Download - WASTE MANAGEMENT AND HEALTH - DiVA portal

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

2

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

3

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

4

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

5

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

6

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

7

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

8

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

9

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

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


12 Wikipedia, 2006-04-20

13 Ekonomifakta 2006, 2006-04-20

14 Avert.org, 2006-04-20

11

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

12

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


13

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


24 Interview with Tutor at the School of hygiene


26 Cambridge Advanced Learner’s Dictionary, 2006

14

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


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


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


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


52 M. Amin, 1998

53 Ibid

54 M. Michael, 2005

55 Interview with Health inspector 1, 20060131


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



59 Observation of Industrial division, 20060201

60 Interview with tutor at School of hygiene, 20060216


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


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


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


72 Observation of Namatala, 20060206





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





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.


88 Observation at the waste disposal, 20060127


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


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


98 Observation of the small market, 20060201


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





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



109 Water and Sanitation Program, 2000:4


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






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


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



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!