Beyond a facility: A cross-sectional survey on WASH service levels and informal social accountability in childcare centres in Nairobi's informal settlements

There is a rapid pace of urbanization in low- and middle-income countries (UNICEF 2018). Africa's urbanization is identified as the most rapid, resulting in the expansion of informal settlements and increasing urbanization of poverty (Fox 2012; Mberu et al. 2016) and unmet needs among marginalized and vulnerable groups: children, older persons and persons with disability (Chumo et al. 2023b). The major challenge facing marginalized and vulnerable groups in informal settlements are linked to access to service deficit in vital sectors of water, sanitation and hygiene (WASH), education, solid waste management housing and health services, which are exacerbated by the near absence of the public sector (Soura et al. 2015; Chumo et al. 2023a). Among children under five years in childcare centres, who were identified among the most marginalized and vulnerable, the need for WASH services presents a specific profound challenge, particularly as children spend a significant portion of their day in childcare centres, while their parents search for employment and livelihood opportunities, often leaving home very early in the morning and returning very late in the evening (Chumo et al. 2022c).

WASH service delivery beyond the household, and particularly in the childcare setting, is crucial to child health, child development, education and overall child wellbeing (WHO/UNICEF Joint Monitoring Programme for Water Supply & Sanitation (JMP) 2018). This importance is captured in the nurturing care framework, which describes the need to support children from risks related to unsafe environments by creating safe communities (World Health Organization (WHO) 2018). Additionally, the importance of WASH service provision in a childcare setting is implicitly captured in the Sustainable Development Goals (SDGs) relating to universal high-quality education in safe, effective and inclusive environments (SDG 4) and universal access to clean water and sanitation (SDG 6) (Mishra & Huber 2019). Consequently, achieving the nurturing care framework on safety and attaining the SDGs 4 and 6 will enable young children to establish positive WASH-related attitudes, skills, behaviours and habits at an early age that can benefit children throughout their lives and within their families, and be important in WASH service delivery (Wagner & Pramling Samuelsson 2019).

In Nairobi's informal settlements, available evidence has pointed to a strong belief by parents that enrolling children in a childcare centre is beneficial for their holistic development and future success (Clark et al. 2021). However, access to WASH services is a challenge in childcare centres, more so in informal settlements (Piper et al. 2017; Wagner & Pramling Samuelsson 2019; Clark et al. 2021). It is with this understanding that questions relating to social accountability become relevant, as it is identified as a positive force in WASH service delivery in childcare centres (Chumo et al. 2022b), following the lack or near absence of services from the formal sectors in informal settlements (Soura et al. 2015; Hollander et al. 2020; Chumo et al.2022a, 2022b, 2022c). Social accountability is a process in which individuals (childcare providers) are obliged to explain their actions to other individuals (children, childcare providers, parents or local authorities), who have the right to judge them and administer positive or negative consequences in response to the actions taken (Lodenstein et al. 2018). Informal social accountability mechanisms (iSAMs) are an alternative to formal social accountability, and include informal sanctions, rewards, responsiveness and reports from any actor involved in service delivery or use (Chumo et al. 2022b). Despite how iSAMs help to counter challenges in access to WASH services in informal settlements (Chumo et al. 2023c), grey literature and practitioners mainly focus on formal social accountability mechanisms (Lodenstein et al. 2018; Melariri et al. 2019). Consequently, this paper explores and uncovers the iSAMs that are common in informal settlements and their association with WASH service delivery in the context of childcare centres. This becomes critical in the context of poor service delivery and weak or near absence of formal accountability systems in informal settlements.

The World Health Organization (WHO) and the Joint Monitoring Programme (JMP) produce internationally comparable estimates of progress on WASH service levels. The 2021 data showed WASH levels for primary and secondary schools (i.e. 67% of primary schools and 76% of secondary schools had a basic drinking water service; 68% of primary schools and 75% of secondary schools had basic sanitation; 58% of primary schools and 60% of secondary schools had a basic hygiene service) (WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation (JMP) 2018). Data were insufficient to generate global estimates for childcare centres. However, there are reports of low access to WASH services, and inadequate data on WASH service levels (WHO/UNICEF Joint Monitoring Programme for Water Supply & Sanitation (JMP) 2018; Wagner & Pramling Samuelsson 2019). The status of iSAMs and their roles in childcare centres in Nairobi's informal settlements is also unknown (Chumo et al. 2022c). This study builds on the importance of WASH services for under five years children and the WASH service deficits in childcare centres, inadequate data on WASH levels in childcare centres in informal settlements, together with the need for evidence on iSAMs and their roles in WASH service delivery in childcare centres in two deprived informal settlements in Nairobi, Kenya.

Our study explores the associations between iSAMs and levels of WASH service delivery in childcare centres in Nairobi slum settlements.

The study is nested within a multidisciplinary, multi-country and multi-year study: Accountability and Responsiveness in Informal Settlements for Equity (ARISE Hub) (Tolhurst et al. 2024). The study was conducted in Korogocho and Viwandani informal settlements in Nairobi. Korogocho has a stable and settled population and residents have lived in the area for many years (Emina et al. 2011), while Viwandani is located next to an industrial area with many highly mobile residents who work or seek jobs in the industrial area (Emina et al. 2011). Each of the informal settlements has eight subdivisions/units/villages. There are approximately 50 and 60 childcare centres in Korogocho and Viwandani, respectively (Chumo et al. 2022b). Close to 70% of childcare centres have between 10 and 25 children enrolled. Many centres are owned by individuals (home-based care), few are owned by faith-based organizations and very few are centre-based (attached to primary schools), all of which were operating mostly during the day (between 6 am and 5 pm) (Wagner & Pramling Samuelsson 2019).

This was a cross-sectional survey study with 40 and 37 childcare service providers in 40 and 37 childcare centres in Korogocho and Viwandani, respectively. We drew our sample from a sampling frame of childcare centres mapped during community profiling in the study sites. Community profiling involves locating notable features such as WASH services in a study area (Martín & Meza 2010; Dannaway et al. 2014). It is an iterative process, with some information collected early in a project phase, while others may not be uncovered until later in project development or production (Martín & Meza 2010). In the ARISE project (Tolhurst et al. 2024), where this study was nested, 55 and 62 childcare centres were profiled in Korogocho and Viwandani informal settlements, respectively, in May–June 2020. Consequently, we collected data from only functional/operational centres in the sampling frame. Due to logistical challenges, the need for accurate data on WASH services and social accountability, and the dynamics of childcare centres, our decision on the sample size was pragmatic.

Consultative and advisory meetings were held between researchers and community advisory committees in the two study sites. The committees offered advice among many other roles of education and awareness creation, protecting community interests and acting as gatekeepers, for effective data collection processes (Chumo et al. 2022a), including the best time to collect the data, and support for locating the childcare centres during data collection. Data were collected from centre providers between January and March 2022, anytime between 9 am and noon, during which time children were actively involved. The data were collected electronically on a tablet using a structured questionnaire that was informed by a literature review, such as on WASH service level monitoring using JMP variables of basic, limited and no service (WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation (JMP) 2018), and from the exploratory qualitative study phase on social accountability variables: rewards, sanctions, responsiveness and voice variables) (Chumo et al. 2022b). The study tool had items on WASH, social accountability and socio-demographic variables including sex, educational status, certification status and type of childcare centre. The study tool had a section for research assistants to observe WASH facilities. Research assistants received training for 6 days on the aims of the study, data collection tools, electronic data collection process and research ethics. We piloted the study tools with one centre provider in each of the study sites, followed by a debriefing session. The pilot exercise enabled us to adjust the translated tools to the language understood by the study participants and to estimate the time an interview would take. We excluded the two centre providers from the two pilot childcare centres from the main study. Researchers accompanied research assistants to assess data quality through spot-checks. Debriefing and reflection sessions among the research assistants and between them and the researchers were held at the end of each working day to assess progress and ensure quality data collection. The interviews lasted between 30 and 45 min.

We describe outcome and predictor variables of the study.

Outcome variables comprised components of WASH measured by the level of access and use of WASH at the time of study. This culminated in documenting the level of availability as a service ladder (WHO/UNICEF Joint Monitoring Programme for Water Supply & Sanitation (JMP). 2018). Building on the WASH service classification in schools (WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation (JMP) 2018), the options were grouped into three categories basic, limited and no access levels for WASH (see Table 1).

Predictor factors included social accountability mechanisms that were identified in an exploratory study using governance diaries and multimethod qualitative longitudinal data collection (Chumo et al. 2022b). Accountability measures used included rewards, sanctions, voice/complaints and responsiveness by childcare managers (Table 2).

Descriptive statistics were used to describe the number and proportion of socio-demographic, outcome and predictor variables. Percentages and frequencies were computed to present WASH service ladder levels and their relationship to social accountability indicators. Chi-square test was conducted to compare bivariate differences in proportions between predictor and outcome variables and to identify informal social accountability variables independently associated with WASH. Multinomial logistic regression was used to examine the strength of associations between the social accountability predictor factors and WASH service levels (limited or no service) using basic service as the reference category. This included stepwise elimination of the least significant variables (i.e. those with the highest p values) at every step until a parsimonious model was achieved. This is achieved when most variables had a p-value < 0.05 (Chowdhury & Turin 2020). The likelihood-ratio test was used to assess the goodness-of-fit of the adjusted final reduced model against the initial full model containing all explanatory variables. The multinomial logistic regression model was adjusted for the study site and ownership type of childcare centre, e.g. individually owned, faith based and centre based. Adjusted relative risk ratios (aRRRs) and 95% confidence interval (CI) were reported for the predictors.

We sought ethical clearance from the AMREF Ethics and Scientific Review Committee (ESRC) and a research permit from the National Commission for Science, Technology and Innovation (NACOSTI). The committees reviewed the protocol to ensure sufficient safeguarding and protection of participants, namely their rights to autonomy, confidentiality, voluntary participation in the research and scientific soundness of the study.

Verbal consent to participate in the study was initially sought when we explained the nature of the study and asked individuals (parents and childcare providers who were selected to participate in the study) if they would like to participate. After receiving their verbal consent, we went through the informed consent process before data collection began. Each participant who accepted to participate was then asked to sign the consent form if convinced. All participants were informed of their right to withdraw from the study at any time, with no risk of any associated implications for their ongoing role. Throughout the research process, anonymity and confidentiality were critical priorities. During the reporting of findings, we ensured that no personal identifiers were revealed.

In the two study sites, the majority of childcare providers were female, and had certification in childcare. Many centres were owned by individual entrepreneurs, home based and notably, with higher percentages in Korogocho than in the Viwandani study site (see Table 3).

All childcare centres had access to WASH in the two study sites (Table 4). Particularly, centres in Korogocho had access to water only from improved sources (i.e. tap in the compound – 88% and public taps – 14%). In Viwandani, in addition to the improved water sources (i.e. tap water in the compound – 38%, public tap – 41% and bottled water – 19%), a small percentage (2.7%) of childcare centers depended on an unimproved water source, namely a borehole. Many sanitation (toilet facilities) in childcare centres in both study sites were improved. Remarkably, centres in Viwandani had more unimproved toilet facilities without slab (11%) compared to centres in Korogocho (3%). For handwashing stations, more than three-quarters of the handwashing facilities were located near the sanitation facilities and in the classrooms in childcare centres in both study sites, with slightly higher rates in Korogocho than Viwandani (see Table 4).

From Pearson chi-square tests, rewards and sanctions were significantly associated with access to sanitation in the Viwandani study site, while only responsiveness was significantly associated with access in the Korogocho site. Voice/complaints were, however, not significantly associated with sanitation in both study sites. Sanctions were significant, while voice and responsiveness were not significantly associated with access to water in both study sites. Rewards, on the other hand, were only significantly associated with access to water in the Viwandani study site. The three iSAMs were associated with hygiene in both study sites, i.e. sanctions, voice/complaints and responsiveness by childcare managers.

Rewards, sanctions and responsiveness that were associated with sanitation service provision in bivariate analysis were subjected to multinomial analysis, and all three co-variates had a strong association with WASH service outcomes. In the model comparing basic service vs no facility/services, participants who used rewards, sanctions and responsiveness (versus not used) in sanitation services were more likely to have basic services, with relative risk ratios (RRRs) for rewards (aRRR 5.14; 95% CI 3.71, 9.1); sanctions (aRRR 1.8; 95% CI 1.39, 9.36) and responsiveness (aRRR 1.6; 95% CI 1.4, 16.57). On water services, participants who used sanctions (versus not), were more likely to have basic services (aRRR 6.7; 95% CI 2.97, 9.5). On hygiene services, participants who used responsiveness (versus not) were more likely to have basic services, with RRRs (aRRR 3; 95% CI 2.27, 8.46). The sequel for other mechanisms are sanctions (aRRR 2; 95% CI 1.16, 4.12) and feedback reports (aRRR 2; 95% CI 1.29, 3.27). Notably, in Model 2; aRRR on the association of iSAMs and access to basic water and hygiene services were higher in no service compared to limited services and were less likely associated with basic sanitation vs limited sanitation service delivery (Table 5).

Our results showed that access to WASH was higher in Korogocho than in Viwandani study sites. This was different from the norm, where access to basic services such as health care, education and WASH services were usually higher in Viwandani than in Korogocho due to structural differences between the study sites (Emina et al. 2011; Beguy et al. 2015). Structural differences in our current results were depicted by higher education levels of childcare providers, with those attaining beyond the secondary level of education at 75% in Korogocho and 84% in Viwandani, whereas capacity building on childcare-related skills was 80 and 89% in Korogocho and Viwandani, respectively. This was also illustrated by other studies done in the two study sites, describing how the Viwandani study site is bordered by an industrial area, and attracts migrants with relatively higher education levels, while residents in Korogocho are more stable and have a higher proportion of co-resident couples and multi-generational households (Beguy et al. 2015).

Our data collection was implemented during the peak period of the Covid-19 outbreak, and the overall improved access to WASH is attributed to several WASH interventions that emerged in the community during the Covid-19 outbreak. In principle, Covid-19 interventions could be the motive for better access to water and hygiene and lower access to sanitation. Water and hygiene service provision was prioritized in informal settlements during the peak seasons of the Covid-19 outbreak control measures (Parikh et al. 2020; Kim & Laituri 2022). This was portrayed by actors, including the governments, distributing clean water and establishing handwashing stations in the community and in childcare centres (Chumo et al. 2022c; Kim & Laituri 2022). Local, national and internationally recognized intervention strategies for Covid-19 containment included water and hygiene measures (Belle et al. 2020; French et al. 2020), hence the high levels of water and hygiene service delivery in childcare centres at the time of this study.

Notably, iSAMs co-variates of rewards, sanctions, voice and responsiveness differed in their association with WASH service provision levels. Particularly, sanctions were significantly associated with all the levels of the WASH service ladders, in relation to having basic vs no services. This was also illustrated in other studies conducted in urban areas describing how sanctions are significantly associated with the provision of basic water services, and that sanctions are effective when used without compromise (Lodenstein et al. 2018). Those who receive sanctions change their behaviour or increase their contributions (Kamei et al. 2015). A previous study in the same setting described how sanctions were associated with access to WASH service delivery, because, when a centre performs below expectations, parents/guardians use their discretion to punish or send reputational signals that may have adverse implications for a childcare centre (Chumo et al. 2022b). This study extends the previous study by offering quantitative measurements of iSAMs including sanctions (Chumo et al. 2022b; Chumo et al. 2023c). The outcome could be attributed to the fact that residents in informal settlements have many unmet needs and may be willing but cannot afford to reward childcare centre providers (Chen et al. 2018; Baek et al. 2020; Chumo et al. 2023b).

There were three iSAMs associated with sanitation compared to one mechanism associated with water, yet access to basic water was higher than basic sanitation in both study sites. This depicts how quality and not the number of accountability mechanisms is key to achieving WASH service delivery in informal settlements (Friis-hansen et al. 2013). Equally, iSAMs are essential in the WASH sector for several reasons. Firstly, it is a human rights principle and is needed for the realization of the human right to WASH. Secondly, it is a key mechanism to strengthen WASH systems, though it is given scant or no mention in WASH systems strengthening literature to date (Hollander et al. 2020). Remarkably, childcare providers and parents who are key actors (Chumo et al. 2022c) are likely overwhelmed contributing to poor WASH service delivery in low-income settlements in Africa (Deffains 2013; Melariri et al. 2019), and hence the need for exploration of iSAMs and how it can amplify WASH service delivery.

The strengths of the study included strong networks in the study sites, and well-trained and skilled data collectors recruited from the community. This heightened the validity of the study results. Our study is not without limitations. The study was conducted in only two informal settlements in Nairobi; Korogocho informal settlements have a more steady population and multi-generational inhabitants have resided in the region for several years (Emina et al. 2011). Viwandani is situated near an industrial zone with more educated occupants who work or travel for jobs in the nearby industries outside the informal settlements (Emina et al. 2011; Chumo et al. 2022c). At the outset of the study, we aimed to do a comparison of results between the two study sites, with 77 childcare centre owners from the two informal settlements. The findings were necessary for painting a picture of the levels of WASH service provision and social accountability beyond household levels to include childcare settings in informal settlements. iSAMs that were identified during the exploratory phase during governance diaries data collection that included rewards, sanctions, voice and responsiveness (Chumo et al. 2022b) were included in the study. There could be other iSAMs that were missed. Notwithstanding, the four mechanisms provided a reference point and basis for other iSAMs.

This paper argues for and develops in detail the idea that informal social accountability is key for strengthening WASH service delivery in the context of weak formal service delivery structures. Childcare providers in Nairobi's informal settlements have operational iSAMs that have been a critical support for the provision and access to WASH services in their childcare centres. The iSAMs heightened during the Covid-19 pandemic and hence improved access to WASH services was recorded over the period. Although cross-cutting measures and interventions can have an impact on WASH service delivery, the roots of opportunities or challenges to WASH service delivery may lie not only in the infrastructures and access to interventions, but beyond the facilities to include important dimensions of the social structure such as iSAMs. Given the reported progress in WASH service delivery linked to informal social accountability, it is necessary to continue building, rebuilding and strengthening iSAMs in WASH service delivery. It is useful to view our results from a perspective that sees iSAMs not simply as an alternative but also as a complement to formal social accountability mechanisms in informal settlements. As such, relevant Ministries in Kenya may need to continually support all childcare centres in their efforts to ensure adequate and appropriate WASH service delivery to the most vulnerable sub populations.

To the best of our knowledge, this is the first study in childcare centres in informal settlements using the JMP ladder to establish the status of WASH, as such, it is important to have another future study to compare and validate these findings, more so after the peak period of the Covid-19 outbreak. Furthermore, in addition to one-time assessment, efforts may need to be made by governments and other actors to establish continuous monitoring systems to regularly track the needs and improvements needed as related to WASH service delivery in childcare centres.

We acknowledge all study participants, study community members, the research team, APHRC staff and ARISE consortium members for their guidance and input during this project.

The GCRF Accountability for Informal Urban Equity Hub (‘ARISE’) is a UKRI Collective Fund award with award reference ES/S00811X/1.

Ivy Chumo contributed to conceptualization, data curation, formal analysis, visualization, methodology and writing the original draft. Blessing Mberu, Helen Elsey, Penelope A. Phillips-Howard and Caroline Kabaria contributed to supervision and validation of this research. Hellen Gitau contributed to validation of this research.

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

The authors declare there is no conflict.