanitation Transformation Series; document WHO/EOS/98.3).
Quick RE et al. Diarrhoea prevention in Bolivia through point-of-use water
treatment and safe storage: a promising new strategy. Epidemiology and
Infection, 1999, 122:83-90.
Rozendaal JA et al. Vector control: methods for use by individuals and communi-
ties. Geneva, World Health Organization, 1997.
Safe water systems for the developing world: A handbook for implementing
household-based water treatment and safe storage projects. Atlanta, GA, Centers
for Disease Control and Prevention, 2000 (available at www.cdc.gov /safe-
water / manuals .htm) .
Sobsey MD. Managing water in the home: accelevated health gains from improved
water supply. Geneva, World Health Organization, 2002 (document
Stern P, ed. Field engineering: an introduction to development work and construc-
tion in rural areas. London, Intermediate Technology Publications, 1985.
1 08 HEALTHY VILLAGES: A GUIDE FOR COMMUNITIES AND COMMUNITY HEALTH WORKERS
Surface water drainage for low-income communities. Geneva, World Health Orga-
Water for health: taking charge. Geneva, World Health Organization, 2001 (doc-
Watt SB, Wood WE. Hand-dug wells and their construction. London, Intermedi-
ate Technology Publications, 1979.
Werner D. Where there is no doctor: a village health care handbook. London,
Werner D, Bower B. Helping health workers learn: a book of methods, aids and ideas
for instructors at the village level. Palo Alto, CA, The Hesperian Foundation,
Williams T, Moon A, Williams M. Food, environment and health: a guide for
primary school teachers. Geneva, World Health Organization, 1990.
Selected WHO publications of related Interest
Vector control: methods for use by individuals and communities.
1997xiii + 412 pages
Surface water drainage for low-income communities.
1991 *v + 88 pages
A guide to the development of on-site sanitation.
R. Franceys, J. Pickford, R. Reed
1992* viii + 237 pages
Food, environment and health: a guide for primary school teachers.
T. Williams, A. Moon, M. Williams
1990 xix + 129 pages
Guidelines for drinking-water quality, 2nd ed.
Vol. 3. Surveillance and control of community supplies.
1997xii + 238 pages
Food, water and family health: a manual for community educators.
1994 v + 99 pages document WHO/HEP/94.2
The PHAST initiative: participatory hygiene and sanitation transformation.
1997 vi + 39 pages document WHO/EOS/96.11
Basic food safety for health workers.
M. Adams, Y. Motarjemi
1999 iii + 116 pages document WHO/SDE/PHE/FOS/99.1
Further information on these and other WHO publications
can be obtained from Marketing and Dissemination,
World Health Organization, 1211 Geneva 27, Switzerland.
Health is determined by many factors, including income,
environmental conditions - such as access to adequate sanitation
safe water supplies- individual behaviour, and health services,
n half of the world's population lives in villages arid rural
d most of those without access to safe water sources or
litation are rural dwellers.
inabling rural populations to protect and improve their health is a
iajor challenge worldwide. In response to this, an informal "healthy
n r, movemen t nas evolved. A healthy villages project
local actions by community members, mobilizing human
and financial resources to build healthy environments and promote
This guide is intended to provide community leaders with
information to assist them in implementing and sustaining a healthy
Ullages project. It covers topics such as water and sanitation,
.rainage, waste management, housing quality, domestic and
;ommunity hygiene, and provision of health services, providing
xtensive source materials for adaptation to local needs and