WASH conditions in a small town in Uganda: how safe are on-site facilities?

Inadequate hygiene coupled with the conjunctive use of the shallow subsurface as both a source of water and repository of faecal matter pose substantial risks to human health in low-income countries undergoing rapid urbanisation. To evaluate water, sanitation and hygiene (WASH) conditions in a small, rapidly growing town in central Uganda (Lukaya) served primarily by on-site water supply and sanitation facilities, water-point mapping, focus group discussions, sanitary-risk inspections and 386 household surveys were conducted. Household surveys indicate high awareness (82%) of domestic hygiene (e.g. handwashing, boiling water) but limited evidence of practice. WHO Sanitary Risk Surveys and Rapid Participatory Sanitation System Risk Assessments reveal further that community hygiene around water points and sanitation facilities including their maintenance is commonly inadequate. Spot sampling of groundwater quality shows widespread faecal contamination indicated by enumerated TTCs ( Escherichia coli) ranging from 0 to 10 4 cfc/100 mL and nitrate concentrations that occasionally exceed 250 mg/L. As de ﬁ ned by the WHO/UNICEF Joint Monitoring programme, there are no safely managed water sources in Lukaya; ∼ 55% of improved water sources comprising primarily shallow hand-dug wells show gross faecal contamination by E. coli ; and 51% of on-site sanitation facilities are unimproved . Despite the critical importance on on-site water supply and sanitation facilities in low-income countries to the realisation of UN Sustainable Goal 6 (access to safe water and sanitation for all by 2030), the analysis highlights the fragility and vulnerability of these systems where current monitoring and maintenance of communal facilities are commonly inadequate.

Island in Uganda, for example, 76% of respondents reported having no toilet with 48% of respondents also reporting ailments due to diarrhoeal diseases including dysentery (WaterAid ). In Angola, where 55% of the urban population resides in slums, cholera has been endemic with over 80,000 cases and 1,000 deaths in 2006 and a recurrence of cholera in 2013 (Buckley & Achilles ). In Benue State, Nigeria, children who failed to wash their hands regularly after toilet use showed a high prevalence (49%) of enteric infections (Atu et al. ). In Siaya County, Kenya, increased water fetching times and longer distances to water sources were found to result in an increased risk of diarrhoeal disease (Nygren et al. ).
Provision of WASH services is widely considered to be an essential requirement to control the occurrence of water-related diseases. There is, however, mounting evidence that improved water sources comprising a basic service following criteria of the WHO-UNICEF Joint Monitoring Programme (WHO/UNICEF-JMP ) may still be prone to faecal contamination in low-income settlements. According to Onda et al. (), 12% of sampled piped water supplies and 45% of other improved water sources including boreholes and protected springs and wells in Ethiopia were found to be contaminated by thermo-tolerant coliforms (TTCs). In Lilongwe, Malawi, faecal contamination was observed in 10% (59%) of improved sources in high-income (low-income) areas; the statistical difference (p < 0.05) between water quality in low-income and high-income areas was attributed to inadequate infrastructure and maintenance (Boakye-Ansah et al. ). In Benue State, Nigeria, private wells demonstrated the highest prevalence (52%) of contamination by faecal pathogens compared to boreholes and tank water facilities (Atu et al. ).
In Ghana where over 70% of urban sanitation facilities are shared (Buckley & Achilles ), studies reveal these facilities are more likely to be unsanitary (Mazeau et al. ) and have an increased risk of diarrhoeal disease associated with their use (Heijnen et al. ).
To achieve sustainable and universal access to safe water and sanitation under United Nations (UN) Sustainable Development Goal (SDG) 6 requires an improved understanding of the status and risks posed by the use of on-site water and sanitation systems, which will feature centrally in most low-income towns and cities in realising UN SDG 6. Here, we assess the WASH conditions in Lukaya Town in central Uganda, a rapidly growing, small town using the shallow subsurface conjunctively as a source of safe water and repository of faecal matter. The specific objectives of this work were: (1) map and characterise water supply sources and sanitation facilities; (2) identify sources of pollution threatening potable water supply sources including on-site sanitation facilities; (3) assess water supply facilities and the quality of water used by the community; and (4) to compare observed on-site water supply, sanitation and hygiene characteristics to the very limited, available evidence of morbidity from local healthfacility records and self-reporting during household surveys.

STUDY AREA Location
Lukaya is located in Kalungu District of central Uganda on the equator between latitudes 0 6 0 0″ and 0 11 0 0″S and longitudes 31 49 0 0″ and 31 56 0 0″E (Figure 1). The total land area defined by the town council is 57 km 2 with a population density on inhabited land (38 km 2 ) of ∼640 inhabitants per km 2 and population growth rate of 3% per annum (PDP ); remaining land (19 km 2 ) is occupied by wetlands adjacent to Lake Victoria. The region experiences a seasonally humid climate in which rainfall is bimodal with rainy seasons in March-April-May (MAM) and September-October-November (SON). Mean annual rainfall is ∼890 mm with mean monthly peaks of 117 mm (April) and 102 mm (October) (Figure 2). Monthly minimum and maximum temperatures range from 10 to 16 C and 16 to 25 C, respectively; estimated potential evapotranspiration ranges from 1,350 to 1,750 mm year À1 (NWRA ).
Physiographically, the town lies primarily within a lowland plain that is the result of downwarping during the Late Quaternary in the Upper Nile Basin associated with inter-rift tectonics (Taylor & Howard ). Depositional features which developed along valleys on the plateau and on the margins of Lake Victoria influence hydrology of local Rivers Katonga and Katungulu which flow into Lake Victoria. Mean elevation over the most eastern part of the town exceeds the mean lake level of 1,134 m above sea level (masl). The western part of the town is on relatively higher ground with an average elevation of 1,238 masl.

Water and sanitation
The water supplies of Lukaya derive primarily from groundwater abstracted from shallow wells using hand pumps and unprotected springs. A tiny minority of inhabitants is connected to a piped water system that is supplied by a borehole with a depth of 61 m below ground level (mbgl), equipped with a submersible pump in a neighbouring subcounty (Bukullula), and managed by the National Water Sewerage Corporation (NWSC). For the most part, sanitation facilities comprise partially lined, elevated pit latrines due to the shallow water table (0.5-5 mbgl) in lowlying areas. Other sanitation facilities include ventilated improved pit latrine, urine-diverting toilets and flushing toilets discharging into septic tanks. The town possesses neither a sewer network nor a wastewater treatment facility so faecal effluent is entirely contained in the shallow subsurface using on-site sanitation. Emptying of sanitation facilities is done by either digging another pit or transferring of the faecal matter to another pit. It also has been observed that Despite the existence of legal and policy frameworks in Uganda for water and sanitation, key limitations in these have been identified. For example, sanitation is not included at public service level; enforcement of stated regulations has been minimal; continuous provision of data on water and sanitation service delivery has been inadequate with a limited budget that affects the monitoring of services (MWE ). In small towns, low return on water and sanitation investments, a lack of feasible and cheap technological options to provide sanitation services, inappropriate

Observed health conditions
Commonly reported morbidity in Lukaya includes malaria and diarrhoeal diseases ( Figure 2). Records from one of the most frequently visited health facilities indicate that disease incidence is dominated by malaria (81%) followed by diarrhoeal diseases (19%). The high incidence of malaria is associated with flooding during the rainy season when water levels in Lake Victoria are high thus draining the wetland area (see Figure 1) due to the close proximity of Lukaya Town to the lake. It is noteworthy that reported cases of diarrhoeal cases exceed malaria at the end of the dry seasons (March and August) when ponding is at a minimum.

MATERIALS AND METHODS
The study is cross-sectional in its design employing iterative quantitative and qualitative data collection methods; these included key informant consultations, FGD, field mapping of water supply points and sanitary facilities, sanitary inspections of the facilities, HH surveys, Rapid Participatory Sanitation System Risk Assessment (RPSSRA) and waterpoint sampling.

Water sources and sanitary facilities
To obtain data on water sources and sanitary facilities, consultation with Lukaya town council officials, and its health inspector was initiated in May 2016. This consultation was followed by field mapping of all existing water sources and sanitary facilities within the study area. All facilities were geo-referenced using a handheld Garmin eTrex ® 10 Global Position System. Water supply points were categorised according to WHO/UNICEF-JMP (, ) as 'safely and 'no facility' based on the mode of faecal matter containment, transport/treatment and disposal/use and facility structural integrity. Service levels for water sources are defined as: safely managed when water is from an improved water source that is located on premises, available when needed and free from faecal and priority chemical contamination; basic when drinking water is from an improved water source provided collection time is not more than 30 min for a round trip; limited when drinking water is from an improved source but collection time exceeds 30 min for a round trip including queuing; and unimproved when the water sources are not protected against contamination (e.g. unprotected dug well or unprotected spring).

Ethical considerations
Ethical approval to carry out the study was obtained from

RESULTS AND DISCUSSION
Water source and sanitation facilities mapping water sources that are classified as providing a basic service is due primarily to the high number of self-supply shallow wells that are located close to user HHs (<30 min for a round trip) whose quality was perceived to be good (83%).
Additionally, standpipes from a piped water supply network supplied by a borehole and operated by the National Water and Sewerage Corporation (NWSC), also provide a basic service but is estimated to be used by less than 40 (<1%) of the 6,349 HHs mapped in Lukaya Town (UBOS ) due to high costs of water tariffs that include the introduction of 18% VAT on piped water in 2012 (NAPE ).
Each of the 66 on-site water sources, whether improved (vast majority) or unimproved (minority), is consequently shared by an average of 92 HHs. A total of 2,099 on-site sanitation facilities, primarily pit latrines, were also mapped. On average, this total suggests that each on-site sanitation facility is shared, on average, by 3 HHs. Based on WHO/UNICEF-JMP () criteria, the majority of these facilities (51%) are pit latrines without slabs, providing an unimproved service. Of the remainder, 26% of the mapped facilities provide a limited service; 22% provide a 'basic' service whereas <1% is safely managed.

Sanitary-risk inspections of the water sources indicated
∼74% of the water sources as having low-to medium-risk scores (0-6) (

HH surveys
Most respondents (85%) to HH surveys were women whose level of education was commonly at primary-school level

Rapid participatory sanitation system risk assessment
The results of the RPSSRA categorise three major risk indicators (hazardous events, exposure and vulnerability) and showed medium risks (

Water quality
The quality of 37 sampled water sources is summarised in

CONCLUSIONS
• Substantial dependence on the conjunctive use of the shallow subsurface for both a supply of safe water and a repository of faecal waste is demonstrated in small but rapidly growing town in central Uganda (Lukaya).
• Construction and maintenance of commonly shared (communal) on-site water sources, primarily shallow wells and sanitation facilities (pit latrines) are inadequate as indicated by high-risk scores in sanitary-risk surveys.
• HH surveys indicate that awareness of basic hygiene (e.g. handwashing, boiling water) is high but basic hygiene is commonly not maintained in practice (e.g. absence of facilities, absent or unsanitary water containers).
• Community hygiene evaluated using WHO Sanitary Risk

Surveys and Rapid Participatory Sanitation Systems Risk
Assessments, is often inadequate and may contribute to reported incidences of diarrhoeal diseases and malaria recorded by local health facilities and during HH surveys.
• Siting of on-site water and sanitation facilities, determined by convenience or preference, commonly disregards unenforced regulations.