Post on 05-May-2023
Health and Society
WASTE MANAGEMENT
AND HEALTH A CASE STUDY IN MBALE, UGANDA
SARA BERGQVIST LISA WIESLANDER
__________________________________ Degree project Malmö University
Bachelor Health and Society
Public Health 205 06 Malmö
0506 e-mail: postmasterhs.mah.se
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WASTE MANAGEMENT
AND HEALTH A CASE STUDY IN MBALE, UGANDA SARA BERGQVIST LISA WIESLANDER Sara/Bergqvist, S & Lisa/Wieslander, L. Waste management and health. A case study in
Mbale, Uganda. Degree project in Public Health 10 poäng. MalmöUniversity: Health and
Society, Public Health departement, 2006
ABSTRACT
Sophantering är av avgörande betydelse för folkhälsan i utvecklingsländer. I Uganda är ett av
huvudproblemen för folkets hälsa den bristfälliga sophanteringen. För att fastställa problemet
har vi genomfört en fallstudie under 10 veckor genom att studera hur sophanteringen fungerar
i staden Mbale (Uganda) samt vilka konsekvenser denna får för befolkningens hälsa.
Intervjuer, observationer och dokument har använts för att få en detaljerad beskrivning av
fenomenet. Studien ger en bakgrund till vikten av en adekvat sophantering för folkets hälsa
samt en introduktion till landet Uganda. I resultatet ges en utförlig beskrivning av hur
sophanteringen ser ut i Industrial division, Mbale och vilka problem som påverkar den. I
diskussionen redogörs för underliggande problem utifrån A. Sens teori Utveckling som frihet.
B. Murphy’s modell The fourth dimension of health promotion används för att utvärdera det
hälsoarbete som görs samt ge förslag till förbättring. Problemen kan sammanfattas genom att
poängtera vikten av att samhället tar sitt ansvar för befolkningen bl.a. genom prioritering av
infrastrukturen. Långsiktiga och hållbara lösningar bottnar i bekämpandet av korruption och
fattigdom. Det förebyggande hälsoarbetet behöver förändras till att bli mer empowerment
baserat.
Nyckelord: empowerment, fallstudie, folkhälsa, infrastruktur, korruption, sophantering,
Uganda
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ABSTRACT
Waste management is of crucial concern for public health in developing countries. In Uganda
one of the main problems connected to public health is a poor waste management system. To
define the problem of waste management and to investigate its consequences for people’s
health we made a case study during ten weeks in Mbale, Uganda. Interviews, observations
and documents have been studied. Uganda as a country is introduced in the background and
the importance of waste management for the public’s health is explained. An extensive
description of how waste management works in Industrial division, Mbale and the problems
affecting it is given in the results. In the discussion the underlying problems are described
with the help of A Sen’s theory Development as freedom. B. Murpy’s model The fourth
dimension of health promotion is used to evaluate the health promotion work that exists and to
give suggestions of improvements. The problems can be summarised with the importance for
the society to take responsibility for the population e.g. by prioritising the infrastructure.
Sustainable and long-term solutions are grounded in combating corruption and poverty. A
change in the health promotion work needs to be done and based upon empowerment.
Keywords: case study, corruption, empowerment, infrastructure, public health, Uganda, waste
management
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ACKNOWLEDGEMENTS
We would like to show gratitude to the people that made this study possible. First of all we
would like to thank Tomas Odoi, our supervisor in Mbale, for inviting us to his country. This
study would not have been feasible without having his support and assistance. Second, we
would like to thank the three Health inspectors at Industrial division and the Tutor at the
School of hygiene. They have been our guides in Mbale and have been given us plenty of
useful information. Finally we would like to express our gratitude to all the wonderful people
that we met and that were willing to participate in the study. Here in Sweden we would like to
thank our supervisor Per-Anders Tengland for assistance during the writing. And last but not
at least we would like to thank SIDA1 for the help of financing the study.
1 Swedish International Development cooperation Agency
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INTRODUCTION
This is a study of public health work in a developing country. Africa is and has long been a
symbol of the developing world and Uganda is in the heart of Africa, so we thought this
country would be a good choice for our study. We got into contact with Thomas Odoi who is
a former Head of Public Health Department2 in Mbale Municipality, Uganda and he
emphasised the problem of waste management in Mbale. We got interested and decided to
make a case study there.
Waste management is of crucial concern for public health. A poor waste management
increases the morbidity and mortality in different ways. In many developing countries the
development of waste management has not kept up with the rapid urbanisation and growing
consumption and has therefore grown to a big problem.
In order to define the problem of waste management in Mbale and in order to investigate its
consequences for people’s health we have made a field study during ten weeks which has
included interviews, observations and the study of documents.
2 Will be abbreviated to Former HPD
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TABLE OF CONTENTS
ACKNOWLEDGEMENTS
INTRODUCTION
1. BACKGROUND ............................................................................................................................................... 8
DEVELOPMENT OF WASTE MANAGEMENT ........................................................................................................... 8 HEALTH CONNECTED TO WASTE MANAGEMENT IN A DEVELOPING COUNTRY ...................................................... 8 WASTE MANAGEMENT IN DEVELOPING COUNTRIES ........................................................................................... 10 UGANDA ........................................................................................................................................................... 10 History ......................................................................................................................................................... 11 Diseases in Uganda ..................................................................................................................................... 12 Socio-economic costs for poor sanitation in Uganda .................................................................................. 12 Benefits of improved sanitation ................................................................................................................... 13
2. DEFINITIONS ................................................................................................................................................. 13
3. PURPOSE AND RESEARCH QUESTIONS ............................................................................................. 14
PURPOSE ........................................................................................................................................................... 14 RESEARCH QUESTIONS ...................................................................................................................................... 14
4. METHOD ......................................................................................................................................................... 14
CASE STUDY ...................................................................................................................................................... 14 IMPLEMENTATION ............................................................................................................................................. 15 RELIABILITY AND VALIDITY .............................................................................................................................. 16 DISCUSSION OF THE METHOD ............................................................................................................................ 17 ETHICAL ASPECTS ............................................................................................................................................. 17
5. THEORY ......................................................................................................................................................... 18
DEVELOPMENT AS FREEDOM ............................................................................................................................. 19 THE FOURTH DIMENSION OF HEALTH PROMOTION ............................................................................................. 20
6. RESULTS ....................................................................................................................................................... 21
MBALE MUNICIPALITY ...................................................................................................................................... 22 The collapse of waste management in Mbale .............................................................................................. 23
INDUSTRIAL DIVISION ....................................................................................................................................... 24 WASTE MANAGEMENT IN THE INDUSTRIAL DIVISION ........................................................................................ 24 WATER SUPPLY ................................................................................................................................................. 26 RESIDENTIAL AREAS ......................................................................................................................................... 26 Health centres .............................................................................................................................................. 28 Diseases ....................................................................................................................................................... 28 Health education ......................................................................................................................................... 29
MARKETS .......................................................................................................................................................... 29 INDUSTRIES ....................................................................................................................................................... 30 THE WASTE DISPOSAL ....................................................................................................................................... 31 OPINIONS AMONG THE POPULATION .................................................................................................................. 32 Waste management services ........................................................................................................................ 32 Contents and handling of domestic waste .................................................................................................... 32 Health consequences and diseases .............................................................................................................. 33
RECYCLING ....................................................................................................................................................... 33 PROBLEMS LEADING TO POOR WASTE MANAGEMENT ........................................................................................ 34 Lack of commitment among politicians and health workers........................................................................ 34 Corruption ................................................................................................................................................... 35 Lack of awareness and poor practices among the people ........................................................................... 36 Women marginalised ................................................................................................................................... 36 Poor infrastructure and lack of space ......................................................................................................... 36
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7. DISCUSSION OF THE RESULTS .............................................................................................................. 37
MACRO LEVEL - COMMON GOODS ..................................................................................................................... 37 Low priority ................................................................................................................................................. 37 Corruption ................................................................................................................................................... 38 Poverty ......................................................................................................................................................... 39 Reduction of garbage................................................................................................................................... 39
MESO LEVEL - EMPOWERMENT ......................................................................................................................... 39 Evidence based ............................................................................................................................................ 40 Collaboration .............................................................................................................................................. 40 Engagement and understanding .................................................................................................................. 41 Cultural norms............................................................................................................................................. 41 Action requires possibility ........................................................................................................................... 42 Health education ......................................................................................................................................... 43
8. CONCLUSION ............................................................................................................................................... 43
9. REFERENCES ............................................................................................................................................... 45
APPENDIX
INFORMATION ABOUT THE STUDY
INTERVIEW GUIDE
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1. BACKGROUND
In the following chapter waste management in developing countries and the connections to
public health is described. The country of Uganda is introduced as well as its history, disease
burden and possible benefits of an improved sanitation.
Development of waste management
Throughout history populated areas have created a need for sanitation services such as
drainage and collection of solid waste. Humanity has fought this problem and developed
advanced techniques to solve it. While the countries in West and Central Europe, North
America and Japan head for a more refined waste management based on recycling and well-
arranged deposits, people in the cities of developing countries fight an uneven battle against
growing rubbish mountains, badly organised sanitation and not least, poverty. UN:s action
program Agenda 21 stresses the issues of sanitation and deposits that are environmentally
acceptable as the most important goal. The need for sanitation is not only big in the cities of
the developing countries, even in the developed countries the poorer areas have worse
sanitation; by this we can see that waste management is often a question of class.3
Health connected to waste management in a developing country
The major influences on morbidity and mortality are social and environmental factors. Social
advances in general living conditions, such as improved sanitation and nutrition, have been
responsible for most of the reduction in mortality achieved during the last century. The
contribution of medicine to reduced mortality has been minor, when compared with the major
impacts of improved environmental conditions.4 Despite continuous attempts to improve
sanitation, 40 % of the world's population is still without basic sanitation. Poor waste disposal
practices are responsible for a significant proportion of the world's infectious disease burden.5
If a society is going to work, it ultimately requires that its people’s health is good. The
infrastructure and the environment are important determinants for health and are often the
3 Berg P E O, 2004
4 Naidoo J & Wills J, 2000
5 WHO, 2006-05-17
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focus of public health work. Due to the strong link between low socioeconomic standard and
poor health, poor countries have to get access to the basic conditions needed for healthier
population- pure water, organised waste management and working sewer system etc, to be
able to avoid epidemics.6
There are five basic conditions to consider in the preventive work to minimize the disease
burden:
1. Good housing (ventilation, light, construction and environment).
2. Clean and safe drinkable water.
3. Good control of pests like mosquitoes, flies and rats.
4. Good control of wastes like sewage and garbage.
5. Good food (a balanced and nutritious diet).7
All these things are linked together, if the waste management is improved it will have an
effect on all the other conditions:
� A good environment – due to a reduce in littering.
� Drinkable water – as it is often polluted due to a poor waste management.
� Control of pests – as they thrive in garbage.
� Good food – as the food will not be infected by flies to the same extent.8
Examples of diseases and health problems caused by poor sanitation are cholera epidemics,
outbreaks of bubonic and pneumonic plague, diarrhoea, typhoid, typhus and dysentery.
Infestation by disease-ridden carriers such as insects and vermin is another problem e.g. the
water that collects in urban detritus, such as polythene bags, nurture mosquitoes, which spread
malaria, yellow fever and dengue fever. Rats thrive on the mountains of waste and are
principal carriers of bubonic and pneumonic plague.9 Accidents due to poorly disposed
wastes, like surgical needles, glass materials etc. is also a health hazard.10
T H E P R O G
6 Werkö L, 2003
7 Interview with former HPD, 20060206
8 Harpham T & Tanner M, 1995
9 Khan A H, 1997
10 Interview with former HPD, 20060206
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Waste management in developing countries
There are several things to consider regarding waste management. There need to be dustbins
where you can put the garbage. All the dustbins should be equipped with a lid so it is not
accessible to flies and insects. At the collection centres, where people empty their bins, should
be portable containers (skips) which are used to transport the garbage to the disposal ground.
The containers need to be placed close to the people to make it a simple choice to empty the
garbage in them. If there are not enough containers the garbage will be thrown on the ground
and the waste workers have to shuffle the garbage manually. This poses a threat to their
health. It is of great importance that the vehicles are properly constructed for the purpose. If
they are not, the garbage might fly off the vehicle and pollute the environment. The best way
of waste management is producing less garbage and the second best is recycling. After this
there are different types of waste management; controlled tipping, crude tipping, combustion
and composting. Controlled tipping is when the garbage is compressed and covered with soil
(minimum 15 cm); the disposal site is then called a landfill. Crude tipping is when the garbage
is thrown wherever on a disposal ground. Crude tipping will not prevent animals like dogs
and rats to rummage through the garbage and in turn be part of vermin infestations. Problems
with burning the garbage are fire outbreaks and pollution caused by the smoke. When
combustion is carried out correctly, an incinerator is used to burn the garbage. To compost in
a good way the garbage must be put in a small pit (1x2 m) and be covered with soil every
third day. After six months the soil can be used as fertilizer.11
Uganda
Uganda is a fertile country in east Africa. The climate is tropical with two dry seasons.
Agriculture is the main occupation and coffee is the major export product. Nearly all the
electricity is produced by water power and Uganda also exports electricity. 35 % of the people
live below the limits of poverty12 which is one dollar a day according to the World Bank.
13
One of the big health problems is Aids, though Uganda is one of the few countries where the
rates of HIV infections have declined. 15 % of the population was infected in the early 1990s
and now there is still around 4 % (2003) that have the virus.14 The disease kills mostly young
adults and has resulted in many orphans. The average age is 14.7 years (2002), the average
11 Interview with former HPD, 20060206
12 Wikipedia, 2006-04-20
13 Ekonomifakta 2006, 2006-04-20
14 Avert.org, 2006-04-20
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length of life is 44.9 years (2003) and the infant mortality rate (less than one year) is close to
9 % (2003). There are around 20 different ethnical groups with their own languages, but the
official language is English. 66 % of the people are Christians, 18 % belong to native
religions and 16 % are Muslims. In 2003 around 30 % of the population over 15 years were
illiterate.15 Statistics from 1995 show the big difference in illiteracy rate among men 26.3 %
and women 49.8 %.16
Picture 1: The country of Uganda
History
Uganda became a British colony in 1894, and the British people ruled by creating chaos and
favored the people in the south. At the end of the 19th century Asians came to Uganda to build
the railway to the harbor in the Kenyan town Mombasa, they have since then dominated the
Ugandan business world. In the middle of the 20th century resistance grew against the colonial
rule and Uganda became autonomous in 1962. In January 1971 the dictatorship of Milton
Obote was overthrown by a military coup led by General Idi Amin. Amins eight years as
15 Wikipedia, 2006-04-20
16 Global Urban Observatory and Statistics Unit, 2006-04-20
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dictator led Uganda to an economic crisis, social misery and serious crimes against human
rights. Amin’s regime is responsible for 300 000 deaths. In 1972 Amin drove away all people
with Indian origin and the country’s trade and economy broke down. Amin attacked Tanzania
but they fought back and with the help of a national liberation army Milton Obote went back
to power. In 1986 the former minister of defence Yoweri Museveni started a guerrilla war to
make an end to the dictatorships. For long, Museveni did not allow other parties because he
wanted to stabilize the country.17 Museveni has with the help from abroad, tried to stabilize
the economy through currency reforms, higher prices for export crops and higher salary for
governmental workers. With this the government wants to achieve less inflation and a higher
grade of export. Between 1990 and 2001 the economy was improving, but Uganda’s
involvement in the war in Congo (Kinshasa), and governmental corruption during the last
years has made the situation worse.18
Diseases in Uganda
Sanitation related diseases such as malaria, diarrhoea, worm infestations, eye infections and
skin diseases account for roughly half of all medical outpatient visits in Uganda and are major
causes of mortality and morbidity (1996). About 440 children die of diarrhoea every week in
Uganda and cholera has become a common feature.19
Socio-economic costs for poor sanitation in Uganda
Poor health keeps families in a cycle of poverty and loss of income. The national cost of lost
productivity, reduced educational potential and curative health care is substantial:
• 40 million work days are lost each year because of sanitation related diseases. This
represents on average about 3.5 % of workers time lost to sickness.
• Government pays 17 million USD20 a year for treatment of sanitation related diseases,
including 2.3 million USD for treatment of diarrhoea.
• Individual households also pay large sums of money for the treatment of sanitation
related diseases.21
17 Studieförbundet, Vuxenskolan, 2006-05-04
18 Wikipedia, 2006-05-04
19 Water and Sanitation Program, 2000
20 1 USD = 1 738 Ush Fitzpatrick M, Ray N, Parkinson T, 2003
21 Water and Sanitation Program, 2000
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Benefits of improved sanitation
WHO’s report Evaluation of the Costs and Benefits of Water and Sanitation Improvements at
the Global Level shows that all the water and sanitation improvements in the study (e.g.
providing piped water and sewage connection) were found to be cost-beneficial.22
Improving sanitation and hygiene could have a range of impacts in Uganda:
• Diarrhoeal morbidity rates would decline by as much as 36 % with improved excreta
disposal and 33 % with improved hygiene.
• Households would lose less time in sickness and be more productive – 140 million
work days would be saved each year from reduced morbidity.
• Government and households would save hundreds of millions USD annually from
savings on curative health care – this would release resources for preventive health
care.
• The ultimate benefit would be an improvement in the health status of the population
and through that, improvement of the economic and social status of the country.23
2. DEFINITIONS
Pit latrine – a constructed hole in the ground purposed for faeces. The minimum depth should
according to the sanitation rules in Uganda be 4.5 m. The maximum depth must not reach the
ground water level wherever possible.24
Polythene bag – a small thin plastic bag.
Sanitation – is when people demand, develop and sustain a hygienic and healthy environment
for themselves by erecting barriers to prevent transmission of disease. It includes waste
management, a safe water chain, vector control and a good personal, domestic and food
hygiene.25
Septic tank – a tank, usually below ground, for containing sewage to be decomposed by
anaerobic bacteria.26
22 Hutton G & Haller L, 2004
23 Water and Sanitation Program, 2000
24 Interview with Tutor at the School of hygiene
25 Water and Sanitation Program, 2000
26 Cambridge Advanced Learner’s Dictionary, 2006
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Sewage - waste matter from domestic or industrial establishments that is conveyed in sewers
(an underground conduit for carrying off drainage water and waste matter).27
Waste management – private and governmental services of solid and liquid waste
management and domestic solid and liquid waste management.28
3. PURPOSE AND RESEARCH QUESTIONS
Purpose
The purpose of our thesis is to study waste management in Industrial division in the town of
Mbale (Uganda) and to actualise waste management’s importance for public health in a
developing country.
Research questions
1. How does the waste management work in Industrial division, Mbale?
2. What problems lead to poor waste management in Industrial division, Mbale?
3. What public health problems are connected to poor waste management in Industrial
division, Mbale?
4. How could waste management be developed in Industrial division, Mbale?
4. METHOD
Case study
A case study is an intensive and detailed study of a certain case, either because it is important
in itself or because of the fact that the case enlightens a general phenomenon or problem.
The researcher carefully examines different variables over an arbitrary or natural period of
time depending on the phenomenon. 29 A case can be individuals, groups, movements, a
specific event, geographical units etc. The data is qualitative which means that empiric
27 Ibid
28 Ibid
29 T. Brante, H. Andersen & O. Korsnes, 2001
15
material in form of texts and interviews, impressions, words, photos, symbols are examined.30
The aim is to get a deep understanding and/or explanation of one single specific and complex
phenomenon.31
Analytic induction is often used, which means that the researcher avoids applying theories
during the process of collecting data. The purpose of this is that the researcher does not want
to affect the people that are being observed or interviewed. When the collection of relevant
data is completed the process of analyzing the material begins.32 The samples in qualitative
studies are selected specifically for the purpose of the study. The aim is to find key persons
for the study, not to examine a great quantity of individuals.33
Implementation
We have made a case study where we have used different ways of collecting data to get a
detailed description of waste management in Mbale as a specific issue. The different ways of
collecting data have been interviews, observations and the study of official documents.
We have limited our study to one division of Mbale municipality. As the municipality is
divided into three divisions we have focused our study on Industrial division because it is the
most varied area. We include all categories of waste: industrial waste, commercial waste,
domestic waste, medical waste and excreta waste since they are connected to each other and
are all connected to health. Our focus lies on domestic waste since the study would be too
wide otherwise.
The following persons have participated in our interviews: one former Head of the health
department (former HPD), one tutor at the School of hygiene, three Health inspectors at
Industrial division, two workers at two different health centres and two Chairmen at two
different markets. The interviews were often informal and open ended (i.e., without a fixed set
of questions or answer categories), especially when we interviewed the health inspectors as
this was more of a conversation. Since a lot of the interviews have occurred during the
observations they have taken place at the interviewees’ location. The interviews were not
30 W. Lawrence Neuman, 2003,
31 T. Brante, H. Andersen & O. Korsnes, 2001
32 J. Hartman, 2004
33 Ibid
16
always prepared but they were always recorded after permission. We also took notes during
the interviews. All these interviewees spoke English and we had no problems in the
communication with them. We also made interviews with residents in the two different
residential areas Namatala and Malukhu. These were structured and we chose not to record
them and took notes instead. Since many of the interviewees in Namatala and Malukhu were
not educated they did not speak English and therefore we had to use an interpreter. One of the
health inspectors helped us with the translation and the sampling. We interviewed nine
women and one man, four in Malukhu and six in Namatala. The reason for this uneven gender
sample was because it was easier to find the women as they were staying at home. We did not
see this as a problem because we thought it was most relevant to interview the women since
they are the ones taking care of the households, and accordingly the waste management.
In addition to interviews we made observations and registered what the environment looked
like considering waste and activities connected to waste management. We visited different
areas of Industrial division taking notes and pictures. Observations were made in Industrial
division, including many waste collection points, the disposal ground, the two different
residential areas Namatala and Malukhu, two markets and a factory.
We studied two different documents that we got from the health inspectors: The National
Sanitation Guidelines from year 2000 emissioned by the Ministry of Health in Kampala and
the Three year development plan, 2005-2008 for the Industrial division council.
The interviews have been transcribed on a daily basis when possible while the information
was still fresh in our minds. When we had collected all data we let three of our key persons
read through the material to make comments if there were any misunderstandings. During and
after the collection of our data we tried to identify connections between different
variables/problems and categorise them into themes.
Reliability and validity
To increase the reliability qualitative researchers use different ways of collecting data that is
consistent over a period of time.34 Validity has to do with the observation’s correctness, i.e.
how accurate it presents the world as it is.35 The researchers must, according to William
34 W. Lawrence Neuman, 2003
35 J. Hartman, 2004
17
Lawrence Neuman (2003), continuously search for diverse data to get a detailed description
with many angles of approach of the phenomenon.36
We have used different ways of collecting data; we interviewed people from different sections
of the society; people from the population and different officials. Observations have been
done in Industrial division (including many collection points) on a regular basis during two
and a half months. The disposal ground and the two different residential areas Namatala and
Malukhu were observed twice.
Discussion of the method
The main problem of our study is that we have to consider the reliance of our sources of
information. This problem has to do with the fact that we are white, since most of the white
people in Mbale are missionaries and voluntary workers with the purpose of helping people.
Because of our interviewee’s expectations of getting our help we have to be careful not to
completely rely on our sources of information. We have to be critical in that sense that there is
a risk that our interviewees were trying to take advantage of the situation by seeking help to
improve their situation. The information might therefore have been affected in some way and
this also placed us in a strange position since offering help was not our main purpose. Of
course our intention in the long run is to improve waste management but this is a process that
will take time.
The fact that the interviewees in the residential areas were aware of that a health inspector
was present might also have influenced the answers in that way that the interviewees might
have wanted to give a favourable report. Some statements made by the interviewees tended to
sound prejudiced. We have therefore been cautions when interpreting these claims.
Ethical aspects
People who are interviewed should give an informed consent which means that they get a
brief description of the purpose and procedure of the research, what risks and benefits that
could be associated with participation and a statement that participation is voluntary and can
36 W. Lawrence Neuman, 2003
18
be terminated at any time. Confidentiality in research means that private data will not be
presented. It is the researcher’s ethical responsibility to verify the collected data.37
We received an informed consent by giving the interviewees information about the study and
by receiving a positive answer when we asked if they wanted to participate. When we wanted
to use the recorder we asked the interviewee for permission to do so. There is no risk that we
encroached the participants’ integrity since the questions were not sensitive or personal and
since the material that we have collected is confidential. Specific places are not mentioned
and the interviewee’s are referred to by their titles. The recordings have also been destroyed
after writing the thesis. The ethical permission that we received from Malmö University has
been followed. The study will hopefully have positive consequences for the interviewees as
the study can be a part of the development of waste management in Mbale. There are no
negative consequences to consider. We let the people who had accompanied us the most and
participated in many interviews read through our collected material to verify the results.
5. THEORY
In our collected material we could define problems at both meso and macro level. Theories of
social movements or communities are often at the meso level. Macro level theory concerns
the operation of larger aggregates such as entire cultural systems and whole societies.38 We
used the economist and philosopher Amartya Sen’s (2002) macro level theory Development
as freedom as a tool to analyse the problems with being a developing country. He discusses
where the emphasis needs to be put in developing work and identifies different problems that
should be dealt with. To analyse the public health work at a community level we used
Murphy’s model The Fourth dimension of health promotion which is a model at the meso
level.39
37 Kvale S, 1997
38 W. Lawrence Neuman, 2003
39 B. Murphy, 2004
19
Development as freedom
Sen states that the government must take certain responsibilities for their people. He
emphasizes the need to prioritise the people’s health to fight poverty and to get the economic
development going. There is a deep and reciprocal connection between individual ability to
take action and social arrangements. His theory advocates a free market but sees the need to
go beyond this when it comes to the common goods like basic health care, education and
environmental protection. These costs must be covered by taxes. Sen thinks it is especially
important with public efforts in developing countries to create social possibilities. In many
East Asian economies like Japan and South Korea they started to provide public health care
and basic education long before they experienced the economic development. When the
economic development came the social investment resulted in that more people could gain
from the growth. In India for example where they did not have the same public efforts there
has been greater inequalities in the distribution of the gains from the economic development
and there is still a huge population without basic education and health care. The widely spread
social possibilities in the developed countries has made it possible for the whole population to
take part in the economic development.40
According to Sen, freedom is not just the main goal for development but also its most
important tool. Individual freedoms are needed not just to improve the individual lives but
also to make the social arrangements more sufficient and effective. Economic and political
freedom strengthen each other and social utilities like education and health care helps the
individuals to take part in the economical and political life. Economic possibilities can
improve the individual welfare and the common recourses for social welfare. Like this the
different kinds of freedom can strengthen each other. Individual freedom must become a
social obligation for the government. One important way to increase people’s freedom is to
enhance the influence people have over the “social improvements” they are exposed to.41
Corruption is according to Sen one of the worst obstacles for economic development.
Corruption is transgression of rules about personal benefits and gains. The temptation of
being corrupt is strongest when the employee has considerable power but is relatively poor.
To some degree it is possible to fight corruption through organizational reforms like systems
for inspection and punishment. How people act depends on how they consider that other
40 A Sen, 2002
41 Ibid
20
people act. The most effective way to fight corruption might be through the norms of
behavior. Emphasis must be put on how people with power and authority behave. Corrupt
behavior in high positions may affect things way beyond this behavior.42
The fourth dimension of health promotion
Berni Murphy (2004) uses the fourth dimension of health promotion as a model to work with
health promotion where empowerment is a central idea.43
Murphy stresses that the health promotion program should be based on evidence from
epidemiological and qualitative data to be able to evaluate and see the results from the
interventions.44
A collaborative partnership is required to be able to promote health in ways that would be
impossible for actors working in isolation. This requires collaboration at the macro level in
infrastructure and systems, especially concerning policy, funding and service delivery. It is a
problem to deliver integrated services for the individuals in order to change their behaviour
and adopt a healthier lifestyle if the collaboration within the health sector does not work.
Murphy stresses the importance of community engagement and empowerment by supporting
individuals in the community in identifying the factors that are influencing health in their
environment. Social movements that lead to better health outcomes are likely to emerge when
communities are engaged, supported, empowered, and motivated to challenge the status
quo45. Community engagement obliges a commitment to the process and it is a process that is
going to take time. It is a mutual relationship that allows much collaboration and the aim is
that the health workers should work with individuals and communities rather than on them.
Murphy means that empowerment has to be implemented at several levels in order to effect
the social changes that tackle inequalities in health while promoting health for all. Examples
of empowerment at the individual and community level can be building personal skills and
confidence to take action or to develop knowledge and understanding of determinants, issues
42 Ibid
43 B. Murphy, 2004
44 Ibid
45 Ibid, 156
21
and contexts. One way to work with empowerment is by implementing health education, but
according to Murphy, this must be much more then just telling people what they must know
and what they have to do in order to implement a healthier lifestyle. Otherwise there is a great
risk that such programs becomes victim blaming and patronising and determined by the health
workers own values. The work should be upstream taking into account the influences that
infrastructure and systems have on people living in a community.46 Murphy stresses the term
health literacy which means to be sufficiently educated to access and use information that can
impact on health issues. Health literacy provides individuals with options that would
otherwise not be available to them.47
It is of great importance that the health promotion program has a good leadership. Murphy
stresses the importance of that the health leader must be aware of the issues, determinants and
approaches, and also the importance of mediating between health providers, other sectors and
communities to strengthen and build new partnerships. Advocating for change is part of the
health leader’s role, while being respectful of individual values that are different from the
collective goals.
Sen’s theory and Murphy’s model are to a certain extent connected to each other since both
emphasize the importance of structural settings and environment as determinants of health.
This is a prerequisite for development and for combating poverty.
6. RESULTS
In the results we first give an introduction to Mbale and Industrial division where we also
describe how the waste management services and water supplies are working. After this we
make reports from our observations and interviews at the residential areas, markets, industry
and waste disposal. The opinions among the population and different problems connected to
waste management are described.
46 B. Murphy, 2004
47 Ibid, 188
22
Mbale municipality
Mbale is situated in eastern Uganda and it is a town with around 100 000 inhabitants. The few
tarmac roads that exists are badly maintained, garbage is thrown everywhere on the streets
which gives the town an unkempt atmosphere. The surroundings though are green and
beautiful with Wanale mountain in the east. It is in the early mornings and in the evenings that
the city is vibrant with activity due to the high temperature during day time. However the
town has a constant high noise level; taxi drivers shouting out their destination and if you are
white, people shout “Mzungu! (White man!) How are you?” There are many small local
restaurants on the streets with typical African food like matoke (banana pudding), posho
(maize pudding), chicken, goat and beans. The most common vehicle in town is the “boda-
boda” which is a taxi-bicycle. On the back of the bicycle there is a cushion upon which you
can sit. You can also see some taxi-motorcycles. There are not many cars but the minibus-
taxis, which are just supposed to take 14 people but more commonly take around 25, are
frequently used. People are properly dressed, mostly in western type clothing although some
of the women wear traditional dresses. There are also a lot of street children who wear
extremely dirty and threadbare clothes which really weighs your heart down. The electricity
goes off every now and then which creates a lot of problems and is obviously vexing for the
inhabitants. When it happens during night time the town gets totally dark except for some
places that have generators. The domestic areas can be divided into the African quarters, the
Indian quarters and the European quarters. This gives a hint of Mbale’s history. The town was
built by the Indians in the 30’s which the Indian architecture along the main street bares
witness to.
Picture nr 2: A street in Mbale.
23
The management of Mbale municipality is run “politically” by a mayor and “technically” by a
town clerk. Under them there are political workers on the “political side” (committees,
councillors and chairmen) and technical workers on the “technical side.” The health
inspectors that work on the political side decide upon a program for waste management. The
technical officers of engineering on the technical side do the practical work in collaboration
with the Public Health Department. This might entail such projects as attaining access to
roads and vehicles etc. The waste management is managed by a private firm called Keep
Mbale Clean. They sweep the streets, collect the garbage and bring it to the waste disposal. 48
In the constitution of Uganda, under the Public Health act, it is stated that the Local authority
must provide sewage systems and domestic waste collection (to a waste disposal) for the
community of the urban areas. Due to the lack of infrastructure in peri-urban areas there is a
problem to run waste management. Instead health officials from the Health Department
advice people individually where to dispose of their garbage.49
The collapse of waste management in Mbale
When Uganda was a British colony the waste management services were, according to the
former HPD, properly carried out. Mbale was the cleanest town in East Africa. It had many
health workers, waste vehicles and laws that controlled the handling of waste.50
When the British authorities left the country a breakdown in waste management took place,
due to the following reasons:
1. The majority of the Europeans, who carried the knowledge of where to obtain and
renew equipments for waste management, left the country.
2. The country was at different time periods run by dictators who did not care much for
the people’s best (for example from 1971 during military rule).
3. In central Mbale there were mostly Asians staying but when Amin drove them away
his people took over the city. The new influx of people did not know the facilities well
and therefore misused them. They were a people with a different culture and different
concepts of the world and they did not listen to the health workers. The health workers
became disparaged by the resistance to their ideas about hygiene. The degeneration
48 Interview with former HPD, 20060206
49 Ibid
50 Ibid
24
continued and the systems of the municipality collapsed one by one. The African food
was also different from the Asian food and therefore also the type of garbage changed.
The garbage of the Asian people was light since their food was sparsely packed. The
African people ate mostly heavy foods, fruit and vegetables (one household could eat
many clusters of bananas every day) and therefore left more heavy and volumious
wastes.51
4. A too rapid urbanization lead to a overpopulation in the cities.52
Industrial division
In the 1990’s Mbale municipality was decentralised and divided into three different
geographical areas (divisions): Industrial division, Northern division and Wanale.53 The three
divisions are similar to each other but Industrial division is the most complex. It has
residential areas, shops, industries and the waste disposal centre is situated there. That is the
reason why we choose to make our field study in Industrial division.
Industrial division had a population of 30 929 inhabitants in 2002, this constituted 43.9 % of
the population in Mbale municipality. The population of the division is very young, the
medium age is 6 years which indicates a high fertility, the fertility rate is 6.2 and the
population growth is 2.7 %.54
Waste management in the Industrial division
Mbale municipality council has hired Keep Mbale Clean to take care of the waste
management services in the town. The company has around 30 workers in the Industrial
division, some of them are waste workers (mostly men) and others are street sweepers (mostly
women). The work is done on a daily basis but that is not enough to cover the whole area.55
The Industrial division has 35 skips (containers without lids), to be used for waste
management and one vehicle (Mercedes-Benz) that was given to them 1986 by the World
Bank.56 From time to time the vehicle that Keep Mbale Clean uses to empty the skips does not
51 Interview with former HPD, 20060206
52 M. Amin, 1998
53 Ibid
54 M. Michael, 2005
55 Interview with Health inspector 1, 20060131
56 Interview with former HPD, 20060206
25
have any fuel because the council has delayed their payments to the company. The lack of
fuel and the breakdowns of the vehicle make the whole program of waste management
difficult.57
It is common that the street sweepers and other people burn garbage aside the streets. It is
illegal to burn garbage in public areas because it pollutes the air and can cause fire outbreaks,
but the Environmental Management Authorities now recommend people to burn the garbage
because it results in lesser environmental problems.58 It is also common to burn the garbage in
the skips as this is the only way to reduce its volume when the waste collection does not work.
This burning destroys the skips and makes them last shorter. Another problem is that the skips
do not have any lids which results in garbage falling off the skips.59
There are three health inspectors in Industrial division who are working with health education
and inspection connected to waste management. They also inspect factories, food and give
recommendations of building plans e.g.60
Industrial division has a three year development plan (2005-2008) which includes
development of waste management. In their budget they estimate the cost of purchase of
refuse skips to be 5 800 USD per year and the purchase of a refuse truck to 23 000 USD per
year. In 2004 they used nearly the entire budget for buying skips and sadly they have not yet
had the possibility to buy a refuse truck because it is too expensive. According to Health
inspector 2 the money budgeted for the vehicle is never there at the end of the year, it has
been spent elsewhere.61 In addition to the work of Keep Mbale Clean the plan (2005-2006)
includes home visiting, institute home improvement competition, inspection and prosecution.
Health education is also being conducted to mobilize and sensitize health issues. To improve
health and standard of living there is a focus on school hygiene, sanitation and nutrition.
Pupils are taught in school to use toilets/latrines in a proper manner, to wash their hands and
to use proper refuse bins.62
57 Interview with Health inspector 2, 20060201
58 Interview with Health inspector 1, 20060131
59 Observation of Industrial division, 20060201
60 Interview with tutor at School of hygiene, 20060216
61 Interview with Health inspector 2, 20060201
62 M. Michael, 2005
26
Water supply
Water is an important link between wastes and diseases. Before the 1990’s the water was free
in the suburban areas but then the council decided to start charging for the water. It is the
governmental company National water and sewage corporation that provide the water and
the sewage lines in Mbale but all households are not covered by the sewage system. It is the
government that decides the price of the water and where it will be provided.63 The people
who are not covered by the sewage system can get technical advice on how to construct a
septic tank or a pit latrine in the right way but according to Health inspector 2 people neglect
to get advice because they fear the costs.64 There is only one water source in Mbale, except
for some private boreholes and natural sources. The water source is situated in Wanale and
from there the water is treated and pumped out to the rest of Mbale municipality. There are
several taps where people can go and collect water but they have to pay 0.03 USD per 40
litres. Not everyone can afford this and instead they get water from the river or from natural
wells. This water is often contaminated and there is no guarantee that the people who use it
will boil it because they might not be able to afford the cost of fuel to heat their stoves. The
health officers advise people not to use this water but they continue to do so anyway. It looks
clean to them and they do not have any other option, it is a problem of poverty and not only
lack of knowledge.65
Residential areas
There are two big residential areas in Industrial division; Namatala and Malukhu. Namatala is
the area in Industrial division which has the largest population of residents (11 844
inhabitants) and it is the only area with a slum like kind of settlement pattern. The majority of
the people living in this area are internally displaced people from Karamoja in the northeast of
Uganda. Mud and wattle houses roofed with either grass or iron sheets dominate.66 The living
conditions in the area are very bad and many live in crowded homes. The hygiene is very poor
and the people do not have sufficient toilets. Most of the people in this area use pit latrines
and when one is full they just dig another one. This is a problem because there will soon be a
lack of land. The houses are very simple and temporary so if someone wants to build a proper
house in this area the people who live in the simple houses have to move away. Moreover the
63 Observation of Namatala 20060206
64 Interview with Health inspector 2, 20060201
65 Interview with worker at Namatala health center, 20060209
66 M. Michael, 2005
27
waste can not be collected because there are no roads for the waste vehicles; instead the
people usually burn their waste in rubbish pits. Namatala is placed in a valley so when it rains
all the dust from the town collects there. Therefore cholera epidemics are common in the area.
When we walked around in Namatala nearly all the people we saw were children. Many of the
people in Namatala have not been to school and they start to reproduce early. According to
health inspector 1 there is no awareness of family planning. Many of the children in Namatala
are orphans and belong to extended families. There are very few parents that take their
children to school. There is no school fee for the primary levels but the parents have to pay for
school uniforms, books and meals. According to one of the health inspectors the schools in
Namatala are not of a high standard.67
In Malukhu there are mostly brick houses roofed with iron sheets. Many of the houses are
painted and green seems to be a popular colour. The area looked quite nice with proper
houses, however the area was in worse condition than Namatala during the 90’s. An NGO68
constructed the houses and offered them as a gift to the people, but the people had to pay back
for the plot they had been given. The ones who could not afford sold the plot and went to
Namatala or rural areas outside Mbale municipality. Because of this the inhabitants in
Namatala do not want the same development there. Health inspector 1 thinks that is very bad
because it prevents further development of the town. When the NGO built the houses they
also built pit latrines because they thought the maintenance of septic tanks would be too
expensive for the people. The ones who can afford it have tapped water in the house; the
others have to buy water from a community tap.69 The area is densely populated and the
people consume a lot of alcohol. According to the nurse at the health clinic the main health
hazards are lack of space and that the people have nowhere to put garbage, the people are
given too small plots and they throw the garbage anywhere. At the present time there is only
one skip in the area and the nurse at the health clinic thinks that there should be at least two or
three. Now the people have to carry the garbage very far.70
67 Observation of Namatala 20060206
68 Non Governmental Organisation
69 Observation of Malukhu, 20060208
70 Interview with worker at Malukhu health center, 20060208
28
Health centres
Both Namatala and Malukhu have a governmental health centre where the people can (or at
least should have the possibility to) get advice, be diagnosed and receive medicine for free.
The clinical officer in Namatala sees around 120 patients in one day, 90 new patients and 30
to be re-attended to. The centres are overloaded with work and the staffs have long working
hours. Namatala health centre does not have any electricity, but has connected water. The
health centres’ waste management is very poor and they do not have a incinerator. They burn
their medical waste outside the centre on an open space except for the needles and other
hazardous materials that are kept in a room in the centre. Since they do not have a pit it is very
difficult to get rid of the waste. The community fears that the waste will spread diseases so
they do not want the centre to throw the medical waste in their pit latrines.71 The government
is supposed to supply with medicine but at the time we went to Malukhu the medicine was out
of stock and the centre could therefore neither treat malaria or diarrhoea. There are some
private centres but far from everyone can afford their help.72
Diseases
The biggest disease burdens in Namatala and Malukhu are malaria, skin infections, blood
diarrhoea and dysentery73 and sexually transmitted infections (like gonorrhoea, syphilis and
Chlamydia). There also exist cases of pneumonia and intestinal worms, mostly among
children less than five years old.74 A health worker in Namatala can certainly see poor waste
management as a health hazard, according to him the main diseases connected to waste
management are; diarrhoea, dysentery, cholera and vomiting.75 According to a health worker
at Malukhu health center there is a clear connection between poor waste management and
diarrhoea. Even malaria is related since it occurs when containers are dumped everywhere.
Intestinal worms could also be connected since people use polythene bags instead of pit
latrines and dispose them in an unsafe way. The health worker at Malukhu health center could
even see connections between tuberculosis and medical waste from the hospital.76 The clinical
71 Interview with worker at Malukhu health center, 20060208
72 Observation of Namatala, 20060206
73 Interview with worker at Namatala health center, 20060209
74 Interview with worker at Malukhu health center, 20060208
75 Interview with worker at Namatala health center, 20060209
76 Interview with worker at Malukhu health center, 20060208
29
officers record the disease burden at their centres so that when a certain disease increases they
try to locate the reasons and then report this to the people.77
Health education
The health center in Namatala is collaborating with the local councils to inform the people
about the connections between poor waste management and diseases. The personnel at the
center and the health inspectors at the Health department conduct home visits where they
advise people on how they can live more sanitary lives. The health center in Malukhu informs
the people about the connections between poor waste management and diseases when the
people are visiting but they also inform them in their houses.78 According to a health worker
at Namatala health clinic the most important thing to carry out is health education. The
problem is that the people do not always follow the advices.79
Markets
Most of the people in Mbale make their shopping at the markets. Nearly everything that is
sold is packed in a polythene bag which is for free. There are also bigger black plastic bags
which are sold (often by street children) for a small amount of money. The vendors at the
main market have to bring the waste to two skips that are placed approximately 200 metres
from the market.80 The sellers are supposed to collect their garbage in bags or plastic
“containers” and they do so most of the time, but there is also garbage strewn about
everywhere. There are four waste workers who collect the garbage on wheelbarrows and they
also pick garbage from the ground. The chairman of the market, says that the main problem
with waste management at the market is that there are not enough waste workers but he can
not afford to hire more. The workers are paid 0.6 USD per day. Before the decentralisation
when the council paid, there were more waste workers but then they hired a company to take
care of it and as a result there were less waste workers on site. According to Health inspector
1 the company squanders the money that the council has paid them.81 The chairman sees it as
an option that people bring their garbage to the collection point themselves and in fact this is
what happens when some of the waste workers are sick. According to Health inspector 1 this
77 Interview with worker at Namatala health center, 20060209
78 Interview with worker at Malukhu health center, 20060208
79 Interview with worker at Namatala health center, 20060209
80 Interview with Health inspector 2, 20060201
81 Observation of the main market, 20060131
30
does not work because of the negligence among the sellers.82 The collecting point consists of
two over filled skips with a lot of garbage spread around them. During our visit there were
some people searching for things of value in the garbage. According to Health inspector 1 the
skips were overfull at this time because the one vehicle that the Industrial division has broke
down two days previously. However we went by many times and there was not a big
difference in how it seemed, sometimes it was even worse.83
We also went to another market where the garbage had not been collected since the vehicle
was out of fuel. As a solution they were burning the garbage in the skip and also beside the
skip.84 The Chairman of the market said that the politicians were late with payments to Keep
Mbale Clean and this resulted in that the collection stopped. This was one of the biggest
problems at the market site according to him. And so the waste produced has not been
collected for an entire month. Another problem according to the manager and chairman is that
during the rain season the place becomes flooded and impossible to access for the waste
workers. He has tried to make Mbale municipality help him dig trenches at the market place
but he was told that there was no money.85
Industries
The industries have to take care of their own waste and many sign contracts for this with
private firms. The workers do not have any protective clothing and sometimes they handle the
garbage with their bare hands. They had spades and malls to throw the garbage on the tipper.
The tipper was quite tall and brimful so it was quite strenuous work. According to Health
inspector 1 this company was not known to the health inspectors and they had also made
mistakes at the disposal ground. The unknown company had put the waste along the pathway
thus hindering the access. He told the waste workers that they can not take the garbage to the
disposal ground before their boss has got instructions on the right way of disposing.86
82 Interview with the Chairman of the main market, 20060131
83 Observation of the main market, 20060131
84 Observation of the small market, 20060201
85 Interview with the Chairman of the small market, 20060201
86 Observation of a factory, 20060202
31
The waste disposal
There is only one disposal ground in Mbale municipality. The waste disposal is situated in the
industrial area of Industrial division. The waste disposal is not well taken care of, the garbage
is carelessly dumped and there is no fence around the area. We could see organic waste, lots
of polythene bags and other plastics, broken glass bottles, cardboards and even medical waste.
There were some people including children collecting garbage to reuse or sell. It is dangerous
to be there, especially for the children, due to broken glass bottles, medical waste etc. There
was smoke everywhere from small fires. Burning at the disposal ground is allowed as long as
the fire is controlled. During the dry season the waste workers burn the garbage for it not to
fly around. During the rain season they do not have to burn it because the rain makes mud out
of the garbage so it is kept down.87 The colours are mainly grey from ash and white and black
from plastic. There is a mountain of ash that has been burning for over 10 years. In front of
the ash there is a pile of rice husks. Women collect rice from the husks that come from the
rice factory.88 As the population rapidly grows there is a problem to find isolated places for
landfills due to the lack of land, this means that the people are living closer and closer to the
waste disposals.89 The council does not have a good solution to the problem.
Picture nr 3: The waste disposal in Mbale.
87 Interview with Health inspector 1, 20060127
88 Observation at the waste disposal, 20060127
89 Interview with former HPD, 20060225
32
The Chairman of Industrial division told us that they have bought a new piece of land from
outside the municipality in a rural setup to use as a landfill. But they have not yet permission
to use it.90
Opinions among the population
We made ten interviews in Namatala and Malukhu to see what opinions the people have about
the waste management services, how they handle their waste and also to know if they are
aware of the health consequences of poor waste management.
Waste management services
Most of the people we interviewed said at first that they thought the waste management
services worked well, apart from two interviewees in Namatala. One of them said they did not
have any skips where he lived and another woman said that the skips were emptied too
seldom. A woman sitting outside her shop blamed the people: It is working well but the
people are still illiterate. We try to tell the people. People don’t bring it to the skip. They just
throw it anyhow. It is a big problem. I try to inform the people to remove the
garbage.91Another said: They are not working well. There are even faeces in the rubbish over
there. When you go there you get diseases, it’s not good.92 All of them said the waste
management services could be improved, mostly through more skips and by a more frequent
emptying of the skips. Sensitisation of the people was also mentioned. The one who said there
were no waste management services in his area said: We need skips but the problem is that we
don’t have any roads, so first we need roads.93
Contents and handling of domestic waste
Nearly all of the interviewees mentioned organic waste when we asked about the main
contents of their waste and some mentioned buveeras (the local word for polythene bag). All
except for two collected their waste and brought it to the closest skip. The other two burnt it
or threw it in a pit. Nearly half of them separated and burned their polythene bags for them not
90 Interview with former HPD, 20060206
91 Interview with a woman with a small business, Namatala, 20060315
92 Interview with a housewife, Namatala, 20060316
93 Interviews in Malukhu and Namatala, 20060315-16
33
to fly away” or because they spoil the soil94. One had done it but had stopped because it is not
good to burn the buveeras. The smoke is not good.95 One reused the polythene bags when
shopping. Another one threw buveeras and glass bottles in a pit latrine because they are
dangerous to the children and to the waste workers.96 Some burned the banana peelings to use
the ash in a mix with water as a type of salt. One used the banana peelings to feed the animals
and another one took the food products to the garden to use as manure.
Health consequences and diseases
All the interviewees could see connections between poor waste management and diseases;
diarrhoeal diseases and cholera was mentioned by nearly all of them. Other diseases
mentioned were; typhoid, malaria, gigolosis, airborne diseases and waterborne diseases.
Injuries were also mentioned. According to Health inspector 1 the people are aware of the
health consequences of poor waste management but says that the problem is lack of recourses
and negligence of advice.97
Recycling
There is a lot of recycling going on in Industrial division, especially at the markets. Some
people are making sandals out of old tiers that they buy cheaply from garages. Others make
boxes, stoves and dustbins out of metals from old vehicles that they buy from individuals. The
wastes from this production and metal that street boys collect from the disposal ground is sold
to agents who sell it to factories in Jinja that produce bars from it. Plastic bottles are
disinfected and used as containers for juice. The same is done with used glass bottles for
selling oil and other fluids.98 There are also factories in Kampala who reuse glass bottles.
When they go to Mbale to sell sodas to the shops they also collect empty bottles and bring
them back to the factories.99
94 Interview with a woman working for Uganda Wildlife Authority, Malukhu, 20060315
95 Interview with a woman with a small business, Malukhu, 20060315
96 Interview with a woman working for Uganda Wildlife Authority, Malukhu, 20060315
97 Interview with Health inspector 1, 20060131
98 Observation of the small market, 20060201
99 Interview with Health inspector 1, 20060131
34
Some people buy organic waste at the market to put in their garden for fertilizing. Others buy
banana peels to feed their animals.100
The Chairman of the small market thought this was
good and he wanted the farmers to come more often. We suggested that he should bring the
organic waste to the farmers, but he was not very keen on our idea.101
At the small market there were educators who taught people how to recycle charcoal dust by
adding mud and forming new charcoals. There had been one mama who tried to do it but
because she lacked money she could not continue.102
At the moment there was no one who
recycled the charcoal dust.
The former HPD can see some problems with recycling; for example the people’s
psychological restraint to use the sewage sediments for fertilizing.103
The tutor at the School
of hygiene said that knowledge needs to be given about recycling because most campaigns do
not stress recycling and its importance.104
Problems leading to poor waste management
To be able to develop waste management it is necessary to examine what problems exist
leading to poor waste management. One of the health inspectors we talked to described the
situation for us from his point of view. We also got some information from “The national
sanitation guidelines”105
where there is a list of problems that have blocked effective
sanitation.
Lack of commitment among politicians and health workers
Many politicians have taken little responsibility for sanitation and neglected it in their
budgets; it is marginalised in planning, budgeting and resource allocation. A lot of the money
that is targeted for solid waste management goes to other activities.106
100 Interview with the Chairman of the main market, 20060131
101 Interview with the Chairman of the small market, 20060201
102 Ibid
103 Interview with former HPD, 20060206
104 Interview with tutor at School of hygiene, 20060216
105 Water and Sanitation Program, 2000
106 Interview with tutor at School of hygiene, 20060216
35
The politicians have been reluctant to enforce laws for fear of losing votes.107
In 2001 the
politicians took away the graduated tax to win votes and to be popular before the election.
This was the main income for the council and they had nothing to replace it with.108
Sanitation is perceived as an individual, not a communal responsibility.109 Politicians might
also interfere in favour of personal interest when a health worker wants to enforce the law.
Furthermore the Public Health Act and other laws are outdated. The penalties are too low, for
example the penalty for not proper disposing of the refuse is around 3.5 USD. A further
dilemma is that the local authorities are in a great need of money which results in corruption
and poor supervision.110
Another problem to consider is the lack of commitment among the health workers. One
reason for this could be, according to the tutor at the School of hygiene, their insufficient
salary. Most of the people need to have a private business to be able to survive and this results
in not taking their governmental job serious. They take bribes and compromise with their
work.111
According to The tutor at the School of hygiene the health workers are too few and there is a
problem of racism in the recruitment of workers. The collaboration is another problem
between the health inspectors and different actors like politicians, clinical officers and
engineers.112
Corruption
The waste management services have gradually gotten worse since the decentralisation in the
90’s. This was when the council hired a company to take care of the waste management.
Previously it was the technical officers’ responsibility to be in charge of the waste
management. The health workers are supposed to supervise and give technical support but the
private firms are just interested in making profits and do not want any supervision. Corruption
often occurs within the council; the private firms might not do a good job but offers the health
worker a bribe to be able to continue their work. Some people pay a little amount of money to
107 Water and Sanitation Program, 2000
108 Interview with Health inspector 2, 20060201
109 Water and Sanitation Program, 2000:4
110 Interview with tutor at School of hygiene, 20060216
111 Ibid
112 Ibid
36
get better waste handling facilities. This creates an unfair distribution and poorer people will
be without service. A quote from one of the health inspectors says a lot: People who have
money are powerful.113
Lack of awareness and poor practices among the people
Certain cultures have developed a phobia on proper disposal of excreta. For example there is
an idea that pregnant woman should not defecate in a pit latrine, instead the women defecate
in the bush or in a polythene bag which they throw among the other garbage.114
There is also a
lack of awareness of the possibility to reuse things; an example is the polythene bags which
are thrown everywhere. The waste management is not considered seriously as part of the
planning of a safe household and environment and people do not see any reason to take
responsibility for their waste. Compost able garbage is also as a result thrown in open places
which end up in breeding flies which in effect leads to different diseases.115
Women marginalised
Women are the ones who have the most to gain from sanitation and are more receptive to its
benefits than men. But they are not educated to the same extent and they do not have the same
power in decision making. This obstructs the prioritising of sanitation.116
Poor infrastructure and lack of space
There is a lack of space in town because of poor planning. The plots are extremely small and
there is not enough space in between. There exists a law saying that there must be at least one
meter in between the houses, but according to the tutor at School of hygiene this law is not
followed. This causes a variety of problems. It is difficult to find a place for new pit latrines
and there will be problems with having an adequate amount of waste collection and
disposal.117
113 Interview with tutor at School of hygiene, 20060216
114 Interview with former HPD, 20060225
115 Interview with tutor at School of hygiene, 20060216
116 Water and Sanitation Program, 2000
117 Interview with tutor at School of hygiene, 20060216
37
7. DISCUSSION OF THE RESULTS
What are the underlying factors leading to poor waste management in Industrial division and
what could be done to fight them?
Macro level - common goods
Sen states that the government must take certain responsibilities for the common goods like
basic health care, education and environmental protection. These elements influence what a
person can actually achieve and have a great impact on people’s health.118
The infrastructure is poor in Industrial division; there is a lack of waste management services,
sewage systems, water provision, drainages, enforcement of laws, health centres and
education. This makes the waste management worse and increase the negative impact on the
people’s health. To improve the waste management and thus the public health in Mbale there
need to be improvements in all these areas. The main reasons causing the poor infrastructure
are low priority, corruption and poverty.
Low priority
In Uganda many politicians do not prioritise waste management or sanitation work. It is
perceived as an individual responsibility, rather then a communal. Sanitation is marginalised
in planning, budgeting and resource allocation and the money that is budgeted for waste
management is often diverted to other things.
There needs to be an increased knowledge about the impact that environmental determinants
have on peoples’ health and the importance of investing in the common goods. If the
politicians were aware of the connections between the infrastructure, people’s health and the
costs for society that comes out of a high morbidity and mortality they would hopefully
prioritise the common goods better. To increase the awareness among the politicians there
need to be a better collaboration with the health sector as they have got good knowledge of
these connections. The health sector (especially the ones working with improved sanitation
and preventive work) has a low status and a limited influence on the politicians.
118 A. Sen, 2002
38
The women are marginalized in the political life and this might also influence the low priority
as they are the ones that have the most to gain from sanitation and are more receptive to its
benefits than men. An emphasis on educating and empowering women and encourage them to
take part in the political life might diminish the low priority of sanitation.
A public opinion needs to be established about the importance of waste management services
so people can influence the politicians to make an effort in this area. Since it is written in the
constitution of Uganda that the local authority must provide sewage systems and domestic
waste collection for the community this is a demand that the people might make. A way of
influencing the population and especially the politicians is by using media.
Corruption
According to Sen corruption is one of the worst obstacles for economic development.
Corruption occurs in Uganda among politicians, companies and individuals. Because of the
widespread corruption many donators have cut down their assistance to Uganda. This
increases the consequences and makes it even more important to fights corruption.
Because corruption is influenced by the norms of behavior and since these norms are set by
the people with power and authority the battle of fighting corruption must start there. It is
important that the legal system works and that corrupt people are punished. The political
leadership must be clear and open about how they use the money they get from the people and
they must also use them in a good and politically correct way.
As the possibility of being corrupt requires power one way of reducing this could be sharing
responsibilities and decentralize power. This must go hand in hand with the control of what
the money is used for. The decentralization of Mbale municipality shows the need of
increased control and other measures as the decentralization does not seem to have had a
crucial impact on the corruption. The decentralization involved privatization which resulted in
a new dimension of corruption. The privatization complicates the control of what is done. But
now there is also a problem that the council fails to pay the companies in time. If the council
shall have a possibility to demand a better service and not accept bribes of the companies the
council itself must manage to pay the companies in a correct way.
39
Poverty
Uganda is a poor country. Donators give some money but a lot disappear because of
corruption as discussed above. Sen emphasise the importance to invest in people’s health to
get the economy going. The politicians have decreased the taxes to be popular and this has
had negative consequences for the sanitation work in the council.119
The taxes might have to
be increased to improve the infrastructure but it is important that they are related to income.
When there is problem with democracy and corruption in a country it is not a good idea to
give financial aid directly to the government. It is better to invest directly in the infrastructure
to improve the conditions, education and health of the people. In this way people can be
empowered to improve democracy and fight corruption. When improvements are made in the
infrastructure it is important not to let it affect the poor people negatively. This happened in
Malukhu where the poorest people had to move away because they could not pay the
entertainment of the houses that they had been given.
Reduction of garbage
The best way of waste management is producing less garbage and the second best is
recycling. The government could take a greater responsibility over what is consumed. The
polythene bags could be banned or targeted with tax so the consumption of them would be
reduced and an alternative of less expensive environmentally safe bags should be used
instead. Business activity around recycling and development of environmentally safe products
should be facilitated.
Meso level - Empowerment
Is the preventive work to improve sanitation in Industrial division working successfully? If
not – why? How can it be improved? To be able to answer these questions we have used
Murphy’s model the fourth dimension of health promotion to analyse the results.120
The health
workers in Industrial division are working with different types of preventive work: recording
of diseases, home visitation, information, inspection, advising and health education.
119 A. Sen, 2002
120 B. Murphy, 2004
40
Evidence based
Murphy emphasise the need of evidence based public health work.121
At the health centres in
Industrial division the disease burden is recorded every month to be able to inform the people
when a certain disease increases. This is one method of preventing disease outbreaks but are
the data really used in setting priorities for health policies? If the data is collected in an
adequate way it can be used to predict and control future epidemics.
Another issue is how the littering affects people in Industrial division regarding the mental
conditions. The littering e.g. the polythene bags that are spread everywhere are of nuisance to
the people and affect them in a negative manner. Qualitative studies are not used to measure
the mental health conditions in the community.
Collaboration
According to Harpham & Tanner (1995) the responsibilities for sanitation, safe water,
transport system and roads, urban development, health and hospitals normally lie within
different departments or agencies. There is seldom a way for these departments to work
together to improve health services, promote individual health, or even to alleviate
community poverty. Nonetheless, without such a framework for coordinated planning and
implementation of activities, it is impossible for a community to collectively or individually
activate the necessary institutions.122
The collaboration between the different sectors in
Industrial division is of poor quality and even within the health sector this seems to be a
problem. Some kind of collaboration exists though, but there needs to be an improvement.
First of all, the fact that the health workers are inconsistent in their advices to the people
makes it difficult to achieve a change in the people’s behaviour. The advices concerning the
burning of polythene bags were for example diverse. There needs to be an agreement on what
advices the people should be given. The people must get a clear message of what to do,
otherwise the health workers can not blame their behaviour. As Murphy claims it is of great
concern that the collaboration is working, not at least considering the improvements to be
made at the structural level. It would be difficult for actors working in isolation to change
policies, funding, delivery services etc.123
121 Ibid
122 T. Harpham & M. Tanner, 1995
123 Ibid
41
Engagement and understanding
One explanation of why the people do not follow the advices are according to Murphy’s
model because the people have not been engaged in the planning of the health promotion
program.124
The work that is being done in Industrial division appears to be more top-down
and expert-led than the fourth dimension suggests. As stated in the Water and sanitation
program, many health workers use the old approaches (i.e. telling people what to do) and lack
the skills to use the new participatory methods. The approaches used in promoting sanitation
have depended too much on coercion and one-way communication of generalised messages
and not enough on discussion, peer group learning, the fostering of commitment and practical
action planning.125
This is related to the problem that if people do not have a deep
understanding of the logic behind the recommendations they tend to ignore them. People are
given advices about practical things e.g. that they should boil the water before drinking it,
without gaining understanding for the reasons on why they should change their behaviour. As
stated in the Water and sanitation program (2000) hygiene education will not necessarily lead
to changed hygiene behaviour. If there is no discussion about the rationale behind the
messages and their relevance to local practices then it will be difficult to change the people’s
behaviour. People tend to ignore the messages especially if the new recommended behaviour
goes against long-standing and traditional habits.126
Cultural norms
The fact that many individuals living in the community come from outside Mbale with
different cultures tends to create a problem. It is important to have an understanding for the
different cultures, if not it will be difficult to work together and have a mutual relationship.
The respect of individual norms should be of main concern among the health workers to
success with a health promotion program.127
The following statements demonstrate the
difficulty of showing respect for cultural norms:
The Karamoja people eat anything and are not so hygienical.128 The hygiene is completely
poor; people spit and make their needs anywhere.129 The people do not know the use of health
124 Ibid
125 Water and Sanitation Program, 2000
126 Water and sanitation program, 2002
127 B. Murphy, 2004
128 Observation of Namatala 2006-02-06
42
centres, they have their own treatments instead or persuade rather than going to the clinic.130
The people are aware of the right thing to do but they are stubborn.131
According to the fourth dimension of health promotion the lack of respect is one of the
problems leading to that people continue with the behavior as they are used to from their
culture.132
The preventive work that is being done does not appear to include the people in the
decision-making. An idea is that health workers work with people from the same cultures with
the same values and ideas to get a mutual understanding about the determinants of health. If
the people can identify themselves with the health leader it will be easier to adopt the
healthier way of living and follow the advices given to them. Because of the problem with
racism in the recruitment of health workers the staff is not very diverse according to culture.
Since it is important to health educate women there should be more women working with
health promotion as it might by easier to receive a message from a person with the same sex.
Another thing to consider is to implement peer-education. This can be done by educating key
persons or informal leaders in a specific group that the rest of the group has a high regard for.
This is a way of taking cultural norms into account.
Action requires possibility
As the fourth dimension suggests it is nearly impossible to engage the community in the
health promotion work if the health inequalities relevant for the marginalized and vulnerable
groups are not addressed.133
Even if people have knowledge they must also have possibility to
adopt the recommendations. There needs to be skips which are emptied on a regular basis if
the people are supposed to empty their garbage at a certain spot. The message of not drinking
unsafe water is meaningless to people who can not afford tapped water or fuel to boil the
water. If no investments are done in the structural settings the people will not have the
possibility to change their behaviour. The same pertain to education, i.e. the people must have
some degree of education to be able to attain advices.
129 Interview with health worker at Namatala health center, 20060209
130 Observation of Namatala 20060206
131 Interview with Health inspector 1, 20060131
132 B. Murphy, 2004
133 Ibid
43
Health education
According to one of the workers at the health centres the most important thing to implement is
health education to mobilize and sensitize health issues. One of the obstacles to this in
Industrial division is the language since many different tribes has got their own foreign
language. Another complication is the high illiteracy rate. These facts decrease the health
literacy because of the difficulties to understand information and read policies etc. In a gender
perspective it is worth noticing that the illiteracy rate is higher among the women which is a
dilemma since it is the women who take care of the households. This means that it is of great
importance that the women become literate to be able to accomplish the messages being given
to them. The society has, because of the above reason, most to gain on educating both women
and men. Before people are able to receive health education in a successful way they need to
be educated. This may be another explanation why the people do not follow the advices and
change their behaviour into a healthier lifestyle. Messages that need to be emphasized in
health education connected to waste management are awareness of the possibility to reuse
things e.g. the polythene bags and the importance of taking responsibility for keeping a safe
environment.
8. CONCLUSION
There is a plan for waste management in Industrial division, Mbale. The plan is basic and is
not properly followed; e.g. the waste is not collected on a regular basis and there is a lack of
waste workers. The main reasons for the poor waste management are due to a poor practice
among the people, lack of priority among politicians, corruption and poverty. The major
health problems caused by poor waste management are diarrhoeal diseases, malaria and
injuries.
The society needs to take responsibility for the population by prioritizing the common goods.
Sustainable and long-term solutions on this area are grounded in combating corruption and
poverty. Common goods like infrastructure and education is a prerequisite for an effective
health promotion work. The health promotion work should be based upon empowerment with
regards taken to the people’s social and economic conditions. Respect must be shown for
individual and cultural norms. An emphasise needs to be put on educating women to fight the
44
inequalities and to improve the sanitation. If investments are done in these areas there are
great gains to achieve in people’s health and in development of the country.
45
9. REFERENCES
Amin M. (1998) Spectrum Guide to Uganda. Nairobi: Caerapix Publishers International
Avert.org >http://www.avert.org/aidsuganda.htm< 2006-04-20
Dictionary.cambridge.org/cald< 2006-04-20
Ekonomifakta 2006 >http://www.ekonomifakta.se/word____497.aspx< 2006-04-20
Fitzpatrick M, Ray N, Parkinson T (2003) East Africa. Victoria, Australia: Lonely planet
publications
Berg P E O (2004) Sopor hit och dit – på vinst och förlust. Stockholm: Formas
Brante T, Andersen H & Korsnes O (2001) Sociologiskt lexikon, Universitetsförlaget:
Stockholm
Global Urban Observatory and Statistics Unit
>http://www.unhabitat.org/habrdd/conditions/eafrica/uganda.htm< 2006-04-20
Harpham T. & Tanner M. (1995) Urban Health in developing countries. Newcastle:
Earthscan Publications Limited
Hartman J (2004) Vetenskapligt tänkande. Lund : Studentlitteratur
Hutton G & Haller L (2004) Evaluation of the costs and benefits of water and sanitation
improvements on the global level. Geneva: WHO
Khan A H (1997) Development’s deadly menace >
http://scholar.google.com/scholar?q=unicef%20definition%20of%20sanitation&hl=sv&lr=&o
i=scholart< 2006-05-18
Kvale S (1997) Den kvalitativa forskningsintervjun. Lund: Studentlitteratur
46
Lawrence Neuman W (2003) Social research methods (5th edition). Boston, USA: Pearson
Education, Inc.
Michael M (2005) Three year development plan, 2005-2008. Mbale municipality: Industrial
division council
Murphy B (2004) In search of the fourth dimension of health promotion: Guiding principles
for action. I: Keleher H & Murphy B (Eds) Understanding health: a determinants approach.
Victoria, Australia: Oxford University Press, p 152-169
Naidoo J & Willis J (2000) Health promotion (2nd edition). London: Baillière Tindall
Sen A (2002) Utveckling som frihet. Uddevalla: Daidalos
Studieförbundet, Vuxenskolan >http://user.tninet.se/~vxj180a/doc/historia.html< 2006-05-04
Water and Sanitation Program – Africa Region (WSP–AF) (2000) National Sanitation
Guidelines. Kampala: Ministry of Health
Werkö L (2003) Global folkhälsa – tar vi vårt ansvar? Lund: Studentlitteratur
WHO >http://www.who.int/water_sanitation_health/sanitproblems/en/index1.html< 2006-05-
17
Wikipedia, Den fria encyklopedin >http://sv.wikipedia.org/wiki/Uganda< 2006-05-04
47
INFORMATION ABOUT THE STUDY
Waste management connected to health in a developing country – a case study
in Mbale, Uganda
We are two students of Public Health at Malmö University, Sweden. Our study is sponsored
by SIDA, the Swedish international development cooperation agency.
Poor waste disposal practices are responsible for a significant proportion of the world's
infectious disease burden. The purpose of our study is to actualise poor waste management
and its importance for health. We will make a case study to examine how waste management
services work in Mbale and how the population experience the problem of poor waste
management. Our aim is that the study will contribute to the development of waste
management in Mbale.
Your participation is voluntary and you can withdraw when wanted. For practical reasons we
will record the interview, if we have your approval. The material will be confidential and we
will use pseudonyms when transcribing.
Sara Bergqvist Lisa Wieslander
48
INTERVIEW GUIDE -for the interviews in Malukhu and Namatala
1. We want to talk to the one who is taking care of the waste in this household, is that
you?
2. For how long have you been staying here?
3. How many people are staying in this house?
4. How do the waste management services work in this area?
5. What is the main content of your waste?
6. How do you handle the domestic waste?
7. Do you sort anything out?
8. Do you recycle anything?
9. Do you burn anything?
10. Do you see any connections between poor waste management and diseases?
11. How do you think waste management services could be improved here?
12. Would you be ready to pay for improved waste management services?
13. Do you have something to add before we finish this interview?
14. Thank you for your participation!