Challenges associated with access to safe water in Rhino Camp refugee settlement in Arua District, Uganda

A combination of rising conflict (such as the civil wars in South Sudan and the Eastern Democratic Republic of Congo) and natural disasters (such as flooding and mudslides in the mountainous region of Eastern Uganda and drought conditions in North Eastern Uganda) have made East Africa, Horn of Africa, and Great Lakes Region home to 4.82 million or 67 and 20% of the African continent and global refugee population, respectively, with up to 10.57 million internally displaced persons (IDPs) plus approximately 113,701 refugee returnees (UNHCR 2021). In this region, Sudan has the highest number of refugees (1.1 million), returnees (2,060), and IDPs (3.04 million) combined, whereas Uganda has the highest number of refugees (1.52 million). Rhino Camp is one of the prominent settlements accommodating these displaced populations. Established in 1980, it currently houses 190,742 refugees as of September 2020, with the majority coming from South Sudan (UNHCR 2020). The settlement continues to grow as shown by a significant refugee population increase of almost 58% in just four months, growing from 120,482 refugees in June 2020. The projected growth in refugee populations presents major challenges in providing adequate living conditions, including access to clean water and proper sanitation, within the settlement camp.

Access to water supply and sanitation is crucial for maintaining health, preserving dignity, and saving time (Montgomery & Elimelech 2007). Unfortunately, the situation is particularly dire for refugees globally, with an estimated 2.1 billion people lacking access to reliable and safe drinking water. Refugees in fragile contexts are eight times more likely to lack basic drinking water services (United Nations Children's Fund (UNICEF) 2019). In Africa, over 90% of refugees do not have access to improved drinking water sources or satisfactory access to sanitation facilities (Cronin et al. 2009). Women and girls in refugee settlement camps, particularly in countries like Uganda, Chad, Central African Republic, South Sudan, Kenya, and the Democratic Republic of Congo, bear the brunt of the consequences associated with inadequate access to water and sanitation services (World Health Organization 2014). A notable consequence of unsafe drinking water is that it often contains harmful microbes, leading to the transmission of diseases such as gastroenteritis (World Health Organization 2014).

The Humanitarian Charter and Minimum Standards in Humanitarian Response recommend 15 litres/person/day (L/p/d) as the minimum water quantity needed for drinking and domestic hygiene (Sphere Association 2018). These standards also provide guidelines for the number of individuals using a water facility (e.g., 250 people per tap stand), the maximum distance from a household to a water source (e.g., less than 500 m), and the acceptable waiting time (e.g., less than 30 min) at a water facility. However, in 2014, the estimated water supply in the Rhino Camp refugee settlement was estimated to be 17.9 L/p/d, primarily sourced from unimproved sources (United Nations High Commissioner for Refugees (UNHCR) 2015). Furthermore, up to 29% of the refugee population had no access to improved sanitation facilities and had limited knowledge about proper hygiene practices (Wendee 2015).

Following the escalation of conflict in South Sudan, particularly in 2016, there was a notable surge in the number of refugees in Rhino Camp. This study was conducted in 2017 after this surge to assess the community's accessibility to domestic water from improved sources. It should be noted that, in response to the refugee influx in March 2020, Uganda launched a comprehensive water and environment response plan for both the refugee and host communities. The plan includes an operation and maintenance framework for existing water schemes, aiming to address the challenges posed by the growing refugee population and improve access to water resources.

The household survey was conducted in the camp in the two zones selected (Ofua, Figure 2 and Tika, Figure 3), 199 questionnaires were administered to randomly selected refugee households (63% of the respondents were from Ofua and 36.5%, from Tika); key informant interviews (KIIs) were conducted with selected relevant government and non-governmental organisation (NGO) officials who are handling water issues in the settlement camp and the community leaders (chairpersons) in all the five villages. Four focus group discussions (FGDs) in the five villages were done with community groups. These groups are the environmental groups and water user committees that are made up of male and female refugees. Each FGD comprised 12 members, except the Ofua 1 village, which was represented by about 20 members each. Questionnaires were randomly administered in the two zones. Questions asked during the survey, KII, and FGDs were on water sources available, water consumption per household, number of people in a household, accessibility (amount and distance covered) of safe water, awareness on safe handling of drinking water, and waterborne diseases reported.

Before the commencement of the study, ethical clearance and permission were obtained from the Office of the Prime Minister (OPM) in Kampala, OPM in Arua District, the Rhino Camp refugee settlement management office, and other relevant local government authorities in Arua District. Informed consent was sought from each participant/respondent before the commencement of the interviews in the refugee settlement camp. Participants/respondents were informed that they were free at any time when they wished to end the exercise. Furthermore, all information gathered was handled with strict confidentiality.

Based on the accessibility of the Rhino Camp refugee settlement, water sources in the two study zones of the Rhino Camp refugee settlement were sampled for water quality measurements in September 2017 and June 2018. A total of 51 water quality measurements were taken on randomly selected functional water sources in September (25 samples) and June (26 samples) in Ofua (15 (two hand pumps, seven household containers, three motorised boreholes, and three tanks) in September 2017 and 13 (two hand pumps, six household containers, three motorised boreholes, and two tanks) in June 2018) and Tika (10 (four household containers, five motorised boreholes, and one water treatment facility (Kamkam base) in September and 13 (seven households, six motorised boreholes, and one water treatment facility (Kamkam base) in June). All water samples were collected in the morning hours during the sampling months. For microbiological samples, standard procedures were followed, in which a flame was applied at the point of collection to avoid contamination and water was left to run for 2 min and then collected in a sterilised bottle that was then labelled.

A sanitary risk score assessment was conducted on 31 water sources in Ofua and Tika during the rainy season of September using a sanitary inspection form (World Health Organization 1997) to obtain a hazard score based on the total number of hazards identified for water sources in the camp.

In-situ measurements for the temperature and physicochemical parameters (EC and pH) were carried out using a mercury thermometer and a portable multi-parameter pH meter D46 (pH/mV/OC), respectively. The samples were kept in cooler boxes on ice and transported within 6 h to the laboratories at Makerere University. The samples were analysed for total dissolved solids (TDS), turbidity, sulphates, nitrates, phosphates, and iron at Makerere University Chemistry Laboratory (Department of Chemistry, College of Natural Sciences) using standard spectrophotometric methods (Palintest Wegtech 300), while the microbiological analysis was carried out at the microbiology laboratory at COVAB (College of Veterinary Medicine, Animal Resources, and Biosecurity). All the sampling procedures and analyses were done according to the standard procedures for the Examination of Water and Wastewater (Collins et al. 2004; APHA-AWWA-WEF 2023). Water sources' sanitary conditions were based on physical observation of the surroundings.

At the laboratory, samples were fully mixed and appropriate serial dilutions were done. To determine the presence of faecal enterococci, total coliforms, and thermotolerant coliforms, 0.1 mL of each diluted sample was inoculated on respective media. Thermotolerant coliforms and total coliforms were determined using MacConkey Agar. Plates targeted for thermotolerant coliforms were incubated at 44 °C for 48 h. The red colonies were identified as thermotolerant coliforms. The total coliforms were incubated at 37 °C for 24 h and the red colonies were counted. Faecal enterococci were inoculated on Bile Esculin Agar at 37 °C for 24 h. Colonies surrounded by a brown-black colour were counted as faecal enterococci.

Data collected from the 199 survey questionnaires, and the physicochemical and microbial water analyses, were edited and coded, and entered into a Microsoft spreadsheet. Frequency distributions were presented for quantitative data, which were tested for normality using the Shapiro–Wilk test. Statistical tests were performed in R console version 4.2.4 (R Core Team 2020) and IBM SPSS Statistics for Windows version 23.0. Physicochemical measurements of the water were compared with the World Health Organization (WHO) and Uganda National Bureau of Standards (UNBS) (2014) drinking water standards. The qualitative data collected from the KIIs, FGDs, and personal observations were analysed contextually through the description, narration, and interpretation of the camp's situation.

In the study, the majority of participants were women, constituting 58% of the respondents. Of the 199 respondents, 64.5% were married, while the remaining were either single (26.6%), divorced or separated (4%), or widowed (4.5%). Regarding household leadership, 47.7% of households were led by females, compared with 36.7% led by males. Educational attainment among respondents varied: 29% had no formal education, while the remaining 71% had at least primary-level education. The predominant occupation was crop farming, reported by 31% of the participants. Other common occupations included being a housewife (21%) and a student (15.5%). The median household size across both study zones was seven. Notably, 48% of these households included three or more children under the age of five.

The sanitary risk score of water sources in the Ofua and Tika Zones ranged from low (0) to high (6), with an intermediate (3) median risk score. The sanitary risk score of water sources in Ofua (4 – intermediate) was significantly (p < 0.05) higher than the sanitary risk score of water sources in Tika (2 – low). The highest sanitary risk scores were observed at the household and tank (6 – high), while the lowest sanitary risk scores were observed at motorised boreholes (1 – low).

Water quality measurements showing the determined levels compared with the recommended UNBS and WHO Standards are displayed in Table 1 (Ofua Zone) and Table 2 (Tika Zone). All the physicochemical parameters from the commonly used water sources by the refugees were within the recommended UNBS and WHO Standards (World Health Organization 1997).

Total coliforms, faecal enterococci, and thermotolerant coliforms were registered at all water collection and storage points analysed except river water (Table 3). The study only utilised water samples from one location in the river, which showed undetectable levels for microbial parameters, probably due to the high dilution of the sample. The highest levels of total coliforms and faecal enterococci were observed in household containers. The highest values of thermotolerant coliforms were observed at motorised boreholes (Tika Zone). (The majority of households (87.5%) used 20-litre plastic jerry cans in both study zones.) Using a generalised additive model, we did not however find any significant difference in microbial parameters between zones and water sources (p > 0.05).

The detection of total coliforms, faecal enterococci, and thermotolerant coliforms at various points in the water supply chain signals widespread faecal contamination. Despite the physicochemical parameters being within permissible levels, the study still found unpermissible levels of faecal coliforms. The United Nations High Commissioner for Refugees (UNHCR) standard guideline values for water supply require a water quality of 0 cfu/100 mL of water at chlorinated water collection points. This was not the case for all the water collection points visited except the motorised borehole in Ofua (Table 3). This issue may arise from the limited effectiveness of chlorination and suboptimal water handling practices, which are amplified by the scarcity of daily water supplies, yet enhancing the availability of water should reduce the prevalence of diseases within refugee communities (Dakkak 2023). The substantially higher contamination found in household water supplies is likely linked to the poor handling and storage together with an inadequate number of latrines (UNHCR 2018). Observations at the camp indicate that many refugees reside in unclean environments and the use of jerry cans and tanks – often without lids or covers – for water storage further contributes to the high sanitary risk scores. Unsanitary conditions prevalent around and within households, coupled with improper handling and storage, are probable causes of gastrointestinal illnesses.

Malaria and Typhoid (up to 69.5% of cases in Ofua and 84.2% of cases in Tika) were the most frequently reported diseases in the camp (Figure 6). However, these two diseases were not reported in an earlier study on the Rhino Camp refugee settlement (Refugee Law Project 2015). Malaria is characteristic of mobile and growing populations. By contrast, Typhoid cases are probably triggered by the ingestion of contaminated water (Nahimana et al. 2017). Cases of hepatitis A and cholera (21 and 7.1% in Ofua, respectively) were reported in the camp, which can also be attributed to the spread through drinking water, especially with the population influx (Guerrero-Latorre et al. 2011). Health officers interviewed reported some intestinal disease cases such as diarrhoea, dysentery, and bilharzia. Cases of ringworm were also experienced in the camp, while the UNHCR (2018) recorded cases of Malaria, urinary tract infections, watery diarrhoea, skin infections, and intestinal worms, but this was controverted because the refugees had no idea of the exact diseases diagnosed in the health centres.

The survey found that the majority of the refugees (57.29%) in Ofua and (35%) in Tika use 20-litre plastic jerry cans for water collection and storage and most of the jerry cans and tanks in the camp did not have lids/covers. Containers used for water storage and hand contact with stored water are associated with diarrhoea incidence (Trevett et al. 2018) similar to findings in this study for the Rhino Camp refugee settlement. Water collection that was carried out mostly by adult females (34.7%) was generally low. Water collection primarily carried out by adult females and female children is associated with hygiene and sanitation practices that impact the incidence of disease (Asaba et al. 2015).

Although Malaria was reported to be the most prevalent (up to 69.5% of cases in Tika and 35% in Ofua), the cases of waterborne diseases in Ofua and Tika were just as relatively high. The high cases of waterborne illnesses (Typhoid, Hepatitis A, cholera, dysentery, and giardia Cholera, Dysentery, and Giardia) reported could be due to consumption of contaminated waters. The presence of thermal tolerant coliforms and faecal enterococci in almost all the water sources strongly indicates a high risk of acquiring waterborne diseases/illnesses as both are indicators of faecal contamination. Therefore, the presence of these contaminants in almost all water sources points to a high incidence of waterborne diseases in both zones of the refugee settlement. Although water handling and storage at the household level were shown to be inadequate, treating drinking water by boiling was observed to have an association with lowered incidence of disease in Ofua (hepatitis A (p < 0.05)) (Table 4).

In conclusion, the study highlights the challenges faced by refugees in the Rhino Camp refugee settlement when it comes to accessing safe water. Factors such as insufficient water amounts, long distances, time-consuming water collection, and poor water storage conditions have compromised their access to clean water and may lead to disease incidence. Actions such as the inclusion of water access for refugee communities in national development plans are a good step towards long-term strategic planning in the provision of sufficient safe water.

The study also found that the quality of water from tanks, hand pumps, and household jerry cans in the camp exhibited high levels of microbial contamination as well as high sanitary risk scores. This study therefore shows that the contamination of water is evident along the entire water supply chain from source to water storage containers, which probably may contribute to disease incidences. The prevalence of water-related diseases, such as Malaria, and waterborne diseases such as typhoid, hepatitis Typhoid, Hepatitis A, and Cholera further emphasises the need for urgent action on sanitation within the settlements.

To address these challenges, there is a crucial need for continuing awareness campaigns on proper water handling, as well as continuous monitoring and treatment of water beyond the point of abstraction. These measures are essential to ensure health benefits, including those associated with hygiene, and to improve the overall well-being of the refugee community in the two study zones.

We would like to acknowledge the Water and Society – Africa Project for sponsoring this study and the Uganda Office of the Prime Minister (OPM) in Kampala and the Arua District office for facilitating our access to the refugee camp. We would like to thank the Makerere University Microbiology Laboratory (CoVAB) and Chemistry Laboratory technicians and acknowledge the support from the Maltese International field staff during the survey.

All relevant data are included in the paper or its Supplementary Information.

The authors declare there is no conflict.