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In Zimbabwe’s capital Harare, recurring outbreaks of water-borne infectious diseases pose a major health challenge.


A Water, Sanitation, and Hygiene Toolkit to Fight Cholera and Typhoid Fever

In Zimbabwe’s capital Harare, recurring outbreaks of water-borne infectious diseases pose a major health challenge. © Samuel Sieber/MSF
Operational Research News 
Samuel Sieber - Policy, Practice & Communication Advisor
In Zimbabwe’s capital Harare, recurring outbreaks of water-borne infectious diseases pose a major health challenge. Recently, a cholera outbreak affected almost 10,000 people, and typhoid fever is endemic in several districts. In the city’s densely populated areas, people risk getting infected by drinking contaminated water from taps, hand-dug wells, and boreholes. With an innovative Water, Sanitation and Hygiene toolkit and a comprehensive environmental health approach, MSF is working towards providing safe water and preventing outbreaks.

    What does MSF's innovative WASH toolkit, used to restore damaged or contaminated boreholes, feature?
    -The borehole diagnostic and rehabilitation vehicle
    -The community health club approach
    -Improved drilling and sealing
    -Better siting and geophysical survey

    “Over 200 people fetch clean drinking water here every day for a single dollar per month, and we use people’s contribution to maintain the borehole’s chlorinators, for fencing the borehole site, and community activities.” Hlemina Silver and his colleagues from the Kuwirirana Community Health Club in Glen View are proud to manage one of more than 70 boreholes drilled or rehabilitated by MSF in Harare, Zimbabwe since 2015. During a large cholera outbreak in late 2018, only two cases were reported in the communities around these water points.

    The borehole in Glen View, one of Harare’s poorer districts, was diagnosed and rehabilitated using a custom-fitted vehicle by MSF. Using a submersible camera, a water-sampling probe, various brushes, and disinfection materials, damaged or contaminated boreholes can be restored. “We investigate boreholes and identify the sources of contamination, repair damage, and install an inline chlorinator for disinfection. Then, we hand the working water point over to a community health club,” explained Danish Malik, the Water, Sanitation, and Hygiene (WASH) specialist with MSF Zimbabwe.

    Training and supporting community health clubs in water point management, sanitation, personal hygiene, and containing infectious disease outbreaks is the second cornerstone of MSF’s innovative WASH toolkit. Local health promoters engage community groups in a hands-on training approach. After just eight weeks, the community health club takes over a functional water point and provides clean drinking water for an entire neighborhood. “The sense of ownership and community responsibility plays a major role in making this approach a success,” said Kudakwashe Sigobodhla, a health promoter with MSF. “People improve or decorate their water points and are able to pay repairs on their own after a while, and they only sporadically reach out to MSF for advice.” 

    The toolkit also contains the latest technologies to site new boreholes and improved techniques for drilling and sealing them. The best location for a new borehole is located using a geophysical surveying technology. Subsurface images show rock formations and water running at different depths, and help decide where to drill to hit safe water at deeper levels. 

    As Harare’s water and sewage pipes are often damaged, and latrines or dump sites are located next to water sources, bacteria can contaminate the shallow groundwater and from there get into boreholes. “It’s therefore imperative to use the right drilling techniques and cement a proper sanitary seal around the borehole casing; otherwise, we risk further contamination of the safe deeper groundwater,” Danish Malik added. 

    Research from various low- and middle-income contexts provides clear evidence on the key role safe water, sanitation, and hygiene play for public health. In Zimbabwe and other African countries, MSF is conducting additional studies to evaluate the relevance and feasibility of its WASH toolkit. In Niger, rehabilitating boreholes with MSF’s specialized vehicle has proven significantly more cost-efficient than drilling new ones. A water-quality analysis at several boreholes in the suburbs of Budiriro and Glen View in Harare found that boreholes were contaminated with salmonella bacteria, and suggested a link to an ongoing outbreak of typhoid fever. Data from the latest cholera outbreak in Harare, however, reported only two cholera cases among the 8,000 people receiving water from health club-managed boreholes.  

    Driven by the evidence and promising findings, MSF is currently rolling out the existing WASH toolkit in the Southern Africa region, transferring technologies, skills, and training materials to missions in neighboring countries such as Malawi and Mozambique. Furthermore, partnerships with local universities and the regional research and training network WaterNet have been initiated.

    In Harare, the toolkit is scheduled to be developed further, adding a broader perspective of environmental health. “We are looking to improve the recycling of solid waste in some areas of the city, improve sanitation facilities to reduce open defecation, and evaluate preventive vaccination strategies,” added Head of Mission Bjorn Nissen. MSF is also working closely with Zimbabwean health and environment authorities, and is currently reviewing the national borehole drilling standards to recommend improvements. Innovations that are successfully tested in Harare will be added to the existing WASH toolkit and gradually rolled out regionally.