Justin Stoler

Sachet drinking water in Ghana's Accra-Tema metropolitan area: past, present, and future

Population growth in West Africa has outpaced local efforts to expand potable water services, and private sector sale of packaged drinking water has filled an important gap in household water security. Consumption of drinking water packaged in plastic sachets has soared in West Africa over the last decade, but the long-term implications of these changing consumption patterns remain unclear and unstudied. This paper reviews recent shifts in drinking water, drawing upon data from the 2003 and 2008 Demographic and Health Surveys, and provides an overview of the history, economics, quality, and regulation of sachet water in Ghanas Accra-Tema Metropolitan Area. Given the pros and cons of sachet water, we suggest that a more holistic understanding of the drinking water landscape is necessary for municipal planning and sustainable drinking water provision.

Connecting the Dots Between Health, Poverty and Place in Accra, Ghana

West Africa has a rapidly growing population, an increasing fraction of which lives in urban informal settlements characterized by inadequate infrastructure and relatively high health risks. Little is known, however, about the spatial or health characteristics of cities in this region or about the spatial inequalities in health within them. In this article we show how we have been creating a data-rich field laboratory in Accra, Ghana, to connect the dots between health, poverty, and place in a large city in West Africa. Our overarching goal is to test the hypothesis that satellite imagery, in combination with census and limited survey data, such as that found in demographic and health surveys (DHSs), can provide clues to the spatial distribution of health inequalities in cities where fewer data exist than those we have collected for Accra. To this end, we have created the first digital boundary file of the city, obtained high spatial resolution satellite imagery for two dates, collected data from a longitudinal panel of 3,200 women spatially distributed throughout Accra, and obtained microlevel data from the census. We have also acquired water, sewerage, and elevation layers and then coupled all of these data with extensive field research on the neighborhood structure of Accra. We show that the proportional abundance of vegetation in a neighborhood serves as a key indicator of local levels of health and well-being and that local perceptions of health risk are not always consistent with objective measures.

Improved but unsustainable: accounting for sachet water in post-2015 goals for global safe water.

The advent and rapid spread of sachet drinking water in West Africa presents a new challenge for providing sustainable access to global safe water. Sachet water has expanded drinking water access and is often of sufficient quality to serve as an improved water source for Millennium Development Goals (MDG) monitoring purposes, yet sachets are an unsustainable water delivery vehicle due to their overwhelming plastic waste burden. Monitoring of primary drinking water sources in West Africa generally ignores sachet water, despite its growing ubiquity. Sub‐Saharan Africa as a region is unlikely to meet the MDG Target for drinking water provision, and post‐2015 monitoring activities may depend upon rapid adaptability to local drinking water trends.

Drinking Water in Transition: A Multilevel Cross-sectional Analysis of Sachet Water Consumption in Accra

Rapid population growth in developing cities often outpaces improvements to drinking water supplies, and sub-Saharan Africa as a region has the highest percentage of urban population without piped water access, a figure that continues to grow. Accra, Ghana, implements a rationing system to distribute limited piped water resources within the city, and privately-vended sachet water–sealed single-use plastic sleeves–has filled an important gap in urban drinking water security. This study utilizes household survey data from 2,814 Ghanaian women to analyze the sociodemographic characteristics of those who resort to sachet water as their primary drinking water source. In multilevel analysis, sachet use is statistically significantly associated with lower overall self-reported health, younger age, and living in a lower-class enumeration area. Sachet use is marginally associated with more days of neighborhood water rationing, and significantly associated with the proportion of vegetated land cover. Cross-level interactions between rationing and proxies for poverty are not associated with sachet consumption after adjusting for individual-level sociodemographic, socioeconomic, health, and environmental factors. These findings are generally consistent with two other recent analyses of sachet water in Accra and may indicate a recent transition of sachet consumption from higher to lower socioeconomic classes. Overall, the allure of sachet water displays substantial heterogeneity in Accra and will be an important consideration in planning for future drinking water demand throughout West Africa.

Sachet Water Quality and Brand Reputation in Two Low-Income Urban Communities in Greater Accra, Ghana

Sachet water has become an important primary source of drinking water in western Africa, but little is known about bacteriologic quality and improvements to quality control given the recent, rapid evolution of this industry. This report examines basic bacteriologic indicators for 60 sachet water samples from two very low-income communities in Accra, Ghana, and explores the relationship between local perceptions of brand quality and bacteriologic quality after controlling for characteristics of the vending environment. No fecal contamination was detected in any sample, and 82% of total heterotrophic bacteria counts were below the recommended limit for packaged water. Sachets from brands with a positive reputation for quality were 90% less likely to present any level of total heterotrophic bacteria after controlling for confounding factors. These results contrast with much of the recent sachet water quality literature and may indicate substantial progress in sachet water regulation and quality control.

Evidence of Recent Dengue Exposure Among Malaria Parasite-Positive Children in Three Urban Centers in Ghana

Blood samples of 218 children ages 2-14 years old with confirmed malaria in hospitals across Ghana were tested for dengue virus exposure. We detected dengue-specific immunoglobulin M (IgM) antibodies in 3.2% of the children, indicating possible coinfection, and IgG antibodies in 21.6% of them, which suggests previous exposure. Correlates of exposure are discussed.

Urban but off the grid: the struggle for water in two urban slums in greater Accra, Ghana

This paper seeks to understand the daily lived struggles for water in two slum settlements in Greater Accra, Ghana. Poor infrastructure and governance leave the Ghana Water Company Limited (GWCL) unable to fulfill the demand for water production in the capital city Accra, thus resulting in chronic intermittency of the urban water supply, and a high percentage of households purchasing water from neighbors and alternative sources such as sachet water, water kiosks, and water tankers. Utilizing theoretical insights from informality discourse, we examine household-level water access and the impacts of water supply disruption on daily lives by analyzing the emergent themes of eight focus group discussions (FGDs) about water access that were conducted in two slum settlements in Greater Accra. We observed intricate effects of water interference on daily lives, including negative perceptions about the government’s role in improving water access. The emergent themes from the FGDs included: (1) disruptions of individual and family livelihoods, (2) perceived disenfranchisement from quality water, (3) deprivation in an excluded space, and (4) the effect of exclusion on water rationing. These findings help us better understand the daily lived experiences of residents’ struggle for water security in a rapidly developing city and could have ramifications for slum upgrading projects that aim to improve human health and well-being.

The Sachet Water Phenomenon in Accra: Socioeconomic, Environmental, and Public Health Implications for Water Security

Just 10 years ago over a billion people lacked access to an improved drinking water source, and in 2008 this estimate dropped to 884 million (WHO/UNICEF 2011). In 2010 the Millennium Development Goals (MDG) drinking water target, which called for halving the proportion of the global population lacking sustainable access to safe drinking water between 1990 and 2015, was achieved ahead of schedule, though with substantial inequality of coverage by continent (WHO/UNICEF 2012). In 2012 the estimate stood at 780 million, and in 2015 an estimated 605 million people will still lack access to an improved drinking water source (WHO/UNICEF 2012). Despite this progress, the lack of safe drinking water continues to yield a substantial morbidity and mortality burden in the developing world, a burden largely borne by children under the age of 5, and roughly half of the developing world population is affected annually by diseases associated with inadequate water and sanitation (United Nations Millennium Project 2005). With the global population poised to rise from seven billion to over nine billion by 2050 and with nearly all of this growth projected to occur in developing cities (United Nations 2010), the number of people affected by water- and sanitation-borne diseases is more likely to rise than fall over the next decade.

Fertility in Context: Exploring Egocentric Neighborhoods in Accra

As recently as 1988 the total fertility rate (TFR) in the Greater Accra Region of Ghana was 4.7 children per woman (compared to the national average of 6.4). The most recent (2008) Ghana Demographic and Health Survey estimates the TFR in the Greater Accra Region to be down to 2.5 (compared to 4.0 for the country as a whole). Within the core metropolis of the Greater Accra Region—the Accra Metropolitan Assembly or Accra Metropolis, our data (described below) suggest that fertility has dropped to near replacement level as of 2008–2009. Within Accra, as throughout the nation, this has been accomplished especially through a delay in marriage and reductions in exposure within marriage, accompanied by an increase in the use of abortion and modern contraceptives. At the same time, reported levels of abortion and contraceptive utilization remain substantially below what would be expected in order to achieve Accra’s low fertility. Thus, the exact proximate determinants of the decline remain a bit murky.

Agency, access, and Anopheles : neighborhood health perceptions and the implications for community health interventions in Accra, Ghana

Background Social and environmental factors are increasingly recognized for their ability to influence health outcomes at both individual and neighborhood scales in the developing urban world. Yet issues of spatial heterogeneity in these complex environments may obscure unique elements of neighborhood life that may be protective or harmful to human health. Resident perceptions of neighborhood effects on health may help to fill gaps in our interpretation of household survey results and better inform how to plan and execute neighborhood-level health interventions. Objective We evaluate differences in housing and socioeconomic indicators and health, environment, and neighborhood perceptions derived from the analysis of a household survey and a series of focus groups in Accra, Ghana. We then explore how neighborhood perceptions can inform survey results and ultimately neighborhood-level health interventions. Design Eleven focus groups were conducted across a socioeconomically stratified sample of neighborhoods in Accra, Ghana. General inductive themes from the focus groups were analyzed in tandem with data collected in a 2009 household survey of 2,814 women. In-depth vignettes expand upon the three most salient emergent themes. Results Household and socioeconomic characteristics derived from the focus groups corroborated findings from the survey data. Focus group and survey results diverged for three complex health issues: malaria, health-care access, and sense of personal agency in promoting good health. Conclusion Three vignettes reflecting community views about malaria, health-care access, and sense of personal agency in promoting good health highlight the challenges facing community health interventions in Accra and exemplify how qualitatively derived neighborhood-level health effects can help shape health interventions.