In the vast nation of the Democratic Republic of Congo (DRC), girls may be sent for miles to fetch dirty water, risking both safety and health. Villages strategically located on rivers or lakes only have the illusion of enough water. Untreated, none of these sources are safe to drink.
In 2010, continuing its gradual emergence from years of conflict, the DRC lacked the basic infrastructure to ensure the health of its people. Nationwide less than half the population had access to potable water (rural areas had even lower access at 24 percent), and fewer than one in four had access to adequate sanitation. Widespread malnutrition caused stunting in 43 percent of children under 5. Open defecation was widely practiced, exclusive breastfeeding was not, leading to high rates of diarrheal disease — the number one cause of death in the country.
This was the backdrop against which USAID’s Integrated Health Project (DRC-IHP) started. Building on the Agency’s previous work in the health sector, the five-year, $144-million project to improve the health of the Congolese people ran from 2010–2015 and worked in 78 health zones in four provinces — Kasai Oriental, Kasai Occidental, Katanga, and Sud Kivu. Project activities continued for an additional year under DRC-IHPplus, which expanded to cover 83 health zones and incorporated lessons learned from the first five years of the project.
When it comes to restoring community health it’s important to start with the basics — clean water and sanitation.
DRC-IHP worked closely with the DRC Government to strengthen the country’s health system at every level. Part of the project’s comprehensive approach to health was a focus on improving water, sanitation, and hygiene (WASH) as well as nutrition in which infant and young child feeding activities emphasized WASH. The project also targeted maternal, newborn, and child health; family planning; and malaria, tuberculosis, and HIV/AIDS.
When it comes to restoring community health it’s important to start with the basics — clean water and sanitation. This is the goal of the Congolese Ministry of Health’s village assaini, or healthy village strategy: to provide at least 80 percent of residents access to safe water sources and sanitary latrines. Through community mobilization and sensitization activities, DRC-IHP promoted the idea that a community can take charge of its own health and can improve and maintain sanitation on its own.
The project mobilized citizens to reject the practice of open defecation and adopt latrines. Health zone officials, community leaders, and local masons were trained to advocate for WASH improvements and facilitate latrine construction. DRC-IHP also formed WASH committees to empower the community to take ownership of their WASH priorities. Residents were encouraged to solicit community contributions of materials and labor to improve or construct water points and latrines, and develop a plan to maintain and advance WASH improvements.
“The province needs people capable of engaging with communities through their local traditional leaders to mobilize them to take action,” noted Gaston Lubambo, a doctor responsible for public hygiene in the Sud Kivu Ministry of Health and an IHP training participant. “I know the importance of sensitizing communities and lobbying their support to optimize the results of our work.”
Thanks to community mobilization, more than a million people now have first-time access to potable water, and 858,585 people have access to improved latrines. What does this mean for a typical household? The numbers tell only part of the story.
“Our village is clean and the people of other villages envy us.”
Lubemba village in the Bilomba health zone is similar to many rural areas in the DRC. Before DRC-IHP, open defecation was the common practice and residents did not make the connection between diarrhea and poor sanitation and handwashing habits. The project assisted the village to form a WASH committee and trained its members to be sanitation and hygiene advocates. The committee in turn solicited contributions of sand, gravel, stones, and wooden planks, and volunteers built latrines and handwashing stations.
Now 90 percent of Lubemba’s households have latrines. “Our village is clean and the people of other villages envy us,” said Medard Nzemba, chairman of the WASH committee. “We are increasing our awareness to maintain good hygiene practices such as washing hands, as well as digging garbage holes as IHP has taught us.”
The Kimuka community in Sud Kivu went through a similar transformation. Like 50 percent of the country’s rural population, Kimuka spent a decade without a functioning water system. At the urging of the local WASH committee, Kimuka villagers spent three months digging ditches for water pipes, collecting building supplies, and helping complete eight water points, delivering safe drinking water to 574 families. “Hallelujah!” said Kimuka resident Alice Nalukogo. “I don’t have to wake up at 5 a.m. and risk my life and health for water that was making me and my family sick.”
WASH and Nutrition Integration
Improving health outcomes in the DRC required a re-examination of traditional practices around infant and young child feeding. In many areas of the DRC exclusive breastfeeding for the first six months is not the custom. Complementary foods are introduced early and infants are frequently exposed to illnesses from contaminated food and water.
Even mothers sold on the idea of breastfeeding can find it difficult initially, and when and how to introduce other food into a baby’s diet can be confusing. Before DRC-IHP, only 15 percent of mothers in the village of Kolwezi in the Bunkeya health zone were exclusively breastfeeding. DRC-IHP tackled this issue through health worker training and a weeklong awareness-raising campaign that included door-to-door visits. Important messages about WASH practices such as handwashing, washing utensils and food, and drinking clean water were woven into nutrition activities such as breastfeeding support group meetings, household visits, and cooking demonstrations.
During group sessions mothers and expectant mothers shared their experiences. “I exclusively breastfed my daughter,” said Clementine Kalonda, a member of the breastfeeding support group in Kolwezi, “and she is healthier than my other children.” This change in behavior has resulted in a 50 percent increase in breastfeeding in Bunkeya health zone, a 24 percent drop in chronic diarrhea cases, and an 11 percent decrease in cases of acute malnutrition. “We are now fully aware of the benefits of exclusive breastfeeding for both our children and ourselves, as opposed to misleading and false information we used to receive from our grandmothers, aunts, or friends,” said Ms. Kalonda.
DRC-IHP supported the Ministry of Health’s efforts to train health providers and community health workers and provide nutrition education and services for families in 46 other health zones. Community health workers were taught to emphasize that clean drinking water was one of the keys to good nutrition and to make the link between open defecation, flies, spoiled food, and diarrhea.
Over the course of the project 1.4 million women received nutrition counseling for their children, and the percentage of newborns breastfed in the first hour after birth jumped from 2 percent to 98 percent.
That is the sort of success DRC-IHPplus set out to replicate while promoting greater sustainability through local ownership of health outcomes. “We used to spend our energy and money to treat diarrhea,” said one WASH committee member. “Now we invest in raising awareness on how to prevent it.”
By Wendy Putnam
To subscribe to Global Waters magazine, click here, and follow us on Twitter @USAIDWater. This article appears in Global Waters, Vol. 8, Issue 1; for past issues of the magazine, visit Global Waters’ homepage on the USAID website. For more information about USAID’s Integrated Health Project (DRC-IHP), click here.