Response to COVID-19: building resilience through water and wastewater management in Ghana

While the government's WASH interventions associated with the COVID-19 response were timely and critical, there is limited empirical data on their effects on the water and sanitation system. The study assessed the pressures, drivers, and responses to the pandemic by investigating how the outbreak affected the WASH sector using Ayawaso East Municipality as a case study. The Ayawaso East Municipal Assembly is one of the 29 Metropolitan, Municipal and District Assemblies (MMDAs) in the Greater Accra Region of Ghana. It was carved out of the then Accra Metropolitan Assembly in 2018. The municipality is densely populated, with a population of around 130,256 (Ministry of Finance 2019). While not representative of Ghana, particularly considering rural–urban dynamics, Ayawaso East Municipal Assembly is emblematic of Ghana's WASH challenges. We draw lessons for the country's WASH sector using this case study.

The response was analysed first by unravelling the drivers, pressures, and state of service provision of the core components of the system, pre-COVID-19, and how different categories of actors responded. Risk involves analysing the outcomes and impacts of responses concerning actors' vulnerability (gender, income, age, system access inequalities). Insights were synthesised to identify recovery mechanisms and solutions to address negative outcomes. Diverse recovery processes and solutions were analysed and proposed to stakeholders at different governance levels through appropriate engagement processes, including the BBB policy dialogues.² These solutions help organisations, households, and individuals to build resilience, in the context of water and sanitation, during and after the pandemic. Finally, resilience building processes supported the evaluation of the recovery solutions generated and provided evidence within the BBB Dialogue to inform policymaking and practice at relevant ministries, as well as MMDAs, who are actors within the system. The framework (Figure 3) was used to address and integrate the four specific objectives through a multiple-pronged methodology and complementary studies, as outlined in Table 1. The study was grounded in respect and protection of the privacy of participants, voluntary participation, and informed consent. We ensured that participants were diverse, thus including the voices of all stakeholders. We also ensured that participants experienced no harm because of their participation in the study. The International Water Management Institutes' Institutional Review Board reviewed and approved the study protocol.

Table 2 presents an overview of the roles and mandates of major WASH stakeholders, together with their responses to COVID-19. Stakeholder roles and responsibilities are well-defined, and responses are relatively rapid. Appropriate enabling legislation was also in place to support service delivery. Although policy instruments were not specific to the pandemic, there were opportunities for adjustment and to prepare guidelines to carry out government directives relating to COVID-19. Most organisations also have well-defined visions and goals, articulated in policy documents, strategic action plans, or medium-term development plans. MMDAs are responsible for providing infrastructure and services at the municipality and district levels and overseeing sanitation and waste management services. Funds for services are provided by the central government, internally generated funds, and projects. Small-scale transportation of faecal sludge (FS) was by vacuum truck operators. Generally, vacuum truck operators belong to a trade association and have business permits to operate. Fees charged are determined based on distance, septic tank volume, and client type. The Ghana Water Company Limited (GWCL) and the Community Water and Sanitation Agency (CWSA) provide water services for urban and rural areas. The public pays for service operation and maintenance through a billing system, and in rural areas through direct sales at standpipes and water points.

In response to the pandemic, the government declared free water provision for an initial period of 3 months, later extended to 9 months (March to December 2020) for the general populace (Morgan 2020), and an additional 3 months (January to March 2021) for low-income households consuming less than 5 m³ of water per month. This resulted in a significant increase in water consumption. The GWCL increased water supply by more than 42% and provided more public standpipes, polytanks, and tanker services to meet the demand. Household survey in Ayawaso East showed that around 55% of respondents had access to free water, and water consumption increased by around 37%. The survey indicated that providing handwashing facilities to combat the spread of COVID-19 led to an increase in handwashing throughout Ayawaso East. This finding is consistent with a USAID-funded study on the impacts of COVID-19 in Ghana which documented an increase in handwashing (Tetra Tec 2021).

Increased use of PPE, sanitisers, handwashing, and enhanced hygiene practices contributed to increased solid and liquid waste generation and a decrease in the quality of wastewater. The characterisation of wastewater from handwashing stations in Accra and wastewater treatment plants in Kumasi by this study recorded higher levels of both total solids and chemical oxygen demand (COD) than before the pandemic. Issues such as absenteeism and inadequate supply chains affected the sustainable operation of wastewater treatment plants. The three hospitals included in the study recorded a 3–7-fold increase in medical waste generated because of PPE use as protection against COVID-19. The proportion of highly infectious pathological waste incinerated on-site also increased. This is consistent with other reports that have linked health responses to the pandemic with increased medical waste and concerns about managing such waste (Tsukiji et al. 2020; Andeobu et al. 2022; World Health Organization 2022).

COVID-19 in Ayawaso East Municipality affects women, men, youth,³ and children differently, with women and girls facing a higher burden. Women and girls are generally burdened with collecting water for households, a task which became more demanding because of the additional water needed for COVID-19 hygiene practices such as handwashing. A study by Bukari et al. (2021) found that the impacts of COVID-19 in Ghana were different across genders, with male-headed households able to cope better than female-headed households. More women are self-employed, or are in informal employment, with lower earnings than men. Losing these informal jobs greatly impacted them. Furthermore, the role of women as caretakers, when children had to stay home because of school closure, prevented some from engaging in business activities during the lockdown (Badri 2020).

In a country where some households spend up to 80% of their income on food (Bukari et al. 2022), the loss of income coupled with increased food prices during the pandemic posed a significant threat to food security. Loss of income affected the purchasing power of those relying on informal opportunities. In Ayawaso East, where residents depend largely on informal employment, the economic impacts of the pandemic were significant. According to the household survey, 16% of males and 21% of females did not have sufficient food in the month before being interviewed, yet Government food assistance only reached 4% of males and 10% of females. Bukari et al. (2022) found a statistically significant association between COVID-19 and food insufficiency across 10 regions in Ghana. More than half (58%) of the households interviewed in that study reported going without sufficient food several times due to the pandemic. Schotte et al. (2021) also found that the pandemic and lockdown impact in Ghana were mostly felt by self-employed and informal sector workers.

Access to sanitation was a challenge before COVID-19 (see Figure 1). Ninety percent of respondents shared toilet facilities with other households, potentially exposing them to COVID-19. A study by Caruso & Freeman (2020) suggests that shared facilities could become sources of airborne and contact exposure to COVID-19, especially without adequate water and soap for hygiene purposes. Although SARS-CoV-2 has been detected in feces and remains viable for days on stainless steel and plastic surfaces – materials used for doors and other high-contact surfaces in toilets and latrines – these are not major transmission routes (Lewis 2021) and faecal-oral transmission is a highly unlikely route for SARS-CoV-2 transmission (WHO 2020; Cerrada-Romero et al. 2022). Although urban and peri-urban farmers in Ghana use wastewater diluted with water from other sources to grow vegetables, transmission risks via the food chain through wastewater irrigation remain very low (Haji et al. 2021). Thus, perceptions of risks concerning reuse and recycling of wastewater and FS may be far higher than reality. Adopting a holistic approach to assess the various contaminants and associated risks of wastewater reuse and recycling is crucial because SARS-CoV-2 is not the only contaminant of concern.

Beyond access to water and sanitation, other dimensions of lack of inclusiveness were observed. Waste management workers, for instance, did not receive government support because they were not considered frontline workers. In the three hospitals studied, COVID-19 risk remuneration eligibility did not extend to waste workers despite them facing a higher risk of contracting COVID-19. One respondent reported that medical waste handling staff were ‘left behind’ despite being at risk of contracting COVID-19 infection. As Andeobu et al. (2022) noted, improper handling of medical waste could lead to secondary infection of waste handlers.

The risk to businesses along the sanitation value chain is another pandemic impact. Sanitation service providers (vacuum truck operators) faced reductions in the number of clients served, service fees charged, and increased police hostility during the lockdown. Vacuum truck operators are essential in Ghana's sanitation service delivery chain, providing FS transport to treatment facilities. The closure of schools and business premises resulted in reduced demand for their services. The number of clients served during COVID-19 decreased by 20% for households, 24% for public toilets, and 29% for private institutions. Fees charged for services were reduced by 19% across all clients. Tanker service providers lacked adequate coping mechanisms and did not benefit from government interventions. Only 16% of those surveyed received training from local public sector agencies regarding safe and effective service delivery during the pandemic. For larger, private service providers, the pandemic reduced revenue and loss of clients (mainly for waste management companies) by 25–40%. There was also a corresponding increase in operational expenditure. One company reported a 10% increase in operational costs from providing PPE for staff and running a shift system to reduce staff numbers on duty at any one time.

Public sector agencies focused on delivering government directives and interventions on free water services, by pre-financing the delivery of free water and then billing the government. However, water vendors, who did not get free water, continued to charge residents despite warnings from MSWR, because this is their source of income. Investment in expanding services, asset rehabilitation, and other capital expenditures were affected as operations were re-adjusted to free funds for water service delivery. Due to bureaucratic processes and billing times, government payments were sometimes delayed, reducing operational revenues and system inefficiencies. For example, in Chirapatre (Kumasi), erratic and inadequate water supplies were reported during the free water period (personal communication).

For MMDAs, lockdown meant reduced revenues from markets and central business districts. Key informant interviews revealed that some MMDAs reported revenue reductions equivalent to achieving only 60–70% of their 2020 targets. For the country, the Ghana Revenue Authority reported ‘a reduction of revenue targets for and the petroleum and manufacturing sectors from GH¢47 billion to GH¢42 billion and US$1.57 billion to US$660 million, respectively’ (Ghana Center for Democratic Development 2021). Financial transfers from the central government were reallocated to the COVID-19 response. Despite these impacts, the pandemic provided opportunities for MMDAs to collaborate with sector ministries to improve WASH in public places. MMDAs in Accra in collaboration with the Ministry of Local Government provided handwashing facilities and fumigated markets. Others worked with the Ministry of Sanitation and security agencies, and organised clean-up activities of public places. MMDA waste management departments interviewed highlighted the need to consider healthcare waste management as part of the pandemic response.

Household surveys documented short-term measures, including staying at home (36% of men, 21% of women) to protect themselves against COVID-19. More men than women reported taking other protective measures, including frequent handwashing, practising social distancing, and avoiding handshakes or touching their mouth and eyes. This contrasts with a study in Indonesia which found higher compliance with COVID-19 prevention measures among females (Paramita et al. 2021). In Ghana, the difference could be attributed to women being largely responsible for domestic chores and food provision, which requires them to go to markets where COVID-19 restrictions were not strictly observed.

According to interview responses, households were highly dependent on purchased sachet water⁴ to meet their drinking water needs in the short term. The GWCL monitored the provision of free services and increased tanker service frequency where needed. Customers could call the national helpline to provide information on where water was needed so the company could respond. The government also paid some private tanker operators to ensure delivery to low-income areas. MMDAs provided innovative handwashing facilities, such as ‘veronica buckets’ (Ministry of Sanitation and Water Resources n.d.) in public places. Hand sanitisers, masks, and waste bins for safe disposal of tissues were provided at handwashing facilities. Additional polytanks and standpipes were provided in some low-income communities. For short-term management, Caruso & Freeman (2020) recommend that handwashing be provided at shared facilities, in addition to ensuring social distancing in queues. Solutions implemented by the Government of Ghana were similar to the short-term solutions recommended by the World Bank for low-income communities (Kotwa et al. 2020). However, these interventions, while providing temporal support to communities, are not sustainable over the long term and have since ceased.

Learning from the country's WASH response to the pandemic, the stakeholders recognised the value of building the resilience of the water and sanitation sector against future pandemics. In this study, participants identified improved waste management practices as an important component of a resilient water and sanitation sector that emerged from responding to the pandemic. Healthcare facilities improved waste management practices because of COVID-19. For example, some facilities that had previously burned medical waste in the open instituted plans to manage this waste more professionally. One respondent reported that COVID-19 enhanced medical waste separation. Outsourcing waste management to private sector actors also increased the professionalisation of waste management. Collaborative approaches to providing water and sanitation services are another dimension of building the sector's resilience that emerged in response to the pandemic. MMDAs collaborated with the Ministries of Local Government, and Sanitation and Water Resources and security agencies to carry out clean-up activities and fumigation. WASH stakeholders also participated in the Emergency Operations Centre, set up under the auspices of the Ghana Health Service, which coordinated the country's response to the pandemic. Recognising the roles of private sector actors in delivering WASH services, engagement with stakeholders such as water tank vendors and vacuum operators was enhanced to improve WASH services. Experiences from such collaborations provide valuable lessons for institutional arrangements in responding to the pandemic.

Stakeholder engagement provides an understanding of requirements from multiple perspectives, ensuring actual needs and challenges are identified and analysed. This helps generate policy and practice insights and recommendations, leading to more inclusive WASH systems that can withstand COVID-19, other pandemics, and related risks. Dialogue provides opportunities for research insights to be shared with stakeholders, while providing a space for them to openly brainstorm and collaboratively identify actions to support the process of BBB. Responses to COVID-19 are multisectoral, highlighting the need to better integrate sectors beyond water and sanitation.

Safe management of sanitation waste remains a pressing challenge in Ghana. However, there are circular economy opportunities for improved solid waste and wastewater management. Sustainable sanitation waste management can be achieved through integrated, circular economy business models that go beyond standard sanitation services, turning FS into valuable resources such as nutrients, organic matter, and energy. This is particularly pertinent to situations where public investment in sanitation is limited. Cost recovery strategies are needed to encourage more private sector investment, leading to enhanced service delivery. Shifting from waste treatment ‘for disposal’ to waste recycling ‘for reuse’ is one important option for cost recovery and business development along the service delivery chain. Effective FS management requires going beyond the provision of toilets to having efficient emptying and transport services, and proper treatment and reuse of FS. In Ghana, and many countries, where resources are scarce, the potential value of reusing this waste remains largely untapped (Sugihara 2020). Harnessing these opportunities could encourage further investment, especially by the private sector, to provide more sustainable waste management infrastructure and processes.

For institutions involved in delivering WASH services, adequate planning and preparation of responses for emergencies, such as COVID-19, provide opportunities for resilience building. Plans should balance longer-term vision and strategies with the need to shift focus and implement rapid, emergency actions. This will ensure that service provision in the longer term is less likely to be affected because institutions will be better prepared to continue to undertake capital expansion and operation and maintenance while increasing service provision.

This study assessed and documented lessons from the impact of the COVID-19 response on Ghana's WASH sector and contributed to BBB. The study's findings revealed that WASH stakeholders collaborated in providing short-term responses to the pandemic. However, these short-term responses require balancing short-term with longer-term vision and strategies with the need to shift focus and implement inclusive and gender-response sustainable WASH interventions. Wastewater management policies need to be updated in response to COVID-19 and future pandemics. Investments along the service delivery chain are needed to improve wastewater management. Adopting circular economy practices along the sanitation service chain can reduce costs and incentivise increased private sector investment. Losses by vacuum tank operators could be offset through training that enables them to benefit from government support while also improving occupational health and safety. Expanding infrastructure to deliver services is a key component of developing the WASH system. The WASH sector is interconnected with other sectors and adopting a holistic approach will enhance its sustainability. Responses to COVID-19 highlighted the need for inter-agency cooperation.

Thanks to William Quarmine for the support in the development of the graphical abstract and Charity Osei-Amponsah for the initial project conceptualisation and The Netherlands Embassy, Accra, Ghana for financial support.

Data cannot be made publicly available; readers should contact the corresponding author for details.

The authors declare there is no conflict.