Meeting Basic Needs in a Rapidly Urbanizing Community: A Water, Sanitation, and Solid Waste Assessment in ,

May 8, 2006

Prepared by:

Sarah Dobsevage, Jennifer Traska Gibson, Kristin Helz, Christina Planert, Arthit Prasartkul, Katie Raye, Anjani Singh, Susan Wofsy

of the School of International and Public Affairs at Columbia University

for:

The Municipal Council of Ruiru, Kenya

Acknowledgements

We would like to thank the following people and institutions whose assistance and guidance made this project possible.

Columbia University: School of International and Public Affairs (SIPA), Center for Sustainable Urban Development (CSUD) at the Earth Institute and the Spring 2006 Urban Planning Studio at the Graduate School of Architecture, Planning and Preservation (GSAPP)

Faculty and Staff: Dr. Jacqueline Klopp, Dr. Charles Downs, Dr. Elliott Sclar, Dr. Sigurd Grava, Dr. Sumila Gulyani, Julie Touber, Nicole Volavka, Dr. Patrick Kinney, Dr. Upmanu Lall, Dr. Roberto Lenton and Dr. Sylvie LeBlancq

University of Nairobi: Department of Urban and Regional Planning (DURP) and Department of Chemistry

Faculty, Staff and Students: Dr. Peter Ngau, Musiyimi Mbathi, Geoffrey Mogondu, Boniface Mworia, Lilian Otiego, Samuel Ouma, Elizabeth Waryiru and Shem O. Wandiga

Ruiru Municipal Council: Joseph Mbugua, Councilor Geoffrey M. Kahara, Dr. Charles Kamau, Councilor Geoffrey Kahara, Henry Karanja, Councilor Jackson Karanja, Councilor Samuel Kibiru, Elizabeth Njoki Kihara, Councilor Mary Mungai, Councilor Morrison Muriuki, Town Clerk Geoffrey Mwangi, Paul Mwangi, Councilor Rose Mwangi, Peter Mwaura, Naomi Ndichu, Councilor Morrison Oyanda, Mayor Wilfred Wamuya and the people of Ruiru

Athi Water Services Board: Engineer Gitau, Engineer Joseph Kamau, Julia Kiruri, Patrick Kinyori, Julius Muiruri, Engineer Lawrence Mwangi, Engineer John Muiruri and Engineer

Nairobi Water and Sewerage Company: Kabando Wa Kabando, Engineer J.P. Kimani and Njeri Magu

Thika Water Company: Engineer Michael Ngare

Thika District Offices: Julius K. Inyingi, Dr. Kamao and Juliana Mutua

FORCUS and other NGOs: Jacinta Achiema Omundi, Hilary Mabubi, Caroline Kagure Machira, Seth Mwangi, Nicholas Njoroge Mugo, Roman Nyanjui Kariuki and Erick Waweru

Tana Water Services Board and Water Company: Engineer Irari, Engineer Kibaki and Lucy Kibui

Other Friends: Royal Thai Embassy, Nairobi; Patrick Adolwa; Benson Owele Akungu; Njuki Githethwa; Nidchu Gitau; Mi Hua; Willie Jackson; Maimbo M. Malesu; Japheth Mbuvi; Malaquen Milgo; Engineer Silas Muketha; Charles Nderithu; Wanjiru Ndichu; Ann W. Njogu Titus Nzuki; Sammy Onyango; Norah Osora; Charles Patterson and Alice Sagwe

1 Contents

EXECUTIVE SUMMARY……………………………………………………………………... 4

I. PROJECT OVERVIEW………………………………………………………………………. 6

II. INTRODUCTION TO RUIRU………………………………………………………………. 8

III. INSTITUTIONAL CONTEXT…………………………………………………………….. 10

IV. STAKEHOLDERS………………………………………………………………………… 11

V. SITUATIONAL ANALYSIS – METHODOLOGY……………………………………….. 13

VI. SITUATIONAL ANALYSIS – FINDINGS………………………………………………. 17

A. WATER……………………………………………………………………………. 17

B. SANITATION……………………………………………………………………... 33

C. SOLID WASTE……………………………………………………………………. 44

D. HEALTH LINKAGES……………………………………………………………... 52

VII. CONCLUSION…………………………………………………………………………… 59

VII. APPENDICES

Appendix 1: SIPA Household Survey (March 2006)………………………………... 61 Appendix 2: Map of SIPA Household Survey Locations………………………….... 72 Appendix 3: Fact Sheet, Ruiru Municipality (survey results)……………………….. 73 Appendix 4: Fact Sheet, Biashara ward (survey results)……………………………. 75 Appendix 5: Fact Sheet, ward (survey results)…………………………….. 77 Appendix 6: Fact Sheet, Gitothua ward (survey results)……………………………. 79 Appendix 7: Fact Sheet, Kahawa Sukari ward (survey results)……………………... 81 Appendix 8: Fact Sheet, Murera ward (survey results)…………………………….... 83 Appendix 9: Fact Sheet, Ruiru Municipality, Low Income (survey results)………... 85 Appendix 10: Fact Sheet, Ruiru Municipality, Middle Income (survey results)……. 87 Appendix 11: Fact Sheet, Ruiru Municipality, High Income (survey results)…….... 89 Appendix 12: Ruiru Health Data……………………………………………………. 91 Appendix 13: Map of Registered Borehole Locations in Ruiru Municipality………. 98 Appendix 14: Contact List…………………………………………………………... 99

2 List of Abbreviations

ALRI Acute Lower Respiratory Infection AMREF African Medical and Research Foundation AWSB Athi Water Services Board DURP Department of Urban and Regional Planning, FORCUS Families, Orphans, Children, Under Stress ICRAF World Agroforestry Centre ITN Insecticide treated mosquito net Ksh Kenyan Shillings LATF Local Authority Transfer Fund LCD Liters Per Capita Per Day MOH Ministry of Health, Kenya MWI Ministry of Water and Irrigation NEMA National Environment Management Authority NGO Non-governmental Organization NCC Nairobi City Council NWSC Nairobi Water and Sewerage Company PSI Population Services International RUJA Ruiru- Water and Sewerage Company SIPA School of International and Public Affairs, Columbia University UN United Nations UNEP United Nations Environment Program URTI Upper Respiratory Tract Infection USD United States Dollars VIP Ventilated Improved Pit WHO World Health Organization WRMA Water Resources Management Authority WRSB Water Regulatory Services Board WSP Water Service Provider

3 Executive Summary

Ruiru, Kenya is a rapidly growing city, facing the challenges of urbanization and unplanned development. National water reforms have put pressure on local governments to take responsibility for provision of services related to water and sanitation. The Municipal Council of Ruiru is currently working with national and local partners to develop plans for improved services for the community. This report presents the work of eight graduate students from the School of International and Public Affairs (SIPA) at Columbia University who worked as consultants on behalf of the Municipal Council to assess the current situation in Ruiru with regard to water, sanitation and solid waste services and to provide recommendations in the context of national water reforms.

To that end, the SIPA team used a literature review, data collection and analysis, key informant interviews with the Municipal Council, borehole operators, regional service boards, local water companies and other experts, as well as a survey of 100 households representing the five wards in Ruiru. The SIPA Household Survey served to explore linkages between quality of services with public health problems and to address the diverse realities and concerns of the community.

This analysis produced three key findings in the water, sanitation and solid waste sectors. Water- related diseases are a public health problem in Ruiru. Due to the interconnected nature of water and sanitation and the health impacts of inadequate sanitation, sanitation is a priority issue. Decentralization is a complicated process. Ultimately, the reforms should facilitate improved service provision in Ruiru, but the Municipal Council is in a time of transition without the capacity to make timely progress.

The community-based situational analysis of water in Ruiru revealed a multiplicity of water providers, inadequate infrastructure, water quality issues, low water use patterns, inconsistent availability, the use of alternative water sources, low awareness of treatment methods and concerns with water availability, quality, cost and distance to source. Further, the study found that point-of-use improvements in water quality are fairly simple but have not been fully exploited. The SIPA team recommends that the Municipal Council undertake a feasibility study to inform the technical aspects of water provisioning and implement quick win solutions including rainwater harvesting and water treatment methods. In addition, the Municipal Council should work with international and local NGOs to increase public health awareness about water- related issues.

Key findings in sanitation include environmental and health challenges due to the lack of a sewerage system in Ruiru, unsatisfactory household sanitation facilities including an over- reliance on pit latrines and improperly placed and maintained septic tanks, poorly maintained and crowded facilities, the illegal dumping of human waste, lack of public awareness about safe sanitation practices and lack of sense of personal control of the problem. To address this situation, the SIPA team recommends that the Municipal Council develop a simplified sewerage system in high-density areas, plant bamboo to clean sewage, investigate ecological sanitation technologies, institute and enforce regulations, build public awareness through health education and take steps to control and properly maintain household facilities.

4 The analysis of the solid waste sector uncovered insufficient collection capacity, a high level of garbage burning, lack of a satisfactory dumping site or formal recycling, widespread illegal dumping and a low level of public involvement. The SIPA team therefore recommends that the Municipal Council implement quick win solutions and set up more communal collection points, re-allocate refuse collection capacity, investigate the potential for increasing its revenue base by using waste as a resource, enforce regulations and explore opportunities for leveraging partners, including schools (for creating awareness), youth groups (for garbage collection) and the community overall (for clean up campaigns).

Ruiru’s problems with water, sanitation and solid waste underscore the health risks for local community members. Using health data, key informant interviews and household survey analysis, the study revealed five key health-related findings. Malaria and diarrheal diseases are among the leading causes of new disease cases at the Ruiru Health Center. While typhoid is perceived to be a major public health problem in Ruiru, there are a relatively small number of cases reported at the Ruiru Health Center. Fluoride levels above World Health Organization (WHO) standards have been found in borehole water in Biashara. Household survey respondents showed a high level of awareness of malaria and how it spreads, and, therefore, residents may be more responsive to prevention efforts. A serious health study must be conducted to more fully examine the epidemiology of the disease burden in Ruiru. To that end, the SIPA team puts forth four recommendations. The Municipal Council should work with the Ruiru Health Center to improve public health education efforts. The Council should work to engage NGOs and community groups in a comprehensive public health awareness strategy. The Council should work with the Ruiru Health Center to scale up provisioning of insecticide-treated mosquito nets. And finally, the Council should invite public health researchers to Ruiru for targeted investigation of these challenges and opportunities.

Given the significant challenges for water, sanitation and solid waste and their related impacts on health in Ruiru, the SIPA team offers both long-term and short-term recommendations. As suggested in Kenya’s national water reform, the next step for the Municipal Council of Ruiru is to write a strategic plan and a business plan (including a plan for financing) for the new joint company, Ruiru-Juja Water and Sewerage Company (RUJA). While an institutional focus on RUJA should continue, the SIPA team concludes that there are abundant opportunities for the Municipal Council to become more proactive about seeking short-term solutions. The focus on the establishment of RUJA should not overshadow complementary short-term efforts. Specifically, behavior change around water, sanitation and solid waste is needed to mitigate effects on public health. Throughout the sectors, the team proposes quick win policies that the Council can implement under current capacity and funding constraints.

The SIPA team is optimistic that by engaging with a wide circle of partners, the Municipal Council can make significant improvements in water, sanitation and solid waste services for the citizens of Ruiru. Where capacity gaps appear, we believe there is considerable mobilization within the Council and among its development partners to build capacity over the long term. It is essential that the council work closely with the community in making plans to address local needs. This report, which draws heavily on the community-based situational assessment should provide a foundation for further work and collaboration among these experts and stakeholders to bring about sustained change.

5 I. PROJECT OVERVIEW

Objectives

ƒ Assess water, sanitation and solid waste services by collecting data from diverse sources;

ƒ Explore linkages to public health problems in Ruiru;

ƒ Understand and address the diverse needs, realities and voices of the community.

Goal ƒ To improve access to services by informing and mobilizing stakeholders in the context of reform.

Background

Our client, the Municipal Council of Ruiru, faces two significant challenges as it endeavors to improve service provision: rapid urbanization and rapid decentralization.

Kenya is rapidly urbanizing: Nairobi now hosts the densest slums in Africa. One solution people find to the severe problems of service provision in the capital is to live in satellite towns like Ruiru, located 16 kilometers from the center of Nairobi. While this helps relieve the housing crisis in the capital, the growing population puts enormous pressures on the local municipal council to provide services—including critical access to water, sanitation and sewerage facilities and solid waste disposal. Without improvement in these services, Ruiru, will face increasing problems of disease, environmental degradation and an inevitable decline in quality of life.

The second challenge confronting the Council is rapid decentralization. The Kenyan national government passed a Water Reform Act in 2002 which decentralized water provision and planning to regional water service boards and direct provision of water to local water service providers. The national reforms provide the Council with the autonomy necessary to improve service provision. At the same time, the Council does not currently have either the capacity or the funding to take full advantage of this reform.

Recognizing these problems, the Athi Water Services Board (AWSB), the regional water service board that works closely with the Municipal Council of Ruiru, invited the School of International and Public Affairs (SIPA) at Columbia University to collaborate with the Council. Through the Workshop in Applied International Development in the Economic and Political Development concentration at SIPA, a consulting team of eight graduate students started to work with the Municipal Council on a strategy for approaching water, sanitation and solid waste problems in the municipality.

Partners

The project is part of a collaborative effort with the University of Nairobi’s Department of Urban and Regional Planning (DURP) and the Urban Planning program of Columbia University’s

6 Graduate School of Architecture, Planning and Preservation. The Columbia University SIPA team’s assessment of water, sanitation and solid waste will complement the Columbia University Urban Planning team’s work on transportation, economic development and air quality and the environment in Ruiru as well as the two urban planning studios conducted by the University of Nairobi.

Scope

The Municipal Council originally asked the SIPA team to write a strategic and/or business plan for water service provision under the new reforms. Although both documents are necessary for Ruiru to improve water service provision, the SIPA team first needed to understand the water, sanitation and solid waste situation in Ruiru, as its literature review turned up information almost exclusively on Nairobi.

To conduct a meaningful assessment, the SIPA team created a dialogue with the community. The team spoke with the Council, borehole operators, regional service boards and local water companies. The team also conducted an extensive survey with 100 households representing the five wards in Ruiru.

Key Findings

Our fieldwork produced three key findings:

1) Water-related diseases are a major problem in Ruiru. This underscores the urgency of improving service provision in Ruiru’s rapidly urbanizing community.

2) Sanitation is a priority issue. The SIPA team originally envisioned this as a project exclusively about water but quickly realized it is not possible to unbundle water and sanitation, especially considering the health impacts of inadequate sanitation.

3) Decentralization complicates progress. Ultimately, the reforms should facilitate improved service provision in Ruiru, but the Council is in a time of transition without the capacity to make timely progress.

Key Recommendations

The SIPA team offers two types of recommendations.

ƒ There are many short-term policies the Council can implement that will produce immediate benefits for the community. These solutions are not as heavily constrained by capacity and funding.

ƒ The long-term solution still requires a roadmap. To this end, AWSB has drafted a service provision agreement for the Municipal Council of Ruiru to become a joint water service provider with the neighboring municipality of Juja. As suggested in the national reform,

7 the next step is to write a strategic and a business plan, including a plan for financing, for the new joint company.

We hope our water, sanitation and solid waste assessment will help not only to move this long- term process forward but also to help the Council make the successful short-term policy choices which are essential for meeting basic needs.

II. INTRODUCTION TO RUIRU

Location Figure 1 The Municipality of Ruiru is located in Kenya’s within , 18 kilometers from Thika Town. Ruiru is located three kilometers from the city limits of Nairobi, the capital of Kenya, and 16 kilometers from Nairobi City Centre. The peri-urban municipality covers 292 square kilometers.

Ruiru’s proximity to Nairobi means that it is integrally connected to the capital city. Ruiru is a satellite town and increasingly serves as a residential base for those who work in Nairobi. As Nairobi’s population has rapidly increased, private landowners have developed large housing projects in Source: Columbia University’s Nairobi Urban Planning Studio Ruiru, and Ruiru’s population has grown 2006. accordingly.

Population

According to Kenya’s 1999 census, Ruiru Municipality had a population of 109,574 people or 34,274 households. Based on Nairobi’s growth rate of 7.3%, the current population of the municipality is estimated to be between 165,000 and 180,000 residents.1

Political Boundaries

The Municipal Council of Ruiru governs the municipality, which is separated into five electoral wards: Biashara (Central Business District), Kahawa Sukari, Gitothua, Murera and Githurai.2 The Municipal Council comprises seven Councilors—one elected from each of the five wards and two who are appointed by the majority political parties.

1 Municipality of Ruiru, University of Nairobi Urban Planning Studio 2005. 2 A map of the five wards of Ruiru is provided in Appendix 2.

8

Local Economy

Ruiru was once a small agricultural town with its own industry, large coffee plantations and infrastructure. Cooperative groups (ranches), lacking farm management capacity, bought many of Ruiru’s large coffee farms and subdivided them, making plots available to individuals and setting the stage for unplanned residential development. This rapid and unplanned growth has hindered economic development in Ruiru. Some industries have collapsed, particularly the steel and packaging industries. However, Ruiru has retained factories, flower farms and mining quarries, which are critical to its present economic base.3

Water

Rapid unplanned growth and informal settlement fueled by Nairobi’s urban sprawl have put high pressures on the capacity of Ruiru’s water infrastructure to provide water services. While piped water is still a major source of water supply in Ruiru, residents access multiple sources to collect water for household use.

The major water suppliers in Ruiru are the Athi Water Services Board (AWSB), the Nairobi Water and Sewerage Company (NWSC) and private borehole operators, which supply both through piped connections and water kiosks. Rainwater harvesting, door-to-door vending, private wells and the rivers are also used.

In addition to the inadequate water services, the water quality in the rivers and in groundwater is infrequently tested4 and often goes untreated. Low consumption patterns of the population create a barrier to hygiene practices and overall health. Ruiru’s greatest challenge is the difficulty of keeping its existing water resources free from contamination and of consistently providing high quality water to its rapidly growing population.

Sanitation

Ruiru’s lack of sanitation facilities creates a public health threat. There is no sewer system to meet the needs of the growing population. Septic tanks and wells have been dug in the absence of government oversight and without consideration for public health outcomes. Pit latrines or septic tanks are often too closely spaced to shallow wells, contaminating the water supply.

Solid Waste

Poor solid waste disposal and collection are significant problems in Ruiru. The Municipal Council provides collection service in some wards, but no ward is completely covered, and the municipal dumping sight is unpopular with local residents and unsafe. Large parts of the population therefore use alternative solid waste disposal methods with negative health, environmental and aesthetic consequences.

3 Municipality of Ruiru, University of Nairobi Urban Planning Studio 2005. 4 Key Informant Interview

9 III. INSTITUTIONAL CONTEXT

Water Reform

To improve water service provision, the Water Act of 2002 separated water resources management from water and sewerage services. “The role of the Government (was) redefined to focus on regulatory and enabling functions, rather than direct service provision.”5 The Water Act of 2002 also decentralized water services to the regional and local levels. By facilitating new, decentralized relationships at the regional and local levels, this new legislation provides an opportunity to improve the efficiency, quality and accountability of water service provision in Ruiru. Specifically, this new legislation provides an opportunity for AWSB and the Municipal Council of Ruiru to work together to improve water service provision in Ruiru.

Athi Water Services Board

Since the Water Act of 2002, AWSB is responsible for service planning and provision in Ruiru. As a water service provider (WSP) serving as an agent of AWSB, the Municipality of Ruiru will be responsible for direct provision of water and sewerage services.

The mission of AWSB is “to ensure efficient, effective and sustainable provision of quality and affordable water services in the area of (its) jurisdiction, through appointment of well-managed service-providers and development of facilities.” 6 The strategy of AWSB is “to focus on operational efficiency, through identification and appointment of water service providers, establishment of rehabilitation requirements, development of investment plans and development of a supervision, monitoring and evaluation system for the water service providers.”7

RUJA

The Municipal Council of Ruiru has made important recent steps toward becoming a water service provider. In February 2006, following the suggestion of the licensing agency, AWSB, the Municipal Council joined with the Municipality of Juja to form the Ruiru-Juja Water and Sewerage Company (RUJA). Ruiru will work together with Juja to manage a particular watershed and provide water regionally for sustainable and integrated water management purposes. AWSB has registered RUJA under the Companies Act Cap 486. While AWSB has the administrative and technical capacity to help Ruiru become a well-managed service provider, there is room for improvement in this new, decentralized relationship. A clear strategy will help to effectively devolve responsibility to the local level.

5 “Handing over the water sector to new managers.” Kisima, Premier Issue, February 2005, p.1. 6 AWSB. AWSB Fact Sheet. 2006. 7 AWSB, “Making Water Services Available, Accessible, Affordable.”

10 IV. STAKEHOLDERS

The overall framework and principles guiding the water reforms provide an enabling environment in Kenya for improving service provision while the decentralized institutional framework creates space for new stakeholders. The reforms aim to strengthen local government, encourage community involvement and facilitate private-sector participation. There is an urgent need fors the capacity, policies, and financing to ensure that these principles genuinely motivate change and increase access to water and sanitation services among the underserved. For Ruiru, success in that endeavor will depend on collaboration between the following key stakeholders:

Municipal Council of Ruiru: The Ruiru Municipal Council comprises seven councilors and approximately 120 administrative staff members led by the Town Clerk.

RUJA: The joint Ruiru-Juja water service company RUJA will lease the infrastructure from AWSB, and it will be responsible for providing water services based on commercial principles.

AWSB: While Kenyan water services boards are designed by the water reforms to appoint and oversee WSPs, AWSB is not only working with the Municipal Council to support the formation of RUJA but it is also directly providing services during the transition.

AWSB is responsible for: 1) ownership of water and sewerage assets and infrastructure, 2) planning, development and expansion of water and sewerage infrastructure, 3) contracting out water and sewerage services provision to WSPs and 4) monitoring and supervision of water and sewerage services provision.8 AWSB is also heavily involved in seeking financing for water and sewerage infrastructure.

AWSB’s jurisdiction includes Nairobi, District, Thika District, District, District and Makueni District. Ruiru and Juja municipality both are within Thika District.

Nairobi Water and Sewerage Company: The Nairobi Water and Sewerage Company (NWSC) became a WSP under the jurisdiction of AWSB in 2004 when it took over water service provisioning responsibility from the Nairobi City Council (NCC) Water and Sewerage Department.

In addition to providing water and sewerage services to Nairobi, the NWSC inherited the NCC’s involvement in water service provision in Ruiru Municipality. The NWSC provides water throughout Githurai ward (where one estimate placed over half the population of the municipality) and a part of Kahawa Sukari. The NWSC does not provide sewerage services to these areas.

Local Private Sector: There is currently an active and very dynamic local private sector in Ruiru Municipality that has grown out of the lack of infrastructure available to meet water demand. Private boreholes are especially successful in capitalizing on this need and providing

8 AWSB. Brochure. AWSB: Making Water Services Available, Accessible, Affordable. 2006.

11 water services while water vendors are not as well trusted and a less frequently used form of water supply.

Nongovernmental Organizations (NGOs): The SIPA team was able to find two international nongovernmental organizations (NGOs) working in Ruiru on water and sanitation issues—Plan International and Population Services International (PSI). PSI is a nonprofit organization that uses commercial marketing strategies to promote health products, services and behaviors. In Ruiru, PSI markets Waterguard, a chlorine-based water treatment. Plan International is currently in the process of phasing out its activities in Thika district. The SIPA team was not able to identify any local NGOs working specifically on water, sanitation and solid waste in Ruiru.

Community: Ruiru Municipality is a dormitory town for residents who work in Nairobi. One key informant estimated that Ruiru Municipality’s day population was one-third to one-half that of its night population. Community perspectives vary with income level and location (more rural wards versus more urban wards). The SIPA team attempted to capture the community perspective as users of water and sanitation services through its household survey.

Community members are also water suppliers. Increasingly, community-owned boreholes are providing water services in addition to the private borehole operators. Community-owned boreholes are recognized as holding great potential as a vehicle for community self-help efforts. At the same time, one key informant reported that these boreholes might be more susceptible to corruption and another said that they were less likely to be properly maintained than privately- owned boreholes.

Ministry of Water and Irrigation (MWI): The MWI is responsible for Kenya’s water sector policy, planning and financing.

Water Regulatory Services Board (WRSB): The WRSB provided AWSB with a license to appoint WSPs. It is responsible for overall supervision and regulation of water and sewerage services in Kenya.

Water Resources Management Authority (WRMA): The WRMA is responsible for the sustainable management of Kenya’s water resources, including the allocating and monitoring of water resources, protecting the quality of water resources, granting permits for water use, managing and conserving water catchments and setting charges for water use.

National Environmental Management Authority (NEMA): NEMA is the government agency responsible for supervising and coordinating environmental policy in Kenya. The agency is involved in monitoring the environmental impact of water, sanitation and solid waste conditions in Ruiru.

Ministry of Health (MOH): The MOH is responsible for health services promotion in Kenya. The Ministry administers the Ruiru Health Center and employs three public health officers at the clinic.

12 V. SITUATIONAL ANALYSIS METHODOLOGY

The SIPA team used a literature review, data collection and analysis, key informant interviews and a household survey as the methodology for this report.

In New York, the SIPA team conducted a literature review as well as qualitative and quantitative data analysis.

The SIPA team made three two-week trips to Kenya in January, February and March 2006. The SIPA team identified key informants based on a stakeholder analysis and conducted 62 key informant interviews in Kenya. The team collected primary health data from the main public health center in Ruiru as well as maps from the Municipal Council and AWSB. In order to bring in the community’s perspective on water, sanitation and solid waste issues, the SIPA team designed a mixed quantitative-qualitative household survey and conducted it in 100 households across the five wards in Ruiru.

The findings described in the following sections draw heavily from the survey results in order to highlight the perceptions and interests expressed directly by community members. The survey results are presented in conjunction with related information gathered through key informant interviews, data collection and observation.

In both Kenya and New York, the team consulted with professors and other experts for technical advice. At Columbia University, the team was able to take advantage of expertise in the development and management of water resources systems, public health, water policy and infrastructure development. In Kenya, the Urban Planning program at the University of Nairobi provided additional insight into the specific experience of Ruiru. The team’s interaction with the academic community and the literature review provide context for the report.

Household Survey

The SIPA household survey was conducted in 100 households over the course of five days. Prior to entering a ward to conduct the study, two SIPA team members toured the ward with the ward Councilor to be formally introduced the community.

Ruiru's population is socio-demographically diverse and speaks multiple languages.9 In order to be able to reach and communicate with all segments of the population, the SIPA team partnered with a local NGO, Families, Orphans, Children Under Stress (FORCUS).10 Once the SIPA team trained the FORCUS volunteers on general surveying techniques as well as the particular subject matter, they were responsible for conducting the survey. A member of the SIPA team accompanied each volunteer in order to improve consistency among surveyors.

9 i.e., English, Kiswahili, Kikuyu 10 FORCUS: Families Orphans Children Under Stress

13 Sample Description

The sample comprises a total of 100 household surveys. This total reflects a compromise of the limited time and funds available for fieldwork and, on the other hand, the need for a large enough sample for analysis. Operational constraints prevented a random selection of households. The sample breakdown reflects the estimation of the percentage share of the population first by ward and then by neighborhood. The SIPA team tried to ensure a broad representation of households by including households from all geographic parts of the municipality and covering all income groups. For the purposes of analysis, the SIPA team has assigned survey respondents to income groups according to their own estimation of household income using the following breakdown: low income is less than or equal to Ksh 11 6,000 per month, middle income is between Ksh 6,000 and 30,000 per month, and high income is greater than or equal to Ksh 30,000 per month. The map in Appendix 2 provides a visual of the geographic locations of survey respondents’ households.

Limitations

The SIPA team believes in the value of the household survey to provide a snapshot of the respondents' current situation with regards to water, sanitation and solid waste as well as their concerns and priorities for change. However, we also recognize the limits of making assumptions about the entire population of Ruiru based on this sample. Some of the limitations for thorough statistical analysis are the non-random selection of households, the sample size and the occasional insufficient precision in the formulation of questions and answers. In addition, the non-differentiation between the dry and wet seasons in the survey is potentially problematic.

The fact that the report focuses on the results from the household survey is a limitation in itself, as the report does not examine in-depth agricultural and industrial water supply and usage, a major component of the overall picture. Further study should be done in this area as the industrial and agricultural pieces of the puzzle play an important role in the economic, environmental and health impacts of the problem.

11 Ksh refers to Kenyan shillings. The exchange rate is 1 USD= Ksh 71.3. May 7, 2006.

14

Ruiru is characterized by its varying population densities and economic disparities.

(top) Ruiru, more densely populated; (above right) Rural Ruiru; (below right) High-income Housing; (bottom) Low-income Housing

Source: SIPA Field Trip (January/ March 2006) 15

(top) AWSB’s water treatment plant, to be handed over to RUJA, jointly shared by Ruiru and Juja; (bottom left) Collecting water from the well, a potentially unsafe source, if left untreated; (bottom right) Rainwater harvesting in Murera.

Source: SIPA Fieldtrip (March 2006) 16 VI. SITUATIONAL ANALYSIS - FINDINGS

A. WATER

Key findings Recommendations • Multiplicity of water providers • Conduct feasibility study to inform technical aspects of water • Inadequate infrastructure provisioning • Water quality issues • Promote rainwater harvesting • Low water use patterns • Plan long- and short-term • Inconsistent availability interventions • Use of alternative sources as • Collaborate with international supplement and local NGOs to educate the public about point-of-use water • Low awareness of treatment treatment methods • Concerns with availability, quality, cost, and distance to source

Kenya’s Water Scarcity

Kenya is recognized as a water scarce country (having less than 1,000 cubic meters of renewable water per person per year) in that the water demand exceeds the amount of renewable freshwater sources. Although Kenya is located in the normally rain-heavy Intertropical Convergence Zone, annual rainfall over most of the country is unusually low and varies from year to year. Because the intertropical belt of cloud and rain passes rather quickly across Kenya in April and October and the north and south monsoons have a track parallel to the coast, these clouds have already passed over large areas of land before reaching Kenya.12 As a result of these climactic patterns, Kenya’s water availability is a low 612 cubic meters per person per year and is declining each year due to population growth.13

Kenya’s total annual renewable water resources (total natural renewable surface and groundwater) amount to 30.2 cubic kilometers per year.14 As compared with its neighbors,

12 http://www.bbc.co.uk/weather/world/country_guides/results.shtml?tt=TT000300 13 http://www.water.go.ke/situation.html 14 Gleick, Peter H. Data Table 1, page 257, The World’s Water: The Biennial Report on Freshwater Resources, 2004-2005.

17 Kenya is the third most water-stressed country in the Great Lakes region of Africa, ranking behind Burundi (1) and Egypt (2), and ahead of Rwanda (4), Ethiopia (5), Uganda (6), Tanzania (7) and Sudan (8).15

Figure 2

Per Capita Water Availability 2,000

1,800

1,600

1,400

1,200

per person) per 1,000 3

800

600

Volume (m Volume 400

200

0 1969 1979 1989 1999 2010 Year

Source: Kenya MDG Needs Assessment Report, p. 8

Given Kenya’s water scarcity, it is crucial that water sources are protected, managed and distributed to meet the needs of Kenya’s rapidly growing population. Furthermore, water and sanitation are essential to achieving the Millennium Development Goals. However, due to climatic characteristics, deficient infrastructure and a history of poor coordination of water service delivery, 43% of Kenyans lack basic access to safe water. While overall coverage rates of water have increased since 1990, many indicators imply that water services and water resources management worsened during the 1990s with funding and investment for water declining over the decade.16

Unlike the northern and eastern regions of Kenya, Ruiru itself is not confronted with the grave challenges of water scarcity. Like the rest of Kenya’s Central Province, Ruiru has two rainy seasons—the longer one lasting from March to May or June and the shorter one lasting from October to December. The rainfall in Ruiru (700-1000 millimeters per year) could be captured by rainwater harvesting systems to complement primary water sources. Furthermore, according to local groundwater specialists, there may be ample groundwater that could be exploited further for human consumption. However, Ruiru’s greatest challenge is keeping its existing water resources free of sewage and agricultural pollutants in order to consistently provide high quality water to its rapidly growing population.

15 http://www.thewaterpage.com/SoicalResourceScarcity.htm. Table 8. 16 “Towards a Water Secure Kenya” Global Water Partnership Newsletter.

18 Existing Water Supply in Ruiru

Water provisioning in Ruiru meets the needs of our household survey respondents in sporadic and unequal ways. Both surface and groundwater are subject to pollution and contamination, mostly due to sewage seepage into shallow wells and rivers, but also due to agricultural run-off from coffee farms. The people of Ruiru obtain their water from many sources, both regulated and unregulated, making systematization of sources difficult. The major suppliers of water in the Municipality of Ruiru are the Athi Water Services Board (AWSB), the Nairobi Water and Sewerage Company (NWSC) and private borehole operators. Borehole operators also sell water through piped connections and water kiosks. Other sources of household water consumption include shallow wells, rainwater harvesting, and the rivers.17

AWSB: Despite Ruiru’s rapid population growth, the same water provisioning system that was built to serve Ruiru’s population of roughly 750 households in the 1950s is still being used by AWSB today to serve the same number of households in Ruiru Town neighborhood within Biashara ward. The is the main water source for the AWSB’s water treatment plant, the Ruiru Water Supply. (All local tributaries flow into Athi, including the Ruiru River.)

While the facility is currently operating at maximum capacity, the Ruiru River itself has not been fully exploited to meet the needs of the current population.18 However, the Ruiru River does not have the capacity to serve all five wards. Currently, there is a proposal entitled “Rehabilitation of Ruiru Water Supply” to expand the storage capacity of the treatment plant.

There is a poor reticulation network and in some places, water use is not metered. After the Water Act of 2002, the Ministry of Water and Irrigation handed over the facility to AWSB. By June 2006, assets are expected to be handed over to the newly founded RUJA.19

Water Quality in the Ruiru River: According to a local water quality specialist, there are coffee factories upstream that are not treating their effluent. This affects the color and taste of water from the Ruiru River. Due to use of fertilizers, there are concentrations of nitrates in the Ruiru River. The river is also contaminated by the overflow of sewage and septic tanks during the rainy season. Generally, the smell cannot be treated.

The limit for Biological Oxygen Demand (BOD) is 20 milligrams per liter; however, in the Ruiru River there are 120 milligrams of BOD per liter. Similarly, the limit for Chemical Oxygen Demand (COD) is 50 milligrams; in the Ruiru River, there are 240 milligrams of COD per liter. The same water quality specialist also noted that there are likely to be heavy metals in the water because of cleaning chemicals poured down household drains. In addition, the high demand for water means that the water is often delivered before the sediment (following treatment) has time to settle.20

17 Municipality of Ruiru. 2005. University of Nairobi Urban Planning Studio Final Report. 18 Key Informant Interview 19 Key Informant Interview 20 Key Informant Interview

19 NWSC: The Nairobi Water and Sewerage Company provides water to parts of Kahawa Sukari and Githurai. The majority of water in Githurai is piped,21 coming from a T-connection at Ruisambo off the main pipe supplying Nairobi. This is sourced from the Ndakaini Dam, which is 40 km away.22

Private Boreholes: Based on a borehole map provided by the Thika District Office, there are more than 60 registered boreholes in Ruiru.23 Ninety-eight percent of boreholes are privately run, though an increasing number are being managed by the community.24 These boreholes provide piped connections in some cases or provide kiosk services in other cases. While by law there must be one kilometer between boreholes, there is no compliance in some places. This problem is most clearly demonstrated by the density of boreholes in the more urban Biashara ward. Borehole, Githurai

It may be possible for groundwater engineers to further investigate recharge and extraction rates in order to find groundwater to complement the use of surface water. A local groundwater specialist surmised that groundwater is currently being extracted at a rate of seven cubic meters per hour. The same specialist logically assumed that the groundwater is being replaced at a faster rate than it is being extracted because it is only being extracted for human consumption.25

According to the United Nations Food and Agriculture Organization, 40% of the boreholes in Kenya are sunk into volcanic rock.26 Likewise, the geology of Ruiru is comprised of tertiary volcanic rocks, including Nairobi stone, which are conducive to building boreholes and for transmitting groundwater.27 Local groundwater specialists in Ruiru believe that the groundwater potential of the area is very high and can be harnessed to meet water shortages in the area. However, overflowing pit latrines and septic tanks and the absence of a sewerage system make groundwater vulnerable to contamination.28

Water Quality in Boreholes: The geology of Kenya is such that fluoride occurs in high concentrations, not only in rocks and soil, but also in surface and groundwater.29 Based on

21 Key Informant Interview 22 Key Informant Interview 23 See Appendix 13 for map of registered boreholes. However, a fairly large portion of the borehole map fails to cover much of Kahawa Sukari, Murera and Gitothua. 24 Key Informant Interview 25 Key Informant Interview 26 http://www.fao.org/ag/agL/swlwpnr/reports/y_sf/z_ke/ketb313.htm 27 National Atlas of Kenya and Key Informant Interview 28 Municipality of Ruiru. 2005. University of Nairobi Urban Planning Studio. 29 http://www.fluoride-journal.com/02-35-3/353-193.pdf

20 anecdotal evidence, we have found that boreholes are not frequently checked for water quality. The Kenya Bureau of Standards recommends a maximum of 1.5 milligrams of fluoride per liter (1.5 parts per million) in drinking water.30 While fluoride levels in many boreholes comply with the Kenyan standard, the fluoride levels in Biashara’s boreholes are double the Kenyan standards for drinking water. This can lead to, and based on our observations has led to, discolored, blackened, mottled or chalky-white teeth.31

Other Water Sources: Shallow wells represent an unregulated and often contaminated source of water. Because well digging is not regulated, and the cost32 is within reach for many residents of Ruiru, numerous shallow wells are currently in use. However, the unregulated nature of shallow wells is of concern because of the threat of water-related diseases associated with the seepage of sewage.

There are also water vendors in Ruiru who get their water from public taps, private boreholes, and illegal connections. This water is of questionable quality and is sold at high prices.

Existing Water Provisioning Infrastructure

In the context of decentralization, infrastructure is being handed over from national level management to the local level. However, rapid unplanned development in Ruiru does not always correspond with the existing infrastructure. While all residents of all wards are served in varying degrees by piped water, the remaining respondents to the SIPA Household Survey used less safe (private wells and river) and/or less accessible water sources. There are also illegal tapping and leakages from piped sources, which further decrease service efficiency.

Biashara ward’s water treatment plant and its distribution infrastructure were built in the 1950s to serve a population of 750 households. This system serves the same number of households today and clearly fails to meet the needs of the growing population. Boreholes have multiplied in Biashara in the last 10 years to meet the needs of the population. However, due to regulations, new ones cannot be constructed. Overall, the infrastructure is insufficient and does not keep up with the needs of a rapidly growing population. Clearly, infrastructure is hampered by regulatory obstacles and lack of funding.

Understanding the Water Situation at the Household Level

Primary Water Sources: In examining Ruiru’s water sources, this study uses the term “water source” in its broadest sense to include water supplied by a public utility as well as by private providers such as water kiosks, door-to-door vending and “free” sources such as individual shallow private wells and rivers. Households surveyed in the five wards of Ruiru use a wide array of primary water sources to meet their needs. Fifty-seven percent of our respondents used piped water sources. Shared yard taps were the most common, with 27% of the households using them as their primary source. Another primary source was water kiosks, which have been

30 http://www.fluoride-journal.com/02-35-3/353-193.pdf 31 http://www.unicef.org/wes/fluoride.pdf p. 2 32 10,000-30,000 KSH or US $141-423. http://www.ascleiden.nl/Pdf/workingpaper66.pdf

21 growing in number in the last ten years. Other primary water sources included potentially unsafe sources such as private wells and the rivers (18% of respondents). It is interesting to note that 2% of our respondents used rainwater harvesting as a primary source. Forty-six percent of the respondents who rented their homes used shared yard taps as their primary water source while 2% of the respondents who were homeowners used a shared yard tap. One barrier to a private connection may be the high connection fee which, based on anecdotal evidence, ranges from Ksh 2500 (for a borehole connection) to as high as Ksh 17,000 (for a private yard tap connection.) Only one respondent relied on her neighbor for water and another on door-to-door vending.

Figure 3 33 Figure 4

Primary Water Sources Water Source by Income

60 6% 2% 50 Shared yard tap 40 Low income 8% 27% HH connection 30 Middle income Water kiosk 20 High income 12% Private yard tap 10 Private well 0 l g Other p n p g n sk a ta in i o wel st ki e rd Other 13% 17% River/stream nectio ve ter yard t ya r a on e ha iver/spr Privat ed r R Rainwater harvesting W r vat e ha HH c i 15% S Pr inwat Ra

In the low income group, 25% of respondents used water kiosks as their primary water source, 17% used shared yard taps and 14% used private wells. In the high income group, 54% used household piped connections, 31% used private yard taps and 8% used both rainwater harvesting and water kiosks. In the middle income group, 43% used shared yard taps, 13% used private wells, 13% used water kiosks and 13% used household connections. The greater reliance on water kiosks by members of the low income groups contrasts with the greater reliance on piped sources by the middle and high income groups. Piped water access for the poor is a concern and should be further investigated by future water provisioning companies in Ruiru.

The ward breakdown for water source suggests piped connections are the primary water source for 85% of respondents in Githurai and 55% of respondents in Biashara, the more urban wards, compared to a smaller percentage of respondents in the more rural wards of Kahawa Sukari (43%), Gitothua (38%) and Murera (23%). In Murera, 31% of respondents relied on private wells. Furthermore, 21% of respondents from Murera and 21% of respondents from Kahawa Sukari used the river as their primary source. Reliance on both private wells and the river is problematic when the water is left untreated due to the seepage of contaminants. Twenty-nine percent of the respondents in Gitothua used water kiosks as their primary source, a higher percentage than the 15% of all respondents who used water kiosks as their primary source.

Fifty-seven percent of respondents use alternative water sources to complement their primary source. Eleven percent of total respondents use a minimum of three alternative water sources, while 2% of total respondents use four alternative sources. Out of the 57 instances of alternative

33 The source of all data figures, unless otherwise noted, is the SIPA Household Survey (March 2006)

22 source use, 35% of respondents reported rainwater harvesting and/or water kiosks and/or another alternative source as the most important alternative source. Twenty-eight percent of respondents reported using water kiosks and 16% reported using private wells as the only alternative source or one of their alternative sources. It is important to note that members of the low and middle income groups seemed to rely more heavily on alternative water sources.

Figure 5 Figure 6

Alternative Water Sources Use of Alternative Water Sources by Income Group

21% rainwater 50 harvesting and/or 40 42 other source 35% water kiosk and/or 40 other source 30 private wells and/or other % source 20 14 16% other alternative sources 10 4 0 low income middle high income income 28% income unknown

Per Capita Water Use: For the aggregate sample, we found that water use averaged about 31 liters per capita per day (lcd), which is only 75% of Nairobi’s average water use per capita per day. At the lower range, five respondents used a meager five lcd or less (which would only meet minimum drinking needs) while on the higher range, one cattle-owning respondent used 283 lcd. In comparison with the widely cited benchmark of 50 lcd as a minimum standard to meet the four basic needs of drinking, sanitation, bathing, and cooking,34 our sample of respondents was only using 62% of this minimum.

According to the SIPA household survey, the highest use patterns were by those respondents who had private household connections (see Figure 7). Furthermore, it is important to note that 27% of our respondents used shared yard taps as their primary source, yet this source also had the lowest average per capita per day use (21 lcd). This may explain the overall lower consumption patterns than would be found if households had greater access to household connections. For those households that did have access to piped water as their primary source, but rather a private connection or a shared yard tap, average water use was 26.1 lcd compared to 36.5 lcd in unpiped households. The median values for water use were even lower - 20 lcd for the sample as a whole, 20 lcd among households with piped supplies and 20 lcd among unpiped households. This might be explained by the fact that the zero-cost water sources such as community wells, rainwater harvesting, and the river have the highest average water use per person per day.

34 Gleick, P.H. 1996. "Basic water requirements for human activities: Meeting basic needs." Water International Vol. 21, No. 2, pp. 83-92.

23 Figure 7 Figure 8

Water use per capita per day by source Water use per capita per day by income

45 40 40 35 35 30 30 25 25 20 20 liters 15 15 10 10 5 5 0 0 Shared yard Household Water kiosk Private yard Private well Low income Middle income High income tap connection tap liters

While low, middle and high income groups did not vary much in their consumption patterns, it is not surprising that average water usage was higher in the high income group.

Moreover, the median consumption of water, at 20 lcd, is 36% lower than the aggregate average consumption of 31 lcd. This demonstrates that 72% of the surveyed households use less water than the mean of 31 lcd. For the other primary sources, average water consumption varies from 2.5 lcd (community borehole) to 28 lcd (community well). It is of interest to note that people using water kiosks as their main source reported that they use 28 lcd on average, which is more than is being used on average by those with shared or private yard taps. This may be because the water use data was self-reported and not measured by water meters. It is likely that those who collect their water from kiosks and pay per twenty liter jerry can are more aware of their consumption patterns than those who have access to a piped connection.

Average water use by ward demonstrates the following use patterns: Biashara (49 lcd), Kahawa Sukari (37 lcd), Murera (35 lcd), Gitothua (29 lcd), and Githurai (23 lcd). While the residents of Biashara were using roughly 49 lcd, the residents of Githurai, the most densely populated ward, were using only 23 lcd. The current level of per capita use is low when compared with previous use levels in Kenya which are reflected by a marked decline in average domestic water use in urban Kenya – it has fallen from 105 lcd in 1967 to 45 lcd in 1997.35 According to our survey, average water use per person per day ranges with a 95% confidence level from 23.4 and 38.4 liters, and average water use per person per day for households with primarily unpiped water sources ranges with a 95% confidence level from 21.4 to 51.7 liters.

According to the World Health Organization, a very high level of health concern arises when the quantity of water used is often below 5 lcd. At this level of use, consumption is not guaranteed and water is not available for hygiene unless it is practiced at a natural water source. A high level of health concern (quantity unlikely to exceed 20 lcd) translates into water usage in which consumption should be assured, but hygiene is compromised. At a high level of health concern, hand-washing and basic food hygiene is possible, but laundry washing and bathing is difficult unless it is practiced at a natural source.36 The SIPA team estimates that 73% of respondents

35 Gulyani et al. Universal (Non)Service. p. 1254 36 WHO. 2002. Domestic Water Quantity, Service Level and Health.

24 Figure 9

Level of Health Concern for Respondents had either a high health concern or a very high health concern Based on Quantity of Water Usage in that their water use was unlikely greater than 20 lcd and

5% less than 5 lcd respectively. The WHO standards take into 17% Very High Health Concern (often < 5 22% l/c/d) High Health Concern account water quantity as well as collection time in (Avg. unlikely >20 l/c/d) Low Health Concern determining the level of health concern. The SIPA team only (Avg. est. 50 l/c/d)

Very Low Health calculated water usage to obtain these results. Concern (Avg. 100 l/c/d and above) 56%

Unit Cost of Water: The unit cost of water was computed for each household in the sample by dividing the reported total expenditure on water by the reported total water use. In general, this data must be used with caution because the reported quantity used may have been underestimated by people with piped connections and the monthly price paid was often reported as a rough estimate and was not based on bills or metering in most cases. Households in Ruiru were spending on average Ksh 0.15 per liter for the water that they used each day. The median cost was Ksh 0.06 per liter–that is 50% of the sample households were incurring unit costs both higher and lower than this value. Respondents in the high income category paid Ksh 0.11 per liter on average for water. Respondents in the low income category paid Ksh 0.12 per liter on average for water. At a confidence level of 95%, we cannot determine that the average water cost per liter paid by the low income respondents is statistically significantly higher than that paid by the high income respondents. The above may reflect the fact that, in contrast with the literature on water prices, water kiosks are not more expensive than piped connections in Ruiru.

Figure 10 Figure 11

Water Cost by Source Water Cost in KSH/l by Ward 0.3

0.3 0.25 0.2 0.2 0.1 0.15 KSH/l KSH/l 0 0.1 0.05

0 Murera Sukari HH private well private yard shared yard water kiosk Githurai Kahawa

Biashara connection tap tap Githothua

By ward, it is clear that respondents from Biashara were paying the most for their water (Ksh 0.25/L), while respondents from Kahawa Sukari were paying the least (Ksh 0.05/L). For comparison’s sake, respondents in Murera, Gitothua, and Githurai were paying Ksh 0.08/L, Ksh 0.14/L and Ksh 0.19/L respectively.

By source in order from most expensive to least expensive, respondents using household piped connections paid Ksh 0.21/L for water, shared yard tap (Ksh 0.19/L), individual yard taps (Ksh 0.24/L), water kiosks (Ksh 0.14/L) and shallow private wells (Ksh 0.02/L). The urban areas of Ruiru (Biashara and Githurai Wards) have current water prices similar to those of Nairobi in 2000,37 which may be due to the high percentage of piped connections in each, respectively 55% and 85%, and the fact that Githurai is also served by the NWSC. The main reason behind the low

37 Gulyani et al. Universal (Non)Service.

25 costs in Murera and Kahawa Sukari is likely to be the high number of respondents who used free water sources such as the river, private wells, and rainwater harvesting.

Water Availability: Sixty-nine percent of respondents said that their primary water source was available more than 16 hours a day. Sixteen percent reported that water was available 8-16 hours a day, while 15% reported that water was available less than 8 hours each day.

The most striking aspect of water availability per day by source is indicated by the irregularity of service of each source. For shared yard taps, 77% of respondents reported more than 16 hours per day of availability; 8% of respondents reported 8-16 hours of water availability per day and 15% reported less than 8 hours of availability per day. Figure 13 demonstrates the irregularity of water availability by the sources our respondents used.

Figure 12 Figure 13

Water Availability Overall Water Availability by Source

100 80 80 60 more than 16 40 60 20 8-16

Hours 40 less than 8 0 Series1 more 8-16 less 20 than 16 than 8 0 s ll ion k e t os rd tap ec i rd tap a k a y nn y Hours per day ater te W Private w HH co Shared Priva

It seems that independent of income, across the board at least 61% of the respondents from each income group have available water more than 16 hours a day, though more statistical analysis would have to be conducted to ascertain any statistically significant difference. Water availability by income group is as follows: high income: 62% (more than 16 hrs per day), 8% (8- 16 hours), 31% (less than 8 hrs), middle income: 74% (more than 16 hrs), 13% (8-16 hrs), 13% (less than 8 hrs) and low income 61% (more than 16 hrs), 25% (8-16 hrs) and 14% (less than 8 hrs).

The breakdown by ward demonstrates that Murera (77%), Kahawa Sukari (86%) and Githurai (79%) had high percentages of respondents with water available more than 16 hours a day. Strikingly, 42% of Biashara’s respondents had water available less than 8 hours a day despite the fact that 54% of respondents from Biashara had access to piped sources. Fifty-seven percent of Gitothua’s respondents had water available more than 16 hours a day, while 33% had water 8-16 hours per day and 10% had water less than 8 hours per day.

Low quantities of water can create a barrier to hygiene practice and contribute to water-related diseases such as diarrhea, skin infections, and eye infections. Given the variations in levels of availability, it is not surprising that water availability was the primary concern of our respondents. For this reason, in the short-term there is a need to look to alternative water sources to compensate for the availability issues, particularly for those who only have access to water for less than eight hours per day.

26 Figure 14 Water Quality: The SIPA team assessed water Do you treat your water? quality based on treatment practices and whether respondents covered and cleaned their collection 90 80 containers. Fifty-one percent of respondents 70 60 reported that they treated their water. The extent 50 do not treat 40 to which respondents treat is likely to be a 30 function of their water source and their awareness 20

% of Respondents % of 10 of treatment methods. While piped sources 0 n p k o ta tap s supplied by the rivers through treatment plants cti river io e k n ard ard r n y y te o a and groundwater supplied by boreholes are c private wellate w v ri hared traditionally considered high quality sources, it HH p s cannot be assumed that these sources are free of contaminants.

In both Murera and Githurai 69% of respondents reported treating their water as compared to Gitothua (38%), Biashara (25 %) and Kahawa Sukari (21%). Fifty-four percent of high income respondents reported treating their water compared to middle (52%) and low income (42%) respondents. Irrespective of source, large percentages of respondents reported that they did not treat their water. In particular, a majority of those who used water kiosks did not treat, while a greater proportion of respondents treated for both piped sources and for the wells and rivers. This is striking because piped water is often considered a safe source, while wells and rivers are vulnerable to contamination.

Of those who treated their water, 86% treated it only for drinking purposes and 10% for drinking and cooking. Seventy-eight percent of those who treated their water did so every time for the aforementioned purposes. Twelve percent of respondents treated their water most of the time. Of those who treated, boiling (62%) was the primary treatment method, followed by chemical treatments (36%) such as PuR, safe water solution or Aquatabs.38

Treatment practices according to income were as follows: 37% of low income respondents treated their water daily as compared with those who treated their water weekly or more often (11%), those who treated their water monthly or more often (23%), those who treated their water irregularly (17%) and those who did not treat their water at all (6%). Middle income respondents treated as follows: daily (30%), weekly or more often (37%), monthly or more often (16%), irregularly (12%), and not at all (2%). High income respondents treated as follows: daily (22%), weekly or more often (22%), monthly or more often (11%) and irregularly (33%).

Respondents reported that 81% of the containers that were used by water collectors were covered during transport. Thirty-three percent of respondents cleaned their collection containers daily as compared with those who cleaned weekly or more often (25%), monthly or more often (18%), irregularly (16%) or not at all (3%).

38 These chemical treatments are used in Kenya, but not necessarily by our respondents.

27 Burden of Water Collection: Most minimum access to water supply standards have been developed in the context of emergency response. While the SIPA team recognizes that the needs of the residents of Ruiru to sustain quality of life and health over time are likely to exceed emergency minimums, the standards described in the Sphere Project on the Humanitarian Charter and Minimum Standards in Disaster serve as benchmarks in our data analysis. According to the Sphere Project, the maximum distance any household should be to the nearest water point during crisis conditions is 500 meters. The queuing time at a water source should be no more than 15 minutes and the time to fill a 20-liter container should be no more than three minutes.39 Piped water does not require traveling a distance to collect in most cases so the time and distance in minutes were often marked as zero. It is clear from Figure 15 that those who used water kiosks reported spending the most time on average per day collecting water. Fifteen percent of our total respondents spent on average 13 minutes collecting water. For those who used the river as their primary source, the average time spent collecting water was 100 minutes.

In Ruiru, respondents reported that they spent 46 minutes on average collecting water per day (range 0-600). Twenty percent spent no time collecting water; 5% spent 1-5 minutes, 7% spent 5-10 minutes, 54% spent more than 20 minutes and 7% spent more than two hours.

Figure 15 Figure 16

Distance to Source by Source Distance to Source by Income

14 8 12 7 10 8 6 6 5

Minutes 4 mean 4 2 median

0 Minutes 3 p ell sk 2 w ta rd r kio 1 te ivate d ya a Pr e W 0 HH connection Private yard Shartap high income middle income low income

The breakdown by income group is as follows: low income respondents spent 49 minutes on average collecting water per day, medium income respondents spent on average 49 minutes per day and high income respondents spent 44 minutes on average per day. While the average minutes spent collecting water in each income group were similar, the median time spent collecting water reflect a clear upward trend from high income to low income. The percentage of respondents who spent zero time collecting water is of particular interest, as reflected by the following percentages: the percentage of low income respondents who spent zero time collecting water is 9%, while 58% of the high income respondents spent zero time collecting water. Sixteen percent of middle income respondents spent zero time collecting water.

The SIPA team measured collection distance by asking respondents to estimate travel time to and from the water source. The collection distance for all respondents ranged from 0-60 minutes with the average being 4.5 minutes and the median being one minute. The collection distance in

39 The Sphere Project. 2004. Humanitarian Charter and Minimum Standards in Disaster Response. p 63.

28 minutes for low income respondents was 7.2 minutes (mean), 3 minutes (median) with a range of 0-50 minutes. For middle income respondents the collection distance in minutes was 2.5 minutes (mean), 1 minute (median) with a range of 0-20. For high income respondents, the collection distance in minutes was 5.5 minutes (mean) and .5 minutes (median) ranging from 0-60. The outlier in the high income group represents one respondent who traveled by car to Biashara from Kahawa Sukari to collect water from a borehole. This respondent also had livestock and used a lot of water. The mean is misleading because of this outlier, but the median clearly reflects a downward trend in collection distance in minutes from low income to high income.

Overall, 36% of respondents carried water on their heads and or shoulders, 40% carried by hand or under their arms, 11% used a wheelbarrow, 7% used a bike, while the remaining 6% used other modes of transportation.

Forty-seven percent of low income respondents and 40% of medium income respondents carried water on their heads or shoulders, while high income respondents did not carry water on their heads and shoulders at all. This may reflect a cultural or class difference. Conversely, 50% of high income respondents carried water by hand or under their arms, while 44% of middle income respondents and 24% of low income respondents carried in this manner. High income respondents might also use wheelbarrows and/or vehicles for transporting water, or may not carry water at all. Middle and low income respondents used bicycles or wheelbarrows in this regard.

The survey did not specifically ask for the gender of the water collector in each household. However, at least two-thirds of the survey respondents were exclusively women. Also, anecdotal evidence highlights the fact that while men may have been the official primary respondents in one-third of the surveys, their wives often contributed when they were unsure how to answer. This reflects the fact that culturally, women are often responsible for collecting water, and therefore bear much of the burden of this task. The SIPA team can say that in 45% of the households, the wife was primarily responsible for water collection. Finally, 12% had hired workers collect their water and 5% did not collect at all.

Household Satisfaction, Concerns and Preferences

Fifty-three percent of survey respondents stated that overall they were satisfied with their water service. While respondents from Githurai (63%) indicated the greatest percent satisfaction with their water service, respondents in Biashara (55%) also indicated a high percent satisfaction with their water service, which is peculiar, given that 42% had water available for less than 8 hours per day. Satisfaction levels in the other wards were as follows: Murera (46%), Gitothua (48%), and Kahawa Sukari (36%). Likewise, high income respondents stated a 54% satisfaction rate with their water source, followed by middle income respondents (51%) and low income respondents (49%). Private yard tap users were 77% satisfied with their water source as compared with household connection users (71%), shared yard tap users (59%), shallow private well users (42%), and borehole users (31%).

Top five concerns: Our survey asked respondents for their top concerns with their household water situation. Twenty-six percent had no concerns with their water supply. The remaining

29 respondents mentioned the following concerns as the or one of their top concerns: water availability (19%), water quality (16%) cost (12%) and distance to source (8%) (see Figure 17). The other concerns (25%) included but were not limited to bursting pipes, taste, health problems, inconvenience and low water pressure. Figure 17 The following concerns were reported based Overall concerns on the primary source that the respondent used: either no concerns, or concerns with 20% 25% water availability, water cost, lower water no concerns pressure, water quality, proximity of source water availability proximity of source and the lack of water delivery by the water quality 19% Municipal Council. While there were similar 12% cost Other concerns with piped sources, including no

16% 8% concerns, or concerns with water availability, water cost, lower water pressure and water quality, it is worth highlighting the major concerns with both private wells and water kiosks. Thirty-eight percent of those respondents who used water kiosks as their primary source were concerned with the distance of the kiosk from their households. Furthermore, 19% of respondents using water kiosks also complained that the Municipal Council should provide them with water. Private wells present a striking phenomenon. While 33% of respondents using shallow private wells as their primary source had no concerns at all, 25% had concerns about the water quality, likely due to the high potential for sewage seepage and contamination of the water source. Overall though, the concerns regarding each source vary, which may reflect that there are problems with all of the water sources that supply Ruiru.

The breakdown of concerns is of interest in the following wards. Low water pressure was a concern in Kahawa Sukari (14%) and Githurai (15%), where most of the piped connections exist. That being said, the highest percentage of respondents in both Githurai and Kahawa Sukari otherwise had no concerns with their water source, 30% and 21% respectively. Forty-two percent of Biashara’s respondents were most concerned with water quality. Thirty-eight percent of Murera’s respondents were most concerned with water availability. Gitothua, with its large concentration of water kiosk users (29%) had residents who reported no concerns (33%) and concerns with proximity of source (19%) and a lack of piped water (14%). Figure 18

The concerns by income reflect that water Concerns by Income availability is the primary concern of high income respondents while low income 70 60 respondents were almost equally concerned 50 low income 40 with water availability, water quality and middle income 30 distance to source (see Figure 18). Cost was of 20 high income 10 greater concern to middle and high income %Respondents of 0

s y e respondents which may reflect that they are ost ern ality urc c ilabilit qu f so less reliant on free water sources such as conc er o o n wat private wells and the rivers. Proximity of water ava roximity source is also one of the top five concerns of p

30 both low and high income residents. Low income respondents had either no concerns (17%) or concerns with water availability (22%), water quality (22%) and/or proximity of source (19%). Middle income respondents had either no concerns (28%) or concerns with quality (23%), availability (19%), cost (19%) and/or low water pressure (15%). High income respondents stated that they did not have any concerns (23%) or had concerns with water availability (62%), water cost (23%), proximity of source (8%), water quality (8%) or believed that the Municipal Council should provide water (8%).

Household preferences: Overall, respondents preferred the following primary water sources: household connection (45%), private yard tap (20%), shared yard tap (18%), meaning that 83% of our respondents would prefer to have a piped connection. Not surprisingly, 34% of the respondents (n=96) gave water availability as the or one of the reasons for preferring that water source over others, followed by convenience (21%) and water quality (19%).

Eighty-one percent of respondents who already had a piped connection preferred this water source. Eight-four percent of those who did not have a piped connection also would prefer to have a piped connection as their primary water source. There were some respondents who preferred community stand posts, rainwater harvesting, the river, and/or community boreholes as their primary preferred choice.

An analysis of preference by income corroborates the preference for a piped connection. Eighty- nine percent of low income respondents preferred a piped connection (household connection, private yard tap, shared yard tap) as compared with 84% of middle income respondents and 77% of high income respondents. Fifteen percent of high income respondents also expressed a preference for a community borehole.

Overall, the or one of the reasons for the preference of water source is as follows: water availability (34%), convenience (21%), water quality (19%), cost (18%) and/or proximity of source (15%). If the preferred water source was a household connection, respondents reported the following reasons for this choice: water availability (30%), convenience (28%), water quality (21%), proximity of source (19%) and/or cost (16%).

The or one of the reasons for the preferred water source by income is as follows: low income respondents reported availability (34%), cost (26%), water quality (20%) and convenience (20%) as the primary reasons for wanting their preferred water source. Middle income respondents reported availability (30%), convenience (30%), proximity or source (18%), water quality (16%) and cost (14%) as the primary reasons for wanting their preferred water source. High income respondents reported water availability (54%), water quality (23%), convenience (15%) and taste (15%) as the primary reasons for wanting their preferred water source.

Recommendations

There are both long-term and short-term recommendations to mitigate the water supply issues cited above. In the long-run, an effort must be made to conduct a feasibility study that will inform the issues concerning maintenance and extension of existing infrastructure. While our recommendations are based on the views of key informant engineers and our own observations,

31 these long-term recommendations cannot be used without the confirmation and analysis of engineers, urban planners, scientists and public health specialists. In that regard, it is likely that a full scale water treatment plant and delivery system will need to be constructed. In order to increase proximity of sources to households, more pipes and distribution points (water kiosks) will need to be installed and developed. In order to prevent leakages and informal tapping, as well as improve water pressure, the system will have to be maintained and regulated. In order to increase the quantity of water supplied, the Ruiru River should be further utilized. It is likely that more boreholes can be drilled in less densely populated areas such as Murera, and parts of Kahawa Sukari.

In the short-run, the SIPA team recommends implementing innovative solutions to address the problems of water availability, proximity and treatment. Rainwater harvesting should be considered as an alternative water source. Rainwater harvesting can be used to compensate for the inadequacies of conventional water supply systems and circumvent the challenges of water contamination and pollution. This method of water supply also encourages local ownership of the water source. Rainwater harvesting, which is already being used as a water source by some Ruiru residents, can be done in both rural and urban areas. The prevalence of metal roofs in Ruiru (which facilitate the collection of rain water) makes this a viable option.40

The SIPA team also recommends that the Municipal Council work with public health officers and NGOs to raise local awareness of point-of-use water treatment methods. Waterguard, a chlorine-based treatment marketed by Population Services International (PSI), is available in Ruiru for Ksh 70 per liter. It is a more user-friendly and cost-effective method of treatment than boiling, which is the primary method used in Ruiru. It works by inactivating the microbial pathogens that cause many water-related diseases. According to PSI, Waterguard is able to treat water for a family of six for the cost of USD 0.30 per month.41

While a water treatment public awareness campaign will require funding and coordination, the Council can partner with local42 and international NGOs that promote health awareness in order to implement the campaign. Specifically, the Council should try to engage PSI to scale up promotion of Waterguard.

40 In this regard, the reader may contact Maimbo Malesu, Regional Coordinator for A Network for Green Water Harvesting in Eastern and Southern Africa and South Asia, based at the World Agroforestry Centre (ICRAF), RELMA in Nairobi, Tel: +254 (0)20 7224421. 41 Population Services International. Safe Water Treatment. http://www.psi.org/our_programs/products/water_chlorination.html. Accessed May 4, 2006. 42 Erick Waweru from the NGO Darubini (based in ) could be contacted for follow up. The Darubini NGO showed interest in water treatment awareness, but was unable to implement a campaign due to lack of funding.

32 B. SANITATION

Key findings Recommendations • Environmental and health • Develop simplified sewer systems challenges due to the lack of a in high-density areas sewer system • Plant bamboo to clean sewage • Unsatisfactory household sanitation • Investigate ecological sanitation facilities technologies o Over-reliance on pit latrines • Institute and enforce regulations o Improperly placed and • Build public awareness maintained septic tanks o Steps to control and • Poorly maintained and crowded properly maintain facilities household facilities • Illegal dumping of human waste o Health education • Lack of public awareness and personal control

The lack of planning for sanitation and particularly the absence of a sewer system constitute a major development challenge for Ruiru Municipality. The existing options for household sanitation are limited to pit latrines and flush toilets connected to septic tanks. A minority of residents lack toilet facilities of their own and therefore either rely upon neighbors’ facilities or dig shallow holes. The degree to which each of these alternatives contributes to health and environmental challenges varies, but without a sewer system to ensure proper human waste disposal, none is ideal.

Household Facilities

According to the SIPA household survey, the breakdown for household toilet facilities is as follows: 21% flush toilet, 57% simple pit latrine, 20% Ventilated Improved Pit (VIP) latrine and 2% dug hole (see Figure 21). However, percentages were not uniform among different income groups. The team found that 8% of low income residents and 17% of middle income residents used flush toilets compared to 54% of high income residents. Reliance on pit latrines was greatest in Githurai and Murera as represented by 85% percent of survey respondents in each ward.

33

Pit Latrines Figure 19 Pit latrines present several environmental and public health problems for Ruiru. First, reliance on pit latrines leads to contamination of groundwater sources through seepage of human waste into the soil (see Figure 19).43 Pathogens which are present in human waste thereby enter the water, leading to infection of the human host via the fecal-oral transmission route when the water is consumed. Guidelines for global environmental health standards recommend that both latrines and septic tanks be placed at least 30 meters from a water source in order to avoid contamination of drinking water. 44 The SIPA survey results found that 65% of households using a private well as a water source had a Source: Adapted from Morris et al. 2003 latrine or septic tank within 30 meters of a the well. Of those, 72% used water from the well for drinking, making transmission of diseases via the fecal-oral route extremely probable. Hazardous placement of latrines was particularly worrisome in Gitothua, where 90% of private wells used were situated within 30 meters of a pit latrine. Survey respondents were aware of the prevalence of diarrheal disease and showed a high concern about the possibility of typhoid outbreaks,45 both of which may be transmitted in this manner. However, they did not report the proximity of sanitation facilities and shallow wells as a major concern, suggesting that the link between pit latrines, well water, and disease is not well understood.

Pit latrines in Ruiru are prone to overflow during the wet season. Contrary to our expectation, most residents did not specifically note this problem (only 3%). However, in the more rural parts of Githurai, particularly in Tinghanga, community members complained that the latrines were full. This was observed in other parts of the ward, both urban and rural. Biological treatment of waste in latrines which absorbs the liquid waste and converts the solid waste to fertilizer is generally not used. Only one household surveyed used this method of sanitizing waste.

Another important consideration for sanitation standards concerns the number of people sharing a toilet facility. The maximum acceptable standard, designated for displaced people in an

43 Adapted from: BL Morris et al., “Groundwater and Its Susceptibility to Degradation: A Global Assessment of the Problem and Options for Management,” Early Warning Assessment Report Series. RS 03-3 United Nations Environment Programme, Nairobi, Kenya. 2003. 44 The Sphere Project. 2004. Humanitarian Charter and Minimum Standards in Disaster Response. Chapter 2. 45 A high level of concern over typhoid was noted among the study sample and indicated through key informant interviews. This level of concern was not substantiated through investigation with public health officials. It was unclear whether typhoid is a current problem in Ruiru or rather that the term is used to refer to a set of other diarrheal diseases. See Section D. of this report, “Health Linkages,” for more detail.

34 emergency setting, is 20 people sharing a toilet facility.46 Seventeen percent of households surveyed used toilet facilities shared with more than 20 people. The greatest percentage of households sharing above this threshold was found in Githurai (28%), followed by Gitothua (19%) and Murera (15%) while no respondents in Kahawa Sukari or Biashara shared a toilet with more than 20 people (see Figure 20). The concentration of people using a toilet was much greater for middle and low income residents compared to high income residents, and among those using pit latrines rather than flush toilets.

Figure 20 Respondents sharing toilet facilities with more than 20 people Percent of respondents

Biashara 0 Githurai 28 Gitothua 19 Kahawa Sukari 0 Murera 15 Low income 14 Middle income 21 High income 0 Pit latrines 22 Flush toilets 0 Overall (17%) Source: SIPA Household Survey (March 2006)

Septic Tanks

Due to the unsanitary conditions associated with pit latrines, the Municipal Council Department of Public Works’ housing regulations require that all new buildings be constructed with flush toilet facilities connected to septic tanks. However, many residences continue to rely on pit latrines, and builders can circumvent the regulation by not registering with the Council for inspection. In fact, pit latrines are still very common, as evidenced by the household survey.

Despite their relative advantages, septic tanks also pose risks to people and the environment due to substandard maintenance of facilities. Both septic tanks and pit latrines must be emptied in order to maintain a sanitary and healthy environment. While the concrete lining of septic tanks gives relatively more protection from seepage than the unlined pit latrine walls, seepage still occurs, particularly if tanks are not regularly emptied. Waste drained into the earth in such cases is likely to contaminate nearby water sources that people rely upon for drinking. Private exhausters are exclusively responsible for human waste disposal in Ruiru. The Municipal Council used to provide this service as well, but since the municipal exhauster broke down, people have had no alternative to the three private exhausters that serve the area. The average cost is Ksh 3500 or USD 50, which is beyond the reach of many residents. Waste that is exhausted from latrines and septic tanks is supposed to be deposited into Ruiru’s only connection

46 The Sphere Project. 2004. Humanitarian Charter and Minimum Standards in Disaster Response. Chapter 2.

35 to the main sewage line for Nairobi, which is located at , but this regulation is typically not followed. Instead, exhausters often dig holes in which they dump the waste, further degrading environmental conditions and contributing to Ruiru’s disease burden.47 The private exhausters operating in the wealthy neighborhood in Kahawa Sukari are a notable exception as anecdotal evidence suggests that they properly dispose of human waste.

Soak Pits

In many parts of Ruiru, septic tanks drain to soak pits to purify wastewater through sedimentation. This is potentially the most environmentally friendly means of human waste disposal available in Ruiru. However, using a soak pit on a large scale in a densely populated area is problematic because it requires land. Ruiru has a number of large soak pits through which wastewater passes in order to filter contaminated solid particles as the water moves toward nearby rivers. By the time the remaining water reaches the river, it is supposed to be thoroughly cleaned. However, the soak pits are not adequately designed to absorb the amount of waste drained into them. Disposal of washwater via septic tanks adds to this problem. Seventy-six percent of households using septic tanks, or 16% of all survey respondents, primarily disposed of washwater by pouring it into a toilet or other drain connected to a septic tank. The abundance of water interferes with the breakdown of excreta and may over-saturate the underlying soil, further increasing the likelihood that contaminated water will reach nearby groundwater sources and/or lead to flooding.48 Such flooding is seen in public areas and along the side of the main roads where run-off from factories, neighborhoods, and other establishments is concentrated.

In Ruiru, areas which commonly flood because of wastewater from the overly saturated ground below are referred to as “lagoons”. One such lagoon exists in the center of Biashara. Biashara’s low income tenement housing in the Majengo Estate is equipped with shared flush toilets which drain to a large soak pit under the central stadium. The stadium area between Ruiru Town and Majengo Estate is trough-shaped and liable to flood during heavy rains. As this is a site of recreation for city residents, individuals playing or resting in the stadium lawn come into regular contact with waste. There are no other drains for washwater in Biashara, so all water, whether contaminated by chemicals or human waste, is emptied together into the ground, flooding the area in which people play and the rivers serving other wards.

Sewage

The lack of a sewerage system in Ruiru poses perhaps the biggest development challenge, particularly in the more urban areas and central marketplaces. The problems of inadequate water supply and inadequate sanitation are inversely related. Sixty percent of water provided becomes wastewater, so neighborhoods with easy access to water through a piped system produce more wastewater. With no sewerage system in place to properly carry the abundance of wastewater out of Ruiru, the environment inevitably becomes contaminated. Currently, water providers are not

47 Key Informant Interviews 48 WHO “A Guide to the Development of On-Site Sanitation.” 1992. Accessed April 26, 2006. www.who.int/entity/water_sanitation_health/ hygiene/settings/hvchap5.pdf.

36 also responsible for wastewater, leaving each household to make its own plan for disposing of washwater and human waste.

While wastewater from septic tanks is either disposed of through private exhauster services or through soak pit filtration, washwater is predominantly dumped onto soil outside of households (66%) which forms streams of water along central market places. There are open gutters along the main road of Biashara carrying wastewater from residences and factories. Contaminated water from factories flows through the gutters in Biashara to the Ruiru River, a primary source of drinking water in Murera and Kahawa Sukari wards. Solid waste and other garbage is picked up by this water, creating dirty open gutters in densely populated areas.

Githurai is the most problematic ward regarding sewage because it has relatively more and easier access to water but no sewerage system to deal with wastewater disposal. In addition, Githurai has the largest population in Ruiru and is densely occupied in parts. Thus, having a greater water supply presents a major problem for Githurai because infrastructure for safely disposing of wastewater is lacking. Instead of a piped sewerage system, there is an above-ground tunnel connected to pipes which lead to the Kiu River. These tunnels are intended for washwater, not raw sewage. However, it was reported that people dump sewage into this tunnel at night. Many residences and apartment buildings in the urban Kwa Ngara area surrounding the market around the main taxi stand have drains for washwater leading directly into the street. Water and garbage line the dirt streets in the area where people and businesses are concentrated. Current plans for the Githuraini sewerage project will cover Githurai. The trunk sewers have been designed but not put into place because of a lack of funding.

In Gitothua, a flower nursery and the prison training school produce large quantities of wastewater which are not disposed of safely. The prison training camp drains its wastewater to the side of the main road where pools of water are always present. The flower nursery’s effluent contaminates the upstream water from a nearby seasonal river (April through June) which affects downstream residents using the water for washing, cooking and bathing.

The Municipal Council lacks the funding for a sewerage system and treatment plant. A feasibility study conducted in 1982 estimated a cost of Ksh 222 million for the construction of a sewerage system. Guesses from council members and engineers for current costs range from Ksh 266 million to one billion.49 According to an AWSB engineer, the nearby town of Kikuyu with a population of 165,000 developed a sewer system costing Ksh 750 million.50 A government grant was issued in 2002 for studying sewerage options in Ruiru. However, the project was quickly terminated and most of the money was diverted to drought mitigation. Baseline information from that study is available, so planners will not be starting from scratch. A loan was offered by the Chinese government to build a sewerage system, but the Council could not afford the interest rate on the loan.

49 Key Informant Interviews (13-24 March 2006) 50 Key Informant Interview

37 Household Satisfaction, Concerns and Preferences

There is a high level of dissatisfaction with sanitation facilities in the community (55% of survey respondents). The primary specific concerns residents raised were lack of a sewerage system (23%) followed by hygiene and cleanliness of household facilities (17%). Other concerns were distance from the household to sanitation facilities (8%), maintenance requirements (6%) and concern over disease associated with poor facilities (5%). Demand for a sewerage system was particularly high in Githurai (50%). When asked to describe their concerns regarding sanitation, many respondents (13%) expressed the opinion that the Council wasn’t taking enough action to provide additional services related to sanitation. These services fell into the categories of building a sewerage system, providing maintenance or construction for household facilities, especially pit latrines and building additional public latrines.

Concerns were not uniform among income groups. The most commonly cited concerns among low-income respondents were cleanliness (17%) and maintenance (11%) of household facilities, while lack of a sewer system was the primary concern among high-income residents (31%).

Community preferences for household sanitation facilities vary (see Figure 21). Seventy-five percent of respondents would prefer to use a flush toilet and, of those, 72% expressed a preference that the toilet be connected to a sewerage system. Those who did not indicate a preference for a sewerage system didn’t necessarily prefer using a septic tank but rather didn’t perceive a sewerage system as a possibility in Ruiru at this time. Interestingly, a quarter of the survey respondents expressed a preference for using pit latrines over flush toilets despite the fact that latrines are associated with disease and environmental contamination. In addition, while 35% of respondents using pit latrines currently use a Ventilated Improved Pit (VIP) latrine, only 24% of those who indicated a preference for pit latrines specified that they would prefer a VIP latrine, indicating that residents are not aware of the hygiene benefits of improved latrine technologies. Figure 21

Preferred Household Sanitation Current Household Sanitation Facilities Facilities Simple pit Flush toilet Flush toilet Dug hole latrine 21% 21% 19% connected to septic tank (2%) VIP latrine 6% 57 % 20 % VIP 54% Flush toilet Simple pit latrine connected to latrine sewer system

Source: SIPA Household Survey (March 2006)

Among the primary reasons for favoring both flush toilets and pit latrines were hygiene and convenience considerations. Maintenance was one of the primary reasons among respondents who indicated a preference for pit latrines (22%), but it was not commonly cited as a reason for preferring a flush toilet. This is consistent with views residents expressed about the water and

38 infrastructure needs for flush toilets. According to residents of Majengo Estate in Biashara, poorly maintained flush toilets frequently become clogged allowing for the accumulation of stagnant pools of dirty water suitable for mosquito breeding. Survey respondents from Majengo believed that blocked toilets significantly contributed to the major public health problem of malaria. Another reason cited by those who preferred to use pit latrines was the lack of a sewerage system to handle wastewater. Residents also expressed concern over water needs for flushing of toilets, explaining that water was unavailable or costly and therefore poorly spent to flush the toilet. One quarter of residents with flush toilets seemed to get around this problem by using washwater to flush the toilet.

Recommendations

Capital investments in infrastructure should be prioritized on building a sewerage system before increasing water supply in urbanizing areas of Ruiru, except in cases where consumers’ water usage does not meet basic health standards. Increasing the water supply in parts of Githurai, for example, without providing for a drainage system would increase the quantity of wastewater in the environment, posing a serious health threat. Planning for such a sewerage system should start immediately with the support of AWSB. As part of a broad framework for improving water and sanitation services in Ruiru, water supply and sewerage infrastructure must be provided by the same entity to ensure that the alleviation of problems concerning water supply doesn’t exacerbate the municipality’s sanitation problems.

Short-term sewerage interventions are urgently needed in densely populated areas such as Githurai market. We recommend that the Council develop simplified sewerage systems in high density housing areas and market places modeled on Brazil’s highly successful condominial system.51 52 As opposed to a formal sewage network, the condominial system is maintained by the community and uses a low-cost piping system laid in easily accessible shallow gutters. The highly flexible design of the shallow pipes is suitable for the irregular zigzag pattern of unplanned peri-urban settlements such as those that exist within Ruiru. The system depends heavily on social cohesion in that each household becomes responsible for maintaining a segment of the pipe that is connected to the home. Neighbors rely on each other for notification of a blockage in the system as individual households are responsible for fixing the problem. These sewerage projects have been very successful where they have been implemented and have served to strengthen community involvement in local sanitation issues. Moreover, they have been found to reduce the cost of sanitation services by up to 40%.53 The condominial system has been replicated in multiple cities in Brazil and in other countries indicating that it has characteristics of high transferability and reliability.

51 Melo, Jose Carlos. August 2005. “The Experience of Condominial Water and Sewerage Systems in Brazil: Case Studies from Brasilia, Salvador and Parauapebas.” Bank-Netherlands Water Partnership. Accessed May 1, 2006 http://wbln0018.worldbank.org/water/bnwp.nsf/files/BrasilStudyTour2.pdf/$FILE/BrasilStudyTour2.pdf. 52 Condominial Systems – Brazilian Panorama and Conceptual Elements. Accessed May 1, 2006 http://www.efm.leeds.ac.uk/CIVE/Sewerage/articles/condominial2.pdf. 53 Condominial Water and Sewerage Systems: Lower Cost with Grater Benefit. Accessed May 5, 2006 http://www.wsp.org/condominial/indexeng.html

39 In response to findings that poor drainage and poorly maintained flush toilets lead to an abundance of stagnant water, environmental contamination, vector proliferation and increased disease, we propose that giant bamboo cultivation be promoted in Ruiru for its sewage cleaning properties. Giant bamboo is native to Kenya and is used for a variety of income-generating activities such as construction of furniture. It is less commonly known that bamboo has natural properties for absorbing pollutants from the ground. 54 The case examples of the World Agroforestry Centre’s (ICRAF) projects in Ethiopia and Western Kenya are highly relevant for Ruiru.55 Expert advice is easily accessible given the proximity of Ruiru to ICRAF’s headquarters in Nairobi. Another promising consideration is that there is already a bamboo nursery in Thika, just outside of Ruiru. The SIPA team sees particular potential for planting bamboo along the side of the main road in Gitothua where waste from the prison training camp collects and around the main stadium (lagoon) in Biashara.

We did not find septic tanks to be a sustainable means of excreta disposal in Ruiru, because they are not systematically maintained and they are not properly drained to soakaway filtration systems. To address these problems, and in keeping with United Nations recommendations for urbanizing areas, we recommend that growth in septic tank use be discouraged and limited to 10%. 56 Ecological Sanitation (EcoSan) and other environmentally friendly sanitation technologies currently used in Kenya and other parts of Africa should be investigated and promoted as an alternative if feasible. 57 58 Systems that do not require water would be particularly appropriate for this setting. Among the technologies available is the Skyloo, which can be used in areas where contamination of groundwater is of concern because the community

54 “A Giant Solution to a Giant Problem.” May 2004, World Agroforestry Centre. Accessed May 2, 2006. http://www.worldagroforestry.org/ar2004/tc_story01.asp; http://www.worldagroforestry.org/es/bamboo.asp. 55 Contact Chin Ong, of the World Agroforestry Centre (ICRAF); see contact details on the contact sheet in Appendix 14; also visit www.worldagroforestry.org. 56 “Millennium Development Goals Needs Assessments for Ghana, Tanzania, and Uganda.” Background Paper to Sachs, Jeffrey D., John W. McArthur, Guido Schmidt-Trab, Margaret Kruk, Chanrika Bahadur, Michael Faye, and Gordon McCord. 2004. “Ending Africa’s Poverty Trap” Brookings Paper on Economic Activity. No. 2: 117- 216. 3. Sept 2004. p. 111 57 “Sanitation and Hygiene in Kenya: Lessons on What Drives Demand for Improved Sanitation” Water and Sanitation Program, June 2004. Accessed May 3, 2006. http://www.wsp.org/publications/af_kenya_hygiene.pdf. 58 “Smart Sanitation Solutions: Examples of innovative, low-cost technologies for toilets, collection, transportation, treatment and use of sanitation products” Netherlands Water Partnership, 2006. Accessed May 3, 2006. http://www.ecosan.nl/content/download/944/6696/file/Smart%20Sanitation%20Solutions%20e-book.pdf.

40 relies on shallow wells for drinking water. One potential opportunity for the Municipal Council to set an example for the community would be to subsidize the construction of public toilets using appropriate technologies in the areas where sharing of toilets is particularly problematic. In this case, maintenance of facilities would be important to adequately promote the technology and raise public awareness.

Because almost all toilets in Ruiru require exhausting services, the number of exhausters for emptying latrines and septic tanks should be increased, either through municipal service provision or by attracting private operators. Given the budget constraints of the Council, it unfortunately seems improbable that the Council is in a position to subsidize exhausting services. However, if there is any way to obtain funds for this purpose, it is important that this service not be out of reach for poor residents who already are more likely to bear the highest disease burden.

Regulations and enforcements for proper use and maintenance of sanitation facilities and the greater environment are necessary. Lack of accountability for construction and maintenance of facilities is a major factor contributing to substandard sanitation conditions. The Municipal Council, property owners and community members should have a clear set of guidelines for their responsibilities surrounding sanitation, and mechanisms for enforcement must be in place. Key regulations include proper disposal of human waste, especially by exhausting companies, maintenance of facilities, spacing of latrines and groundwater sources and provision of adequate facilities to reduce sharing to an acceptable international standard. In areas where the Council provides low income housing, such as the Majengo Estate in Biashara, there must be accountability for maintenance of facilities to prevent toilets from becoming suitable breeding grounds for mosquitoes because of blockages. A clear set of guidelines is important not only for the health of the community but also to empower residents through firmly established rights and responsibilities that will allow them to govern their own situation.

A final set of recommendations reflects the need to increase public awareness on a variety of sanitation, health and hygiene issues. While survey respondents showed a general awareness of the relationship between major diseases and water and sanitation problems, the SIPA team saw evidence that they did not know how to take small measures to protect themselves. Awareness campaigns about proper use and maintenance of sanitation facilities must be initiated. Given the low level of NGO involvement in water and sanitation in Ruiru, the Municipal Council should strengthen partnerships with community groups and public health officers to promote awareness of health and hygiene practices and water treatment. Strong community-based organizations are a significant asset to the municipality in terms of community mobilization, and the opportunity to educate the public through these groups should be a top priority for all of the environmental health and hygiene considerations. School health clubs are another good entry point for introducing simple lessons about sanitation and hygiene including use of microbial treatment of waste in pit latrines, toilet covers to prevent insect-breeding, the merits of VIP latrines compared to simple pits, and hazards associated with placement of latrines, washwater disposal and poor maintenance of facilities. International NGOs operating in the region such as Population Services International (PSI) and the African Medical and Research Foundation (AMREF) may be good sources of funding and technical assistance.59

59 See contact list in Appendix 14

41

(top left) Open sewage in Githurai; (top right) Latrine at Gachagi squatter village in Gitothua; (bottom left) Household washwater drained directly onto the street in Githurai; (bottom right) Roadside flooding of wastewater from the prison training camp in Gitothua.

Source: SIPA Field Trip (March 2006)

42

(top left) Garbage Dumping Site in Murera; (top right) Communal Garbage Collection Point in Gitothua; (bottom) Illegal Garbage Dumping in Githurai. 43 Source: SIPA Field Trip (March 2006) C. SOLID WASTE

Key findings Recommendations

• Insufficient collection capacity • Set up more communal collection

• Garbage burning points

• Unsatisfactory dumping site • Re-allocate refuse collection

• No formal recycling capacity • Widespread illegal dumping • Regard waste as a resource • Low level of public involvement • Enforce regulations

• Explore opportunities for leveraging partners

• Build awareness in schools • Leverage youth groups for garbage

collection • Encourage community clean up

campaigns

Poor solid waste collection and disposal are significant problems in Ruiru. Within the Municipal Council, the Public Health and Environment Section of the Building & Works Department is responsible for solid waste management in Ruiru. The exact amount spent on solid waste management by the Municipal council is difficult to determine because the corresponding funds are aggregated within the line item "Public Health & Environment" in the Municipal Council's annual budget. The estimate for the year 2005-2006 includes an expenditure of KSH 3.4 million,60 representing about 5% of overall expenditure.61

The Municipal Council and private collectors provide collection services in some wards; however, no ward is completely covered. Hence, large parts of the population use alternative disposal methods with negative health and environmental implications. Additionally, existing dumping and recycling practices are unsatisfactory. Although individual residents, civil society organizations, and survey respondents have voiced various complaints to the Municipal Council, the overall level of public involvement is relatively low.

60 USD 47,000 at USD 1= KSH 71.04. April 24, 2006. 61 Municipal Council of Ruiru. 2005. Annual Estimates July 2005-June 2006.

44 Garbage Collection

The garbage collection rate in Ruiru Municipality is low. The Municipality has a staff of 30 garbage collectors and road graders working under the Public Health Headman. Together they currently operate one truck and one tractor with an estimated garbage collection capacity of about 150 tons per week.62 However, today's estimated 170,000 residents of Ruiru produce about 585 tons of solid waste per week. While private operators additionally collect an estimated 50 tons per week, an uncollected balance of about 385 tons per week remains, implying that current collection rates are about 35% of total generated waste, as illustrated in Figure 22.63 This compares to a collection rate of 25% in Nairobi.64 Figure 22

The high volume of uncollected waste presents a major challenge not only from an aesthetic point of view in terms of smell and appearance, but also from environmental and health standpoints. Uncollected garbage can end up in drains, which can cause blockages and potentially lead to flooding and an unsanitary environment. Furthermore, certain components of solid waste make suitable breeding grounds for flies, as do blocked drains for mosquitoes, both potentially contributing to the spread of disease. Additionally, uncollected garbage degrades the environment and dampens endeavors to keep public and private spaces clean and attractive.65

While not having specific data for Ruiru Municipality, figures for Nairobi indicate that food wastes represent about half (52%) of all solid waste, followed by paper (16%) and plastic (12%), with plastic bags representing a problem of increasing magnitude since grazing animals can die from eating them (see Figure 23).66

62 As of March 2006, a second collection truck has not been utilized for about one year as it needed repair. 63 Own calculations based on interviews with Public Health Headman and Town Administrator. 64 Government of Kenya and UNEP. 2004. Selection, Design and Implementation of Economic Instruments in the Kenyan Solid Waste Management Sector, Final Draft. p. 26. 65 Introduction to Solid Waste Management. 2002. http://www.sanicon.net/titles/topicintro.php3?topicId=4. Accessed April 25, 2006. 66 Government of Kenya. "Introduction to Solid Waste Management." Selection, Design and Implementation of Economic Instruments in the Kenyan Solid Waste Management Sector. p. 25.

45 Figure 23

Within this context, the marked differences in the geographic distribution of garbage collection services are particularly striking. The Municipality offers scheduled garbage collection primarily in the business and residential areas of Biashara, Githurai, and since 2003, in Gitothua. The wards of Kahawa Sukari and Murera are either not served by the Municipality at all (Kahawa Sukari) or are only irregularly served and without prior notice depending on spare capacity (Murera). This picture is also reflected in the household survey in which 50% of the respondents of Biashara indicated having regular garbage collection 67 (38% and 35% in Gitothua and Githurai respectively), compared to only 8% (1 respondent) in Murera. Interestingly, 21% of respondents in Kahawa Sukari indicated having collection services at the household level, which would have to be offered by private operators. (See Figure 24)

Figure 24

67 Including one respondent indicating collection from neighborhood collection point. SIPA Household Survey.

46 The primary method of garbage disposal in the Municipality is burning with about 48% of respondents making use of this method.68 However, burning prevalence ranges from 55% of respondents within Githurai and 50% in Murera to 34% of respondents within Biashara (see Figure 24) As the burnt waste typically includes significant amounts of plastics (see Figure 23), carcinogenic vinyl chloride monomers and dioxins are generated.69 This contributes to upper respiratory tract infections, which are a leading disease cause in Ruiru.70

Business and population densities seem to be the primary factor in explaining the different solid waste collection service levels. The survey results do not support marked differences in service levels based on preferential treatment of high income groups, as 31% of respondents within the low income group indicate having private collection compared to 33% of respondents within the middle income category and 17% respondent within the high income category (see Figure 25). Interestingly, 75% of the respondents within the high income group indicated burning their garbage. Figure 25 While municipal garbage collection is free of charge to those households that are served, serviced households are expected to purchase garbage drums for Ksh 500. Residents expressed the concern that this cost is out of reach for many residents and that the Municipal Council should instead provide bins for free (8% of respondents). Also, 24% of respondents specifically demanded that the Municipal Council provide garbage collection. Applying a consolidated categorization of concerns voiced, 39% of respondents were concerned with a general lack of action by the Municipal Council. The option of contracting private operators that charge about Ksh 100 per month is likely not to be affordable or desirable for much of Ruiru's population.

In addition to household collection, the Municipal Council collects garbage from selected public locations within the community, for instance in Gitothua and in Biashara (see photo on page 43). Households are expected to bring their solid waste to these points for regular collection. High income households, for instance in Kahawa Sukari and Murera, were said to sometimes take their rubbish to a designated dumping site themselves.

68 Including 6% of respondents using multiple methods including composting of biodegradables and burying of plastics. SIPA Household Survey. 69 Government of Kenya, Selection, Design and Implementation of Economic Instruments in the Kenyan Solid Waste Management Sector. p. 28.

70 See Section D “Health Linkages”

47 Garbage dumping

Currently, the only official public dumpsite is located in Murera ward and seems to be a cause of great concern for residents of Ruiru and members of the Municipal Council alike (see photo on page 43). Various shortcomings can be identified, which constitute public health hazards: lack of fencing attracting waste pickers, location in a depression, location too close to residential areas and overall capacity constraints considering Ruiru's rapid population growth. Additionally, negative environmental implications have been noted. Water becomes stagnant at the dumpsite and mixes with collected waste, which then seeps into the sandy soil and infiltrates rapidly into the groundwater. There is no run-off of water from the dumping site. The garbage is not enclosed and – except for the opportunistic collectors on the dumping site – recycling is not currently pursued.

Considering this situation and pressure by residents, the Environmental Sub-Committee of the Municipal Council was charged to identify and acquire a new dumping site in 2005. However, to the knowledge of the SIPA team, attempts to identify a suitable location, for instance by buying land from coffee estates, have not yet been successful. Instead, the Council is currently looking for experts (including NEMA) to conduct an environmental impact assessment to determine an environmentally friendly site.71

Another solid waste management issue is illegal dumping, which is widespread in Ruiru (see photo on page 43) Interviews with key informants suggest that citizens have expressed discontent on this issue with the Council.72 Yet, the pervasive visibility of garbage suggests that overall public action against illegal dumping is low. Even though a fine of Ksh 2,000 exists for illegal dumping, there appears to be little to no enforcement. In addition, private garbage collectors might contribute to illegal dumping in order to avoid costs.

Public involvement in solid waste management

As indicated above, the level of public awareness about safe solid waste management practices seems to be relatively low in Ruiru overall. Thirty-eight percent of respondents did not mention any concern regarding solid waste management. Considering the degradation of the physical environment and the negative health impacts, this low level of concern is striking. Interestingly, the share of respondents not having any concerns regarding solid waste management ranges from 29% in the middle income group to 62% in the high income group and from 23% in Githurai to 71% in Kahawa Sukari (see Figure 26). Yet, the negative environmental and health impacts, for instance air pollution caused by the burning of waste, impact everybody in the community similarly, regardless of income level or ward boundary.

Furthermore, overall 12% of respondents reported throwing garbage anywhere (see Figure 24). This finding further substantiates the need for increased awareness about one's own contribution to proper solid waste management and for a change in attitudes towards waste in general.

71 Interviews with Town Administrator and Councilors, correspondence. 72 E.g., 2005 petition from residents of Upper Mugutha with 134 signatures to Municipal Council protesting illegal dumping in Murera.

48 Figure 26

However, respondents expect the Municipal Council to take more action regarding solid waste management: 39% of respondents mentioned the lack of action on the part of the Municipal Council as the or one of their concerns regarding solid waste management (see Figure 27). Figure 27 Thus, civil society involvement in solid waste management seems to be relatively low in Ruiru, especially when compared to the number of NGOs active in public health and orphan care. Githurai Youth Group collects garbage in selected neighborhoods for a fee of Ksh 100 per household per month. Anecdotal evidence suggests that other civil society organizations have expressed interest in offering similar services. Yet interviews with key informants revealed that the Municipality was not able to engage in an extended collaboration because it lacks capacity in transporting collected waste to dumping sites. However, the SIPA team has identified another form of civil society involvement in solid waste management: selected schools educating students in relevant topics or facilitating the activities of "Environment Clubs."

Recommendations

From an environmental and health perspective, ideally the Municipal Council would provide free and universal garbage collection service to its residents and would then dispose of and recycle waste appropriately. Additional collection vehicles, a safe garbage dumping site as well as garbage recycling facilities would need to be available to the Municipal Council, especially considering Ruiru's rapid population growth and the corresponding increase in garbage produced.

49 Assuming that the Municipality did not utilize additional collection vehicles and that privately collected volumes remained stable, the collection rate would decrease from currently 35% (See Figure 22) to about 25% by 2010 solely because of population growth. In order to provide a constant service level, the Municipality would either have to utilize an additional collection truck itself or increase the privately collected volume threefold to about 150 tons per week. The Municipality is planning to purchase an additional refuse collection tractor in 2005-2006 with funds received from the Local Authorities Transfer Funds, which would alleviate some of the pressure on collection capacity.73 Yet, in order to achieve a significant improvement in service levels (e.g., a collection rate of 75%), the Municipality would need to utilize four trucks (while keeping private involvement at constant levels) or would need to increase private collection tenfold.74 Yet, capital and operating resource constraints need to be considered when planning future service expansions.

Currently, the Municipal Council estimates an income for the fiscal year 2005-2006 of about Ksh 70 million,75 translating into about Ksh 400 per capita (USD 5.60).76 It is obvious that these resources will not suffice to provide for basic needs in all areas. Yet, the SIPA team has identified a set of initiatives that the Council could investigate further in the short-term.

First, the Council could potentially capture some quick wins in terms of increasing garbage collection capacity with existing and newly funded vehicle capacity by setting up more communal collection points and by then re-allocating refuse collection vehicle capacity. The current obstacle to increasing collection volumes seems to be limited vehicle capacity. Hence, the collection vehicles should focus on making more trips between collection points, such as markets and other communal areas, and the dumping site itself, providing high garbage pick-up volumes, instead of making time-consuming low volume household level trips. However, for this quick win to materialize, the Council would need to inform affected households when setting up the communal collection points, so that they accept and systematically make use of them when disposing of their garbage. If resources were available, the Council could offer incentives for participating in the communal collection scheme, for instance offering subsidized dustbins.

Second, another set of measures deals with investigating opportunities for using waste as a resource. As indicated above, due to a lack of formal recycling, only a small share of garbage is currently recycled or composted in Ruiru.77 Yet, case studies taken from locations in various developing countries,78 including Kenya and even in Nairobi, suggest a potential for generating both revenue and employment be re-using waste while reducing the volume of garbage to be eventually dumped.

73 Municipal Council of Ruiru. 2005. Annual Estimates July 2005-June 2006. 74 Own calculations. 75 Including funds transferred from LATF. Municipal Council of Ruiru. 2005. Annual Estimates July 2005-June 2006. 76 Based on an estimated mid-year population of 173,000. US $1=71.04 KSH. April 24, 2006. 77 Only 6% of respondents indicate composting organic waste. SIPA Household Survey 2006. 78 Albina Ruiz, 1996, http://www.ashoka.org/fellows/viewprofile3.cfm?reid=96549. Accessed April 1, 2006. Ravi Agarwal, 1998, http://www.ashoka.org/fellows/viewprofile3.cfm?reid=124335. Accessed April 1, 2006. Cláudio Vinicius Trigueiro Vidal, 1992. http://www.ashoka.org/fellows/viewprofile3.cfm?reid=96994. Accessed April 1, 2006.

50

Nairobi's City Garbage Recyclers is an organization that has spearheaded the initiative in Kenya and is now replicating its model in various communities in East Africa.79 The basic concept is to form a cooperative or small business, whose employees manually separate garbage into organic waste, paper, plastics and other components. The organic waste, which comprises more than half of the overall solid waste produced (see Figure 23), is processed into fertilizer. Briquettes are made out of paper mixed with charcoal and plastic sheeting is washed, shredded and stuffed into sacks as pillows or mattresses.80

Additionally, the Municipal Council could investigate setting up recycling buy-back centers for cans, plastics and paper. This could contribute to bringing existing waste pickers out of the informal sector and mitigate some of the health risks to which they are currently exposed.

While the benefits of these two interventions seem attractive (income and employment generation, cleaner environment, reduced dumping volumes), the Municipal Council should develop a business plan including both associated costs primarily in terms of capital requirements as well as a market analysis for the actual production.

Another intervention recommended to both increase the revenue base of the Municipal Council and reduce illegal littering is to enforce existing regulations. By following through on illegal dumping regulations, the Municipal Council could send a signal to its residents about its seriousness regarding improving solid waste management practices.

Furthermore, the Municipal Council should explore opportunities for leveraging partners in order to both increase public involvement as well as collection capacity. Proper solid waste management practices should be an integral part of the school curriculum for children of all ages. Particular emphasis should be placed on highlighting the importance of individual attitudes and contributions to realize a clean and safe environment.

In addition, the Council should further investigate engaging youth groups and other civil society organizations in garbage collection at the household level. Collaboration with the Githurai Youth Group described above can potentially be replicated in other wards or neighborhoods. Yet, as noted previously, this intervention seems to require additional collection vehicle capacity. Hence, the re-allocation of vehicle capacity described as a quick win earlier is of key importance.

Closely connected to leveraging civil society organizations for collecting waste is the possibility of potentially granting additional licenses to private operators. While both interventions can contribute to reducing the collection gap (see Figure 22), the Council should carefully develop strategies for serving households that cannot afford private collection services.

Finally, the Council could try to organize or support community mobilization efforts targeted at cleaning up the physical environment.

79 Andrew Macharia, 2003. http://www.ashoka.org/fellows/viewprofile3.cfm?reid=143971. Accessed April 1 2006. 80 Andrew Macharia, A Way with Waste, Available: http://www.new-agri.co.uk/03-1/develop/dev01.html, April 20 2006. Parselelo Kantai, The Treasure Buried in Nairobi's Dumps, 18 December 2000, April 20 2006.

51 D. HEALTH LINKAGES

Key Findings: Recommendations:

• Malaria is the second leading cause • Collaborate with the Ruiru Health of new disease cases at the Ruiru Center to build on public health Health Center. Diarrheal diseases are education efforts, incorporating the third. recommendations from the SIPA team report. • While typhoid is perceived to be a major public health problem in • Engage nongovernmental Ruiru, a relatively small number of organizations and community cases have been reported at the groups in a comprehensive public Ruiru Health Center. health awareness strategy.

• Fluoride levels above WHO • Leverage malaria awareness to standards have been found in scale up the provisioning of borehole water in Biashara. insecticide-treated mosquito nets, targeting children and the extreme • High level of awareness of malaria poor. and how it spreads. • Invite public health researchers to • A serious health study must be Ruiru to conduct a serious health conducted to more fully examine the study. epidemiology of the disease burden in Ruiru.

The poor water, sanitation and solid waste conditions described above pose a health risk for the community members of Ruiru Municipality. While this report is not an epidemiological study, through health data, key informant interviews, and household survey analysis, the SIPA team is able to provide insights into the health of the community. A health study should be conducted in order to determine specific causal relationships between water, sanitation, and solid waste services and the disease burden in Ruiru.

Diseases

The SIPA team was able to obtain monthly health data, enumerating new disease cases treated at the Ruiru Health Center, the main public health clinic in the municipality (see Appendix 12. While the data only represents reported disease cases at one health center, it does provide a snapshot of the diseases in Ruiru.81

81 Residents of Ruiru Municipality also have access to two small public facilities, 50 private clinics and informal herbalists within the municipality, as well as a small dispensary, subdistrict hospital and district hospital in the surrounding area.

52

One limitation of the data is that it does not disaggregate cases by gender and age group. In future studies, making this distinction will allow for more targeted policymaking. Even without Ruiru-specific data, it is clear that children are an especially vulnerable population. Previous studies show that children are the most affected by water- and excreta-related diseases because they are unable to mitigate the threats posed by an unsanitary environment through hygiene behavior.82

Top Ten Diseases: For the six-month period from September 2005 to February 2006, five of the top ten diseases identified at the Ruiru Health Center were water- and excreta-related diseases (see Figure 28). These five diseases accounted for 53% of the total number of new disease cases.

Diseases of the respiratory system were the Figure 28 leading cause of reported disease cases at the Top Ten Disease Causes Ruiru Health Center. While other forms of Ruiru Health Center air pollution contribute to respiratory September 2005-February 2006 diseases, the burning of solid waste is also a New Disease Cases Percent of contributing factor. Total Cases Respiratory diseases 32% While the WHO cites the risk of malaria in Malaria 27% Nairobi as low, 83 in Ruiru, just 16 Diarrheal diseases 9% kilometers outside of Nairobi city center, Skin diseases 7% malaria was the second leading cause of Intestinal worms 6% disease at the Ruiru Health Center. Malaria All other diseases 5% made up 27% of total new cases at the Ruiru Eye infections 4% Health Center, which is above the most Rheumatism and joint pains 3% recent public estimates of 21% for the entire Pneumonia 2% Central Province. However, the malaria percentage share of diseases is low Urinary Tract Infections 2% compared to the Nyanza and Western Source: Ruiru Health Center , where malaria accounts for an estimated 43% of reported disease cases.84

The malaria percent of total new cases at the Ruiru Health Center increased from 24% during the six-month period of September 1999-February 2000 to 27% for the period of September 2005- February 2006.85

82 Bartlett, S. 2005. “Water, Sanitation and Urban Children: The Need to Go Beyond Provision.” Children, Youth and Environments. 15(1): 115-137. 83 WHO 2005. International Travel and Health Publication. Country List. Vaccination Requirements and Malaria Situation. Accessed April 30, 2006. http://www.who.int/ith/en/. 84 While the Ministry of Health numbers are posted on its website under “Epidemiological Trends” and dated 2005, it is unclear if these numbers are based on 2005 data. Ministry of Health, Republic of Kenya. 2005. Accessed May 1, 2006. http://www.health.go.ke/ 85 See Appendix 12 for all available health data.

53 Furthermore, although it is not recorded in the data, according to one health professional at the Ruiru Health Center, malnutrition was common, contributing to increased susceptibility of water-related and other diseases.

Typhoid: Both key informants and survey respondents identified malaria and typhoid as the most common diseases in the municipality (see Figure 29). The health data on malaria supports public opinion. However, in the case of typhoid, there is a disconnect between the data and local perceptions. According to the Ruiru Health Center data, between September 2005 and February 2006, out of a total of 18,980 Figure 29

cases of diseases, 67 cases of typhoid were reported (compared Have you heard of this disease to 5,113 cases of malaria during ocurring in your area? the same six-month time period.)

100 However, health officials 90 believed that typhoid was over- 80 reported due to unreliable testing 70 and that many of the people who 60 felt they had typhoid, instead, Yes 50 suffered from diarrheal diseases. No 40 However, officials acknowledged 30 the presence of the disease in 20 Ruiru, estimating that several of 10 the cases treated at the Ruiru 0 Health Center were, in fact, a ia e id ns TI o ms R rh r alar ph tio U typhoid. M Wo Ty l Diar a n sti ye Infec Skin diseases te E Typhoid is not a new disease in In Ruiru. While the SIPA team was not able to obtain the continuous data necessary for rigorous analysis, the available data shows a pattern of a relatively small number of reported cases at the Ruiru Health Center going as far back as August 1997.

Even if more complete data were available, it would be difficult to assess an accurate number of cases of typhoid in Ruiru because the type of blood test (sereological test) used by both the Ruiru Health Center and private clinics in the area tends to result in false positives. Therefore, the number of cases represented in the health data may be higher than the actual number of cases. There may also be unaccounted for cases of typhoid within the diarrheal diseases classification of the health data.

Public health officials cited a typhoid outbreak six years ago near Ruiru, within Thika district, as one explanation for the heightened awareness of typhoid in the area. Another account highlighted that patients prefer a concrete diagnosis of typhoid to the less specific diagnosis of diarrheal disease.

While the data on typhoid has severe limitations, it does suggest that the perception of typhoid as a major public health problem may be exaggerated. However, the presence of any number of

54 typhoid cases in a rapidly urbanizing environment with poor sanitation conditions is still cause for concern.

Further study should be done to explore the disconnect between the data collected at one health center and the population’s perception of typhoid as a major public health problem.

Respiratory Diseases and Solid Waste: Due to the insufficient solid waste collection services, residents often burn garbage in an effort to dispose of it. The burning of solid waste is one factor contributing to both Upper Respiratory Tract Infection (URTI) and Acute Lower Respiratory Infection (ALRI). URTI, which includes laryngitis, tracheitis, and/or bronchitis, is an acute viral illness. In contrast, the small particulate matter from the smoke emitted by the burning of the solid waste leads to ALRI by lodging deep in the lungs, posing a more long-term health threat. Transportation pollution, industrial emissions, and other household pollution from activities such as cooking with charcoal stoves also contribute to URTI and ALRI.

Fluoride Poisoning and Chemical Contaminants: While microbial contaminants in the water contribute to infectious diseases, chemical contaminants also play a role in public health outcomes. High levels of fluoride in the groundwater can lead to fluorosis or fluoride poisoning. Fluoride occurs naturally and is considered safe unless levels exceed the WHO standard of 1.5 milligrams per liter.86 In Biashara, borehole testing revealed fluoride levels of 3 milligrams per liter. Fluorosis may have long-term negative health effects such as severe anemia, stiff joints, painful and restricted movement, mottled teeth and kidney failure. While fluorosis is not explicitly identified in the Ruiru Health Center data, the SIPA team did observe the brown, mottled teeth symptom in many Ruiru residents.

Although this study did not fully examine agricultural and industrial pollution, chemical contaminants from these sources in surface and groundwater can lead to a variety of negative health outcomes. Further research is required.

Water, Sanitation, and Solid Waste Health Linkages

Sanitation and water are clearly linked, as water contaminated by fecal matter is the source of many water-related diseases, such as diarrheal diseases, typhoid and skin diseases and eye infections. Drinking contaminated water and eating foods prepared with contaminated water are not the only causes of water-related diseases. Inadequate amounts of can water prevent hygiene practices (such as proper maintenance of sanitation facilities, hand-washing, bathing and washing), which reduce the spread of many water-related diseases. Proper sanitation prevents human exposure to excrement before it contaminates the water supply and the environment.

Poor water, sanitation, and solid waste conditions can also enable the breeding of insect vectors that spread disease. Solid waste and poorly maintained sanitation facilities are breeding grounds for flies and cockroaches, which can contribute to the spread of fecal matter in the environment.

86 WHO and UNICEF. 2005. Water for Life: Making it Happen. WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation. Pp. 1-33.

55 Standing water provides the breeding grounds for the Anopheles mosquito, the insect vector that transmits malaria.

Improved sanitation, increased water quantity and healthy hygiene practices, as well as improved water quality all contribute to controlling many water-related diseases. Safe solid waste disposal helps to create a cleaner, healthier environment.

Figure 31 Water- and Excreta-Related Diseases and Transmission Mechanisms Disease Transmission Mechanism Link to Water and Sanitation Malaria Mosquito bite Mosquitoes breed in standing water Diarrheal diseases Consumption of contaminated water or Poor sanitation foods prepared by contaminated water; Water contamination poor personal hygiene; also transmitted Inadequate quantity of water for by excreta-related insect vectors (flies personal hygiene and cockroaches) Poor hygiene behaviors Dirty environment Skin diseases Poor personal hygiene Inadequate quantity of water Poor hygiene behaviors Intestinal Worms Contact with soil Fecal matter contaminating the soil Poor hygiene behaviors Eye infections Poor personal hygiene Inadequate quantity of water for personal hygiene Poor hygiene behaviors Typhoid Consumption of contaminated water or Poor sanitation foods prepared by contaminated water; Water contamination poor personal hygiene Inadequate quantity of water for personal hygiene Poor hygiene behaviors Source: Based on charts in The Sphere Project’s 2004 “Humanitarian Charter and Minimum Standards in Disaster Response” and Bradley’s disease classifications chart.

Health Awareness: The SIPA team asked survey respondents the question, “What are the causes of this disease?” for many of the top ten diseases in the Ruiru Health Center data (see Figure 31). While the SIPA team itself has not determined the exact causal links of diseases in Ruiru, this question was designed to gauge general awareness of modes of transmission and hygiene behaviors. The team divided respondents’ answers into two categories: those that included only correct, or possible, disease causes in their responses and those that included incorrect responses or misperceptions. The results provide a rough estimation of general health awareness among respondents, although they do not assess whether people engage in practices to protect themselves from becoming infected. Responses for malaria, typhoid, diarrhea and intestinal worms indicate a high level of general awareness of how these diseases are spread.

56

In the case of malaria, Figure 33 responses included not only “mosquitoes” but What are the causes of these diseases? also “mosquitoes and stagnant water.” This 100 90 level of understanding 80 may facilitate community 70 participation in malaria 60 Responses include only correct causes 50 prevention interventions. Responses include 40 misconceptions The SIPA team learned 30 20 Note: URTI refers to Upper Respiratory Tract Infection of one local belief in 10 Ruiru that reflected low 0 health awareness. Two ia id s s r ea o la rh h ase a URTI survey respondents M yp ection Diar T f In n dise e i expressed preference for y k E S the river as a water Intestinal Worms source because the river was a more “natural” source and, therefore, better. A key informant interview confirmed that, despite the reality of poor water quality in the river, some residents held this belief.

While the SIPA team was unable to assess hand-washing practices, these practices play an important role in health. In settings that lack potable water and sanitation infrastructure, prevalence of diarrheal disease and intestinal parasites is much more highly correlated with dirty hands than dirty water.87 A study assessing the impact of hand-washing behavior showed a 47% decrease in diarrheal disease.88 Hygiene promotion is therefore a key element to any water and sanitation plan.

Health Interventions at the Ruiru Health Center: The Ruiru Health Center, administered by the Ministry of Health, already promotes some health interventions to combat malaria and other water-related diseases. The center sells insecticide treated mosquito nets (ITNs) for Ksh 100 per net to the general population and Ksh 50 per net to pregnant women. The public health officers at the center also visit households as part of a health education campaign on HIV/AIDS and hygiene. However, health officials at the center report understaffing as a barrier to successful implementation of their education interventions.

87 Bartlett, S. 2005. “Water, Sanitation and Urban Children: The Need to Go Beyond Provision.” Children, Youth and Environments. 15(1): 115-137. 88 Luby, S.P., Agboatwalla, M., Painter, J., Atla, A., Billhimer, W.L., Hoekstra, R.M. 2004. "Effect of Intensive Handwashing Promotion on Childhood Diarrhea in High-Risk Communities in Pakistan." Journal of the American Medical Association. 291(21): 2547-2554.

57 Recommendations

The SIPA team recommends that the Council collaborate with the public health officers employed by the Ministry of Health at the Ruiru Health Center to support their hygiene education efforts. Due to its proximity to the Ruiru Health Center and pre-existing relationships, the Council is well positioned to work closely with the public health officials representing the Ministry of Health. Actively building on these relationships will help the Council compensate for the lack of a public health officer on its own staff.89 The Council should also incorporate the health awareness recommendations suggested by the water, sanitation, and solid waste sections of this report into a comprehensive health education strategy in coordination with the public health officers at the Ruiru Health Center.

The Council may also add value by engaging international and local NGOs in public health awareness campaigns. Population Services International is already engaged in Ruiru in HIV/AIDS education and the marketing of Waterguard. The Council may consider looking to PSI for increased involvement. A critical success factor will be local groups. As the SIPA team experienced through its collaboration with FORCUS, the group that assisted in conducting the household survey, there are community groups in Ruiru that the Council can access.

The Council should prioritize malaria interventions and work with the Ruiru Health Center and the Ministry of Health to scale up its insecticide treated mosquito net (ITN) provisioning. The Council should seriously consider appealing for funding from the Ministry of Health to subsidize ITNs not only for pregnant women but also for children and the extremely poor.

Finally, the SIPA team recommends that the Council look for opportunities to sponsor a health- specific study in Ruiru.

While these recommendations will require some element of additional funding, coordination and demand on the time of the Council staff, the SIPA team believes they are valuable steps forward.

89 While there is one staff member at the RMC with the title of “Public Health Headman,” this person is responsible largely for coordinating solid waste collection and not public health strategy.

58 VII. CONCLUSION

The situation analysis laid out in this report serves as a starting point for further investigation and planning regarding water, sanitation and solid waste. Having noted the significant challenges for each of these sectors and their contributions to local health problems, the SIPA team also recognizes various opportunities to bring about meaningful change. The continued commitment of the Council to serve the citizens of Ruiru, the substantial engagement of partners at AWSB, the accessibility and interest of other experts operating in the region, and the positive spirit of the communities themselves are all reasons to be optimistic. Where capacity gaps appear, we believe there is considerable mobilization within the Council and among its development partners to build capacity over the long-term.

The rapid progress toward establishing the RUJA water company is evidence that the Municipal Council embraces Kenya’s water reforms and is willing to adopt a decentralized framework for service provision. However, it is essential that RUJA not focus exclusively on water provisioning. A plan for building and maintaining sanitation and sewerage infrastructure must go hand in hand with the plan to deliver water services. Given the lengthy process and funding requirements for developing such a comprehensive service plan, long-term plans for RUJA must be accompanied by short-term solutions to improve conditions. This will be a meaningful signal to community members that action is being taken to address their immediate needs.

Immediate sector-specific recommendations for water, sanitation and solid waste have been presented in this report. These recommendations are important in that they address concerns expressed by the residents of Ruiru and they reflect the capacity and funding constraints indicated by key informant interviews with Council members and external stakeholders. Further investigation into each of these specific recommendations is advised. In addition, the following overarching themes should be considered on a macro-level and incorporated into short- and long- term strategies.

The SIPA team concludes that behavior change in water, sanitation and solid waste practices is needed. While many services are substandard, community members must also understand how they can make the best of the situation they face. Awareness campaigns and social mobilization schemes should be introduced to focus on these issues. Specifically, hygiene education is advised both in schools and through outreach by public health officers and community-based organizations. Such campaigns should encompass water treatment, hygiene behavior, proper maintenance of toilet facilities and the negative effects of illegal waste disposal and burning of garbage. Outcomes related to behavior change will likely have a significant impact on improving the problems observed in Ruiru and will give residents a greater sense of control over their environment and their own health outcomes.

We further conclude that there are abundant opportunities for the Council to become more proactive about seeking short-term solutions. The focus on the establishment of RUJA should not overshadow complementary short-term efforts. It is important to be aware of other potential partners who have an interest in working with the Council to promote change. The SIPA team identified a number of NGOs and other experts operating in the region who could provide insight

59 into many of the quick win solutions outlined in this report. Follow-up with those experts using the contact sheet provided in Appendix 14 is strongly advised.

Another advantage that the Council should leverage is their relationship with academic institutions such as Columbia University and the University of Nairobi. This should be seen as a practical collaboration, and the Council should actively engage its academic partners. This means that the Council should be creative in thinking about how academics and students can play a helpful role in Ruiru’s development process and reach out to make those proposals known.

The challenges that Ruiru is facing are not unique. They are common in the developing world and are the subject of heated international policy discussion. In the context of the Millennium Development Goals, environmental health concerns such as those posed by the water, sanitation and solid waste problems in Ruiru are a top priority. There are many actors engaged in these issues around the world and a great deal of expertise and funding are available. Ruiru can stand out and make a difference through strong relationships between the Council and those external stakeholders and, more importantly, by bringing the community into the discussion. The Council should be accountable to the community by taking action and conveying that action to the citizens. The Council must also bear in mind that the community itself is an important resource. The Council will be more likely to achieve its mission and be a more attractive target for funders if it successfully engages with the community and brings local people into planning and mobilizing change.

60 Appendix 1: SIPA Household Survey (March 2006)

ASSESSING WATER AND SANITATION IN RUIRU Columbia University in the City of New York Household Socioeconomic Characteristics Survey This survey aims to capture the water supply and usage profile of the household, household sanitation access and practices, solid waste disposal, and health linkages.

0 SOCIO-DEMOGRAPHICS 0.1 Ward Code: 0.1 codes: Ward 1=Biashara/Viwandani (CBD) 2=Murera 3=Gitothua 4=Kahawa Sukari 5=Githurai Kimbo 96=Other area (Specify…)

0.2 Housing type: Code: 0.2 codes: Housing type 1=Villa, detached house, large flat 2=Small house and flats 3=Tenement blocks with high density occupation 4=Farm house 96=Other type (Specify….)

0.3 Roof type Code: 0.3 codes: Roof type 1=no/partial roof 2=full roof – flat 3=full roof – other

0.4 Roof material Code: 0.4 codes: Roof material 1=asphalt 2=wood 3=metal 4=tiles 5=tent 96=other (please specify…)

START TIME: END TIME: Date of Interview: Date Checked: Interviewed by: Checked by:

61 0.5 Main Name: Respondent:

0.6 Gender of Code: 0.6 codes: Gender main respondent: 1=Female 2=Male 3=Couple 4=Multiple respondents (female) 5=Multiple respondents (male) 6=Multiple respondents (mixed) 0.7 Relationship of Code: 0.7 codes: Relation to Household Main Respondent Head to HH Head (R to 0=Head HHH) 1=Spouse 2=Parent 3=Child 4=Grand child 5=Nephew/Niece 6=Son/daughter-in-law 7=Brother/Sister 8=Wife 2 96=Other relative (Specify……….) 97=Other non-relative (Specify……..) 0.8 Number of Code: 0.8 codes: People in household people living in 1=One household 2=Two 3=Three 4=Four 5=Five 6=Six 96=Other (please specify) 0.9 Household Code: 0.9 codes: Household income income in KSh last 1=Less than 2,000 month (incl. all 2=2,001-4,000 sources as well as 3=4001-6,000 money received 4=6,001-12,000 from family) 5=12,001-15,000 6=15,001-20,000 7=20,001-25,000 8=25,001-30,000 9=30,001-40,000 10=40,001-50,000 11=Above 50,000 12=Don't know/refuse to answer

Data Entered By: Date of Data Entry: 62

1. WATER Q 1.1 Where Q 1.2 Q 1.3 What is Q 1.4 How Q 1.5 For what Q 1.6 How do you get Where do the main many hours a purpose(s) do long does it A - WATER most of your you get reason for day is water you use the take you to SOURCES water from? the rest using these available from water from the reach the (check of your individual each source you individual water source? primary water water water sources? use? (code) sources for? (minutes) source only) from? (code) (code) (check all 1 = Less than 8 that apply) 1= Water hrs/day 1=Drinking availability 2 = 8 – 16 hrs/day 2=Cooking 2=Proximity of 3 = More than 16 3=Washing source hrs/day 4=Bathing 3=Water quality 4 = Don't know 5=Livestock 4=Cost 6=Gardening 5=Convenience 96=Other (please 96=Other (please specify…) specify…) a. Household connection (piped) b. Private yard tap (single HH) c. Shared yard tap (multiple HH) d. Private borehole with hand pump e. Private well If a well is used, go to Q 1.7 and Q 1.8 f. Rainwater harvesting g. Door-to-door vending h. Community stand post (public standpipe) i. Water kiosk

j. Resale by neighbors k. Spring If a spring is used, go to Q 1.9 l. River or stream m. Other (Specify)…………

63 Q 1.7 – 1.8 If household uses a WELL, then

• Q 1.7: What is the water table depth? (meters)

• Q 1.8: How is the water extracted from the well? (circle one) 1= Bucket/Rope 2 = Bucket/Pulley (hand-crank system) 3 = Hand pump 4 = Motorized pump 5 = Don't know 96= Other (please specify…)

Q 1.9 If household uses a SPRING, is it (circle one)

1 = unprotected 2 = protected 3 = Don't know

Q 1.10 – Q 1.13 If household uses water for GARDENING

• Q 1.10: How big is the garden? (m3)

• Q 1.11: How big is the area you cultivate? (m3)

• Q 1.12: If you grow any crops, what kind do you primarily grow? (circle one)

1= Cash crops (e.g. coffee, tea) 2 = Staple 3 = Vegetable 4 = Fruits 5 = Flowers 6 = Don't know 96= Other (please specify…)

• Q 1.13: How do you water your garden? (circle one primary method)

1= Watering can/bucket 2 = Treadle pump 3 = Gravity flood 4 = Sprinkler 5 = Drip irrigation 6 = Don't know 96= Other (please specify…)

Q 1.14 – Q 1.15 If household uses water for LIVESTOCK

Q 1.14: What type of livestock do you have? Q 1.15 How many do you have of each kind? (code) (number)

1 = Chicken 2 = Goat 3 = Cattle 4 = Donkey 96 = Other (Specify……….)

64 1 B - WATER COLLECTION

Q 1.16: Who in the household is Q 1.17 From which source do the Q 1.18 How much time do the individual primarily responsible for collecting individual household members primarily persons spend on collecting water each water? (code) collect water? (code) day? (minutes)

0 = Husband 1 = Household connection (piped) 1 = Wife 2 = Private yard tap (single HH) 2 = Child 1 3 = Shared yard tap (multiple HH) 3 = Child 2 4 = Private borehole with hand pump 4 = Child 3 5 = Private well 5 = Grand child 6 = Rainwater harvesting 6 = Nephew/Niece 7 = Door-to-door vending 7 = Son/daughter-in-law 8 = Community stand post (public standpipe) 8 = Brother/Sister 9 = Water kiosk 9 = Wife 2 10 = Resale by neighbors 10 = Nobody (no collection) 11 = Spring 96 = Other (Specify……….) 12 = River or stream 13 = Other (specify…)

Q 1.19 What kind of Q 1.20 How many of each Q 1.21 Q 1.22 Is the Q 1.23 How do you carry the container do you use for container do you use? What is the container containers? (code) water collection? (code) (code) volume of covered each during 1 = Head or shoulder 1 = clay pot 1 = One container? transport? 2 = In hand or under arm 2 = jerry can 2 = Two (liters) (code) 3 = Bicycle 3 = bucket 3 = Three 4 = Wheelbarrow 4 = plastic bottle or jug 4 = Four 1 = Yes 5 = Cart 5 = Sufuria (metal cooking pot) 5 = Don't know 2 = No 6 = Donkey 6 = barrel or drum 96 = Other (please specify…) 3 = Don't know 7 = Don't know 7 = Don't know 96 = Other (please specify…) 96 = other (describe……)

Q 1.24 How often do you clean your collection containers? (circle one)

1 = Daily 2 = Weekly 3 = Monthly 4 =Two times per month 5 = Biannually (2x/year) 6 = Annually 7 = Not cleaned 8 = Don't know 96 = Other (Please specify…)

Q 1.25 How much water in total does your household COLLECT per day? (liters)

Q 1.26 How much water in total does your household USE per day? (liters)

65 1 C – WATER STORAGE

Q 1.27 – In what type of container do you store most of your water? (circle one)

1 = Clay pot 2 = Plastic container (~30 – 50 L) 3 = Jerry can 4 = Bucket 5 = Sufuria (metal cooking pot) 6 = Barrel (wood) (~55 gal or ~ 220 L) 7 = Drum (metal, plastic, other) (~55 gal or ~ 220 L) 8 = Tank (larger than barrel) 9 = Don't know 10 = Don't store water 96 = Other (please specify…)

Q 1.28 If a tank, drum or barrel is used (Q 1.20 = 6, 7 or 8), what is its volume? (liters)

Q 1.29 How do you normally get water out of the container? (circle one)

1 = Bare hand 2 = Cup 3 = Bucket 4 = Pump 5 = Plastic bottle/bucket 6 = Tap 7 = Pouring 8 = Don't know 9 = Don't store water 96 = Other (please specify)

1 D – WATER TREATMENT

Q 1.30 – Do you treat/clean the water before usage? (circle one)

1 = Yes 2 = No 3 = Don't know

Q 1.31 If treated, for what use is the water treated? (circle one)

1 = Drinking 2 = Cooking 3 = Washing 4 = Bathing 5 = Livestock 6 = Gardening 7 = All uses 8 = Drinking and Cooking only 9 = Don't know 96 = Other (please specify…)

Q 1.32 If treated, how often do you treat your water? (circle one)

1 = Every time (100%) 2 = Most of the time (~75%) 3 = Half of the time (~50%) 4 = Quarter of the time (~25%) 5 = Seldom (<25%) 6 = Seasonally 7 = Don't know 96 = Other (please specify…)

66 Q 1.33 If treated, how do you primarily treat your water? (circle one)

1 = Boiling 2 = Filtering (ceramic, sand, etc.) 3 = Chemical treatment (e.g. Waterguard, PUR, etc.) (bleach/chlorine) 4 = UV/Sunlight (solar disinfection) 5 = Sedimentation 6 = Don't know 96 = Other (please specify…)

1 E – ASSESSMENT OF WATER SUPPLY SITUATION

Q 1.34: How much do you pay per WEEK for water from all sources? (KSh)

Q 1.34.1 No shortage period Q 1.34.2 Shortage period

Q 1.35 Do you think the current water price is… (circle one)

1 = High 2 = Fair 3 = Low 4 = Don't know

Q 1.36: Are you satisfied with the existing water supply? (code)

1 = Yes 2 = No 3 = Don't know

Q 1.37 What are the things you are most concerned with regarding your water supply? (enumerate)

Q 1.38: If you could choose, where would you like to get your water from? (circle one)

1 = Household connection (piped) 2 = Private yard tap (single HH) 3 = Shared yard tap (multiple HH) 4 = Private borehole with hand pump 5 = Private well 6 = Rainwater harvesting 7 = Door-to-door vending 8 = Community stand post (public standpipe) 9 = Water kiosk 10 = Resale by neighbors 11 = Spring 12 = River or stream 13 = Other (specify…)

Q 1.39: Why would that be your preferred water source? (circle one)

1= Water availability 2=Proximity of source 3=Water quality 4=Cost 5=Convenience 96=Other (please specify…)

67 2. HEALTH & BASIC HYGIENE

Q 2.1 What are the Q 2.2 In your opinion what are the causes of these diseases? diseases you have DISEASES heard of occurring 1= Drinking dirty water in your area 2=Eating not properly washed food recently? 3=Eating with dirty hand 4=Playing in areas filled of waste and feces 5=Not washing hand before eating 6= Not washing hand after going out of bathroom 7= Don't know 8=Other (please specify) a. Diarrhea Y/ N b. Typhoid Y/ N c. Worms Y/ N d. Eye infections Y/ N e. Skin diseases Y/ N f. Malaria Y/ N g. Upper Respiratory Y/ N Tract Infections

Q 2.3 When do you wash your hands? (circle all that apply)

1 – When going out of toilet facility

2 - After cleaning infant feces

3 – Before feeding an infant

4 – Before and/or after cooking

5 – Before and/or after eating

6 – After using contaminated materials

96 – Other (please specify)

Q 2.4 Today, when you washed your hands, did you use soap? 1—Yes 2—No

68 3. SANITATION (A LATRINE is defined as having a slab/floor and a structure around it for privacy) What kind of Do you How many How many How long does What is the toilet does cover the individuals from individuals outside it take you to distance your toilet within the of the household use walk from your from this household hole with household use the the facility? house to the toilet to the primarily anything facility? toilet? closest use? ? (minutes)? water 3.1 3.2 Specify if it is source? inside the house. (meters) 3.5 3.6 3.3.1 3.3.2 3.4.1 3.4.2 Adults Children Adults Children a. No facility (on ground, forest, flying toilet, etc.) Y/ N b. Dug Hole Y/ N c. Private simple pit latrine (individual Y/ N household or shared) d. Private VIP latrine (individual household or Y/ N shared) e. Public simple pit latrine (within Y/ N community) f. Public VIP latrine (within community) Y/ N g. Small pot/bucket Y/ N h. Connection to a septic tank (pour flush or modern Y/ N flush) i. Other (describe………) Y/ N

Q 3.7 If you have a PIT (simple or VIP) latrine or SEPTIC TANK, what do you do when the pit is full? (circle one)

1 = Usually have it emptied 2 = Dig a new pit 3 = Let it overflow 4 = Other, specify 5 = Don’t Know

Q 3.8 If you have a PIT or SEPTIC TANK, how is the septic tank emptied? (circle one)

1 = By truck 2 = By overflow/seepage 3 = Manually 4 = Other, specify

Q 3.9 If you empty your PIT or SEPTIC TANK, how often is it emptied?

Every ______month (s)

______Don’t Know

69 Q 3.10 Does your primary toilet (the one you use the most), belong to someone outside the household (neighbor, landlord, etc.)

1—Yes

2—No

Q 3.11 Are you satisfied with the kind of toilet your household uses?

1—Yes

2—No

Q 3.12 If you could choose any facility, what kind of toilet would you prefer for your household?

1 = No facility (on ground, forest, flying toilet, etc.) 2 = Dug Hole 3 = Private simple pit latrine (individual household or shared) 4 = Private VIP latrine (individual household or shared) 5 = Public simple pit latrine (within community) 6 = Public VIP latrine (within community) 7 = Small pot/bucket 8 = Composting toilet 9 = Flush toilet (pour flush or modern) connect to septic tank 10 = Flush toilet (pour flush or modern) connected to sewer system 96 = Other (please specify)

Q 3.13 Why would that be your preferred toilet facility? (circle one)

1=Availability 2=Proximity 3=Privacy reasons 4=Cost 5=Convenience 96=Other (please specify…)

Q 3.14 Do you have any concerns about your sanitation facilities?

______ENUMERATOR OBSERVATION: Please verify which of the above toilet structures named by the respondent that you observe to be present on the property.

______

70 4. WASTE WATER AND WASTE DISPOSAL

Q 4.1 How does your household primarily dispose of wash-water? (laundry or dishes or both?) (circle one)

1 – On land within 3 meters of household 2 – On land 4 to 10 meters from household 3- More than 10 meters from household 4– Reuse on cropland/garden 5-Reuse as livestock water 6– Re-use other (specify…………….) 96-Other (Specify…………………..)

Q 4.2 How do you primarily gather rubbish inside the house? (circle one)

1 – In plastic bags 2- In buckets 3 – In the yard 96- Other (please specify…)

Q 4.3 How does your household primarily get rid of the rubbish? (circle one)

1 – Garbage is collected from each house 2- A member of the family takes the garbage to a specific area designated to gather the waste 3 – There isn't a specific area to gather the waste. People throw it any place 4—Burning 5– Don’t know 96 – Other (please specify…)

Q 4.4 How often do you get rid of the rubbish? (circle one)

1 – Every day 2- Every two days 3 – Once per week 4 – Don’t know 96 – Other (please specify…)

Q 4.5 Do you have any concerns regarding how you get rid of your rubbish?

71 Appendix 2: Map of SIPA Household Survey locations

72 Appendix 3: Fact Sheet, Ruiru Municipality, Page 1 of 2

General Number of surveys 100 Gender of respondent(s) Female 61% Male 22% Couple 6% Females 4% Males 1% Mixed 6% Number of people in household Average 4.36 Median 4 Min 1 Max 10 Household income (Ksh) Low (Less than 6000) 36% Middle (6001 – 30,000) 47% High (Above 30,000) 13% Don't know 4% Water Primary water source Shared yard tap 27% Household connection 17% Water kiosk 15% Private yard tap 13% Private well 12% Other 16% Percentage of households using multiple sources 57% Distance to primary source (minutes) Average 5 Median 1 Min 0 Max 60 Quantity of water used (liters/person/day) Average 31 Median 20 Min 2 Max 283 Percentage of households treating water 51% Method of water treatment Boiling 62% Chemical treatment 36% Chemical treatment and filtering 2% Frequency of water treatment Every time 78% Most of the time 12% Quarter of the time 6% Other 4% Water price/ liter (Ksh) Average 0.15 Median 0.06 Min 0 Max 1.37 Percent of income spent on water Average 8% Median 1% Min 0% Max 86% Percentage of households dissatisfied with water 47% Concerns about water* No concern 26% Water availability 25% Water quality 20% Cost 15% Distance to source 10% Peferred water source Household connection 45% Private yard tap 20% Shared yard tap 18% Private borehole 5% Community borehole 3% Other 9%

*Multiple answers allowed; percentages may exceed 100%

73 Appendix 3: Fact Sheet, Ruiru Municipality, Page 2 of 2

Sanitation Toilet type Private pit latrine 51% Flush toilet 21% Private VIP latrine 18% Public pit latrine 6% Public VIP latrine 2% Dug hole 2% Percentage of households using shared toilet 57% Number of people using toilet Average 14.3 Median 6.5 Min 1 Max 154 Distance to toilet (minutes) Average 1.25 Median 1 Min 0 Max 5 Percentage of households whose toilet is within 30 meters of groundwater source 65% Method of emptying pit/septic tank By truck 46% Not emptied 37% Don't know 14% Other 3% Frequency of emptying pit/septic tank Never since respondent moved in 40% Don't know 21% Every 1-3 months 7% Other 32% Method of disposing of wash-water On land within 3 m. of household 37% On land 4-10 m. of household 17% Drainage to septic tank 11% More than 10 m. from household 10% Reuse on cropland/ garden 10% Other 14% Percentage of households dissatsfied with sanitation 55% Preferred toilet type Flush toilet - sewer system 54% Flush toilet - septic tank 22% Private pit latrine 19% Private VIP latrine 6% Concerns about sanitation* No concern 32% Lack of sewer system 23% Hygine/cleanliness 17% Lack of action by council 13% Maintenance 11% Solid Waste Method of garbage collection within the household In buckets 43% In plastic bags 25% In the yard 15% Other 16% Method of garbage disposal Burning 48% Household collection service 31% Dump anywhere 12% Other 9% Concerns about solid waste* Lack of action by council 39% No concern 38% Poor collection 23% Health Percentage of respondents who believe this disease Malaria 86% occurs in their area Typhoid 74% Worms 56% Upper Respiratory Tract Infections 43% Skin diseases 40% Diarrhea 39% Eye Infections 31%

*Multiple answers allowed; percentages may exceed 100%

74 Appendix 4: Fact Sheet, Biashara, Page 1 of 2

General Number of surveys 12 Gender of respondent(s) Female 67% Male 17% Couple 8% Females 8% Number of people in household Average 2.6 Median 3.5 Min 1 Max 10 Household income (Ksh) Low (Less than 6000) 50% Middle (6001 – 30,000) 42% High (Above 30,000) 8% Water Primary water source Household connection 27% Shared yard tap 18% Water kiosk 18% Private yard tap 9% Door-to-door vending 9% Other 19% Percentage of households using multiple sources 75% Distance to primary source (minutes) Average 4 Median 1 Min 0 Max 20 Quantity of water used (liters/person/day) Average 48 Median 27 Min 8 Max 283 Percentage of households treating water 25% Method of water treatment Boiling 67% Chemical treatment 33% Frequency of water treatment Every time 100% Water price/ liter (Ksh) Average 0.25 Median 0.07 Min 0 Max 1.34 Percentage of income spent on water Average 12% Median 2% Min 0% Max 54% Percentage of households dissatisfied with water 45% Concerns about water* Water quality 42% Water availability 33% Distance to source 17% Convenience 17% No concern 8% Peferred water source Shared yard tap 33% Household connection 25% River 17% Private yard tap 8% Private borehole 8% Other 9%

*Multiple answers allowed; percentages may exceed 100%

75 Appendix 4: Fact Sheet, Biashara, Page 2 of 2

Sanitation Toilet type Flush toilet 58% Private pit latrine 33% Private VIP latrine 8% Percentage of households using shared toilet 75% Number of people using toilet Average 8.08 Median 6.5 Min 1 Max 20 Distance to toilet (minutes) Average 1.58 Median 1 Min 0 Max 5 Percentage of households using pit latrines whose toilet is 0% within 30 meters of groundwater source Method of emptying pit/septic tank By truck 60% Not emptied 20% Other 10% Don't know 10% Frequency of emptying pit/septic tank Don't know 60% Never since respondent moved in 20% Every 1-3 months 10% Other 10% Method of disposing of wash-water Pour into toilet 25% Drainage to septic tank 17% On land within 3 m. of household 17% On land 4-10 m. from household 17% More than 10 m. from household 17% Reuse to clean latrine 8% Percentage of households dissatsfied with sanitation 50% Preferred toilet type Private pit latrine 42% Flush toilet - sewer system 42% Private VIP latrine 8% Flush toilet - septic tank 8% Concerns about sanitation* No conern 50% Lack of action by council 25% Maintenance 25% Disease 17% Hygine/cleanliness 17% Solid Waste Method of garbage collection within the household In buckets 50% In plastic bags 17% In dust bins 17% Other 17% Method of garbage disposal Burning 34% Household collection service 50% Dump anywhere 8% Other 8% Concerns about solid waste* Lack of action by council 42% No concern 33% Poor collection 33% Health Percentage of respondents who believe this disease Malaria 92% occurs in their area Worms 75% Typhoid 67% Diarrhea 50% Skin diseases 50% Eye Infections 33% Upper Respiratory Tract Infections 33%

*Multiple answers allowed; percentages may exceed 100%

76 Appendix 5: Fact Sheet, Githurai, Page 1 of 2

General Number of surveys 40 Gender of respondent(s) Female 53% Male 25% Couple 8% Females 5% Males 3% Mixed 8% Number of people in household Average 4 Median 4 Min 1 Max 9 Household income (Ksh) Low (Less than 6000) 23% Middle (6001 – 30,000) 58% High (Above 30,000) 15% Don't Know 5% Water Primary water source Shared yard tap 50% Private yard tap 23% Household connection 13% Water kiosk 10% Private well 5% Percentage of households using multiple sources 30% Distance to primary source Average 2 Median 1 Min 0 Max 10 Quantity of water used (liters/person/day) Average 23 Median 18 Min 5 Max 71 Percentage of households treating water 69% Method of water treatment Boiling 67% Chemical treatment 33% Frequency of water treatment Every time 67% Most of the time 19% Quarter of the time 7% Water price/ liter (Ksh) Average 0.19 Median 0.07 Min 0 Max 1.37 Percent of income spent on water Average 9% Median 1% Min 0% Max 86% Percentage of households dissatisfied with water 38% Concerns about water* No concern 30% Water availability 28% Cost 20% Water quality 18% Low water pressure 15% Peferred water source Household connection 58% Private yard tap 18% Shared yard tap 10% Private borehole 8% Other 6%

*Multiple answers allowed; percentages may exceed 100%

77 Appendix 5: Fact Sheet, Githurai, Page 2 of 2

Sanitation Toilet type Private pit latrine 50% Private VIP latrine 23% Flush toilet 15% Public pit latrine 13% Percentage of households using shared toilet 63% Number of people using toilet Average 20 Median 8 Min 3 Max 154 Distance to toilet (minutes) Average 1.04 Median 1 Min 0 Max 5 Percentage of households using pit latrines whose toilet is 25% within 30 meters of groundwater source Method of emptying pit/septic tank By truck 49% Not emptied 38% Don't know 11% Chemical treatment 3% Frequency of emptying pit/septic tank Never since respondent moved in 46% Don't know 16% Every 3-6 months 11% Other 27% Method of disposing of wash-water On land within 3 m. of household 40% On land 4-10 m. of household 20% Reuse on cropland/ garden 13% Drainage to septic tank 10% Other 17% Percentage of households dissatsfied with sanitation 58% Preferred toilet type Flush toilet - sewer system 63% Flush toilet - septic tank 28% Private pit latrine 8% Private VIP latrine 3% Concerns about sanitation* Lack of sewer system 50% No concern 25% Lack of action by council 18% Hygine/cleanliness 18% Solid Waste Method of garbage collection within the household In buckets 53% In plastic bags 25% In the yard 10% Other 12% Method of garbage disposal Burning 55% Household collection service 35% Dump anywhere 8% Other 2% Concerns about solid waste* Lack of action by council 48% No concern 23% Poor collection 38% Health Percentage of respondents who believe this disease Malaria 83% occurs in their area Typhoid 70% Worms 60% Upper Respiratory Tract Infections 55% Eye Infections 45% Skin diseases 43% Diarrhea 28%

*Multiple answers allowed; percentages may exceed 100%

78 Appendix 6: Fact Sheet, Gitothua, Page 1 of 2

General Number of surveys 21 Gender of respondent(s) Female 57% Male 24% Couple 10% Females 5% Mixed 5% Number of people in household Average 4.14 Median 4 Min 1 Max 8 Household income (Ksh) Low (Less than 6000) 43% Middle (6001 – 30,000) 38% High (Above 30,000) 10% Don’t Know 10% Water Primary water source Water kiosk 29% Household connection 19% Private well 14% Private yard tap 10% Shared yard tap 10% Other 18% Percentage of households using multiple sources 62% Distance to primary source Average 6 Median 4 Min 0 Max 30 Quantity of water used (liters/person/day) Average 29 Median 20 Min 2 Max 135 Percentage of households treating water 38% Method of water treatment Boiling 63% Chemical treatment 38% Frequency of water treatment Every time 100% Water price/ liter (Ksh) Average 0.14 Median 0.09 Min 0 Max 0.89 Percent of income spent on water Average 5% Median 4% Min 0% Max 21% Percentage of households dissatisfied with water 52% Concerns about water* No concern 33% Distance to source 19% Water availability 14% Convenience 14% Water quality 14% Peferred water source Household connection 52% Private yard tap 19% Shared yard tap 19% Private borehole 5% 5% Community standpost

*Multiple answers allowed; percentages may exceed 100%

79 Appendix 6: Fact Sheet, Gitothua, Page 2 of 2

Sanitation Toilet type Private pit latrine 57% Private VIP latrine 24% Flush toilet 14% Dug hole 5% Percentage of households using shared toilet 52% Number of people using toilet Average 13.33 Median 8 Min 1 Max 74 Distance to toilet (minutes) Average 1.33 Median 1 Min 0 Max 5 Percentage of households using pit latrines whose toilet is within 30 meters of groundwater source 90% Method of emptying pit/septic tank By truck 62% Not emptied 24% Don't know 14% Frequency of emptying pit/septic tank Never since respondent moved in 29% Don't know 29% Every 1-3 months 14% Other 29% Method of disposing of wash-water On land within 3 m. of household 33% On land 4-10 m. of household 19% Reuse to clean latrine 14% Other 33% Percentage of households dissatsfied with sanitation 43% Preferred toilet type Flush toilet - sewer system 43% Private pit latrine 29% Flush toilet - septic tank 19% Private VIP latrine 10% Concerns about sanitation* No concern 38% Hygine/cleanliness 14% Lack of water for flushing toilet 14% Solid Waste Method of garbage collection within the household In plastic bags 38% In buckets 38% In dust bins 19% Other 5% Method of garbage disposal Burning 48% Household collection service 38% Dump anywhere 14% Concerns about solid waste* Lack of action by council 48% No concern 38% Poor collection 14% Health Percentage of respondents who believe this disease Malaria 86% occurs in their area Typhoid 81% Diarrhea 40% Worms 38% Skin diseases 38% Upper Respiratory Tract Infections 19% Eye Infections 10%

*Multiple answers allowed; percentages may exceed 100%

80 Appendix 7: Fact Sheet, Kahawa Sukari, Page 1 of 2

General Number of surveys 14 Gender of respondent(s) Female 71% Male 21% Mixed 7% Number of people in household Average 5.21 Median 5 Min 2 Max 8 Household income (Ksh) Low (Less than 6000) 36% Middle (6001 – 30,000) 57% High (Above 30,000) 7% Water Primary water source Household connection 29% Private well 21% River 21% Shared yard tap 14% Water kiosk 14% Percentage of households using multiple sources 79% Distance to primary source Average 10 Median 2 Min 0 Max 60 Quantity of water used (liters/person/day) Average 37 Median 21 Min 3 Max 125 Percentage of households treating water 21% Method of water treatment Boiling 100% Frequency of water treatment Every time 100% Water price/ liter (Ksh) Average 0.05 Median 0.03 Min 0 Max 0.28 Percent of income spent on water Average 6% Median 1% Min 0% Max 33% Percentage of households dissatisfied with water 64% Concerns about water* No concern 21% Cost 21% Water availability 14% Water quality 14% Low water pressure 14% Peferred water source Household connection 40% Private yard tap 30% Community borehole 20% Shared yard tap 10%

*Multiple answers allowed; percentages may exceed 100%

81 Appendix 7: Fact Sheet, Kahawa Sukari Page 2 of 2

Sanitation Toilet type Private pit latrine 64% Flush toilet 29% Public VIP latrine 7% Percentage of households using shared toilet 50% Number of people using toilet Average 7.93 Median 5.5 Min 2 Max 20 Distance to toilet (minutes) Average 1.62 Median 1 Min 0 Max 5 Percentage of households using pit latrines whose toilet is 33% within 30 meters of groundwater source Method of emptying pit/septic tank Not emptied 43% Don't know 29% By truck 21% By overflow/ seepage 7% Frequency of emptying pit/septic tank Never since respondent moved in 50% Never 21% Other 29% Method of disposing of wash-water On land within 3 m. of household 36% Reuse on cropland/ garden 21% On land 4-10 m. of household 14% More than 10 m. of household 14% Drainage to septic tank 14% Percentage of households dissatsfied with sanitation 57% Preferred toilet type Flush toilet - sewer system 73% Flush toilet - septic tank 18% Private pit latrine 9% Concerns about sanitation* No concern 36% Hygine/cleanliness 14% Maintenance 14% Solid Waste Method of garbage collection within the household In the yard 43% In plastic bags 29% In buckets 21% Method of garbage disposal Burning 43% Dump anywhere 29% Household collection service 21% Other 7% Concerns about solid waste* No concern 71% Lack of action by council 14% Health Percentage of respondents who believe this disease Malaria 93% occurs in their area Typhoid 86% Worms 64% Diarrhea 64% Upper Respiratory Tract Infections 50% Eye Infections 36% Skin diseases 29%

*Multiple answers allowed; percentages may exceed 100%

82 Appendix 8: Fact Sheet, Murera, Page 1 of 2

General Number of surveys 13 Gender of respondent(s) Female 77% Male 15% Mixed 8% Number of people in household Average 4.7 Median 5 Min 2 Max 9 Household income (Ksh) Low (Less than 6000) 54% Middle (6001 – 30,000) 23% High (Above 30,000) 23% Water Primary water source Private well 31% River 23% Rainwater 15% Household connection 8% Private yard tap 8% Other 15% Percentage of households using multiple sources 69% Distance to primary source Average 7 Median 1 Min 0 Max 50 Quantity of water used (liters/person/day) Average 35 Median 20 Min 8 Max 102 Percentage of households treating water 69% Method of water treatment Chemical treatment 56% Boiling 33% Chemical treatment and filtering 11% Frequency of water treatment Every time 78% Most of the time 11% Quarter of the time 11% Water price/ liter (Ksh) Average 0.08 Median 0.05 Min 0 Max 0.29 Percent of income spent on water Average 9% Median 1% Min 0% Max 43% Percentage of households dissatisfied with water 54% Concerns about water* Water availability 38% No concern 23% Water quality 23% Cost 15% General dissatisfaction 15% Peferred water source Shared yard tap 31% Private yard tap 31% Household connection 15% Pirvate well 15% Rainwater 8%

*Multiple answers allowed; percentages may exceed 100%

83 Appendix 8: Fact Sheet, Murera, Page 2 of 2

General Number of surveys 13 Gender of respondent(s) Female 77% Male 15% Mixed 8% Number of people in household Average 4.7 Median 5 Min 2 Max 9 Household income (Ksh) Low (Less than 6000) 54% Middle (6001 – 30,000) 23% High (Above 30,000) 23% Water Primary water source Private well 31% River 23% Rainwater 15% Household connection 8% Private yard tap 8% Other 15% Percentage of households using multiple sources 69% Distance to primary source Average 7 Median 1 Min 0 Max 50 Quantity of water used (liters/person/day) Average 35 Median 20 Min 8 Max 102 Percentage of households treating water 69% Method of water treatment Chemical treatment 56% Boiling 33% Chemical treatment and filtering 11% Frequency of water treatment Every time 78% Most of the time 11% Quarter of the time 11% Water price/ liter (Ksh) Average 0.08 Median 0.05 Min 0 Max 0.29 Percent of income spent on water Average 9% Median 1% Min 0% Max 43% Percentage of households dissatisfied with water 54% Concerns about water* Water availability 38% No concern 23% Water quality 23% Cost 15% General dissatisfaction 15% Peferred water source Shared yard tap 31% Private yard tap 31% Household connection 15% Pirvate well 15% Rainwater 8%

*Multiple answers allowed; percentages may exceed 100%

84 Appendix 9: Fact Sheet, Low Income, Page 1 of 2

General Number of surveys 36 Gender of respondent(s) Female 61% Male 25% Couple 6% Females 3% Mixed 6% Number of people in household Average 4.06 Median 4 Min 1 Max 9 Ward Biashara 17% Githurai 25% Gitothua 25% Kahawa Sukari 14% Murera 19% Water Primary water source Water kiosk 25% Shared yard tap 17% Private well 14% River 11% Other 33% Percentage of households using multiple sources 64% Distance to primary source (minutes) Average 7 Median 4 Min 0 Max 50 Quantity of water used (liters/person/day) Average 32 Median 18 Min 2.5 Max 283 Percentage of households treating water 42% Method of water treatment Boiling 60% Chemical treatment 40% Frequency of water treatment Every time 67% Most of the time 20% Quarter of the time 13% Water price/ liter (Ksh) Average 0.12 Median 0.07 Min 0 Max 0.59 Percent of income spent on water Average 11% Median 5% Min 0% Max 86% Percentage of households dissatisfied with water 51% Concerns about water* Water availability 22% Water quality 22% Distance to source 19% No concern 17% Convenience 11% Peferred water source Household connection 34% Shared yard tap 31% Private yard 23% Community standpost 6% Private borehole 3% Other 3%

*Multiple answers allowed; percentages may exceed 100%

85 Appendix 9: Fact Sheet, Low Income, Page 2 of 2

Sanitation Toilet type Private pit latrine 58% Private VIP latrine 14% Dug hole 12% Flush toilet 8% Other 8% Percentage of households using shared toilet 64% Number of people using toilet Average 12.25 Median 9 Min 1 Max 74 Distance to toilet (minutes) Average 1.53 Median 1 Min 0 Max 5 Percentage of households using pit latrines whose toilet is 60% within 30 meters of groundwater source Method of emptying pit/septic tank By truck 41% Not emptied 41% Don't know 18% Frequency of emptying pit/septic tank Never since respondent moved in 35% Don't know 24% Never 12% Other 29% Method of disposing of wash-water On land within 3 m. of household 39% On land 4-10 m. of household 14% More than 10 m. of household 14% Other 33% Percentage of households dissatsfied with sanitation 58% Preferred toilet type Flush toilet - sewer system 49% Private pit latrine 26% Flush toilet - septic tank 23% Private VIP latrine 3% Concerns about sanitation* No concern 28% Hygine/cleanliness 17% Maintenance 14% Lack of action by council 8% Lack of water for flushing toilet 8% Lack of sewer system 8% Solid Waste Method of garbage collection within the household In plastic bags 36% In buckets 36% In the yard 22% Other 6% Method of garbage disposal Burning 47% Household collection service 31% Dump anywhere 14% Other 8% Concerns about solid waste* No concern 39% Lack of action by council 31% Poor collection 14% Health Percentage of respondents who believe this disease Malaria 94% occurs in their area Typhoid 83% Worms 58% Skin diseases 47% Diarrhea 47% Upper Respiratory Tract Infections 42% Eye Infections 28%

*Multiple answers allowed; percentages may exceed 100%

86 Appendix 10: Fact Sheet, Middle Income, Page 1 of 2

General Number of surveys 47 Gender of respondent(s) Female 62% Male 21% Couple 4% Females 6% Males 2% Mixed 4% Number of people in household Average 4.32 Median 5 Min 2 Max 10 Ward Biashara 11% Githurai 49% Gitothua 17% Kahawa Sukari 17% Murera 6% Water Primary water source Shared yard tap 43% Household connection 13% Water kiosk 13% Private well 13% Other 18% Percentage of households using multiple sources 51% Distance to primary source (minutes) Average 2 Median 1 Min 0 Max 20 Quantity of water used (liters/person/day) Average 30 Median 21 Min 5 Max 135 Percentage of households treating water 52% Method of water treatment Boiling 67% Chemical treatment 29% Chemical treatment and filtering 4% Frequency of water treatment Every time 88% Most of the time 8% Quarter of the time 4% Water price/ liter (Ksh) Average 0.16 Median 0.05 Min 0 Max 1.37 Percent of income spent on water Average 8% Median 1% Min 0% Max 82% Percentage of households dissatisfied with water 49% Concerns about water* No concern 28 Water quality 23 Water availability 19 Low water pressure 15 Council should provide service 11 Peferred water source Household connection 48% Private yard tap 23% Shared yard tap 14% Private borehole 5% Private well 2% Other 8%

*Multiple answers allowed; percentages may exceed 100%

87 Appendix 10: Fact Sheet, Middle Income, Page 2 of 2

Sanitation Toilet type Private pit latrine 51% Private VIP latrine 23% Flush toilet 17% Public pit latrine 6% Public VIP latrine 2% Percentage of households using shared toilet 64% Number of people using toilet Average 17.49 Median 8 Min 2 Max 154 Distance to toilet (minutes) Average 1.3 Median 1 Min 0 Max 5 Percentage of households using pit latrines whose toilet is 70% within 30 meters of groundwater source Method of emptying pit/septic tank By truck 56% Not emptied 31% Don't know 11% By overflow/ seepage 2% Frequency of emptying pit/septic tank Never since respondent moved in 38% Don't know 20% Every 1-3 months 11% Method of disposing of wash-water On land within 3 m. of household 43% On land 4-10 m. of household 21% Reuse on cropland/ garden 11% Other 26% Percentage of households dissatsfied with sanitation 55% Preferred toilet type Flush toilet - sewer system 53% Flush toilet - septic tank 22% Private pit latrine 16% Private VIP latrine 9% Concerns about sanitation* Lack of sewer system 31% No concern 26% Hygine/cleanliness 21% Lack of action by council 19% Maintenance 12% Solid Waste Method of garbage collection within the household In buckets 48% In plastic bags 19% In the yard 14% Other 19% Method of garbage disposal Burning 43% Household collection service 33% Dump anywhere 17% Other 7% Concerns about solid waste* Lack of action by council 48% No concern 29% Poor collection 33% Health Percentage of respondents who believe this disease occurs Malaria 87% in their area Worms 70% Typhoid 55% Upper Respiratory Tract Infections 53% Diarrhea 46% Skin diseases 45% Eye Infections 40%

*Multiple answers allowed; percentages may exceed 100%

88 Appendix 11: Fact Sheet, High Income, Page 1 of 2

General Number of surveys 13 Gender of respondent(s) Female 54% Male 23% Couple 15% Mixed 8% Number of people in household Average 5.31 Median 6 Min 3 Max 7 Ward Biashara 8% Murera 23% Gitothua 15% Kahawa Sukari 8% Githurai 46% Water Primary water source Household connection 54% Private yard tap 31% Rainwater 8% Water kiosk 8% Percentage of households using multiple sources 62% Distance to primary source (minutes) Average 6 Median 0.5 Min 0 Max 60 Quantity of water used (liters/person/day) Average 38 Median 31 Min 12 Max 71 Percentage of households treating water 54% Method of water treatment Boiling 57% Chemical treatment 43% Frequency of water treatment Every time 71% Seasonally 14% Don't know 14% Water price/ liter (Ksh) Average 0.11 Median 0.05 Min 0 Max 0.45 Percent of income spent on water Average 1% Median 0% Min 0% Max 3% Percentage of households dissatisfied with water 46% Concerns about water* Water availability 62% No concern 23% Cost 23% Distance to source 8% Water quality 8% Peferred water source Household connection 54% Privaete borehole 15% Community borehole 15% Private well 8% 8% Private yard tap

*Multiple answers allowed; percentages may exceed 100%

89 Appendix 11: Fact Sheet, High Income, Page 2 of 2

Sanitation Toilet type Flush toilet 54% Private pit latrine 31% Private VIP latrine 15% Percentage of households using shared toilet 15% Number of people using toilet Average 5.77 Median 5 Min 3 Max 13 Distance to toilet (minutes) Average 0.46 Median 0 Min 0 Max 1 Percentage of households using pit latrines whose toilet is 100%** within 30 meters of groundwater source Method of emptying pit/septic tank Not emptied 50% By truck 25% Don't know 17% Other 8% Frequency of emptying pit/septic tank Never since respondent moved in 67% More than 2 years 17% Don't know 17% Method of disposing of wash-water Reuse on cropland/ garden 25% On land within 3 m. of household 17% Drainage to septic tank 17% Percentage of households dissatsfied with sanitation 46% Preferred toilet type Flush toilet - sewer system 69% Flush toilet - septic tank 15% Private pit latrine 8% Private VIP latrine 8% Concerns about sanitation* No concern 46% Lack of sewer system 46% Lack of action by council 15% Lack of water for flushing toilet 15% Public awareness 8% Solid Waste Method of garbage collection within the household In buckets 33% In dust bins 33% In plastic bags 17% Other 17% Method of garbage disposal Burning 75% Household collection service 17% Dump anywhere 8% Concerns about solid waste* No concern 62% Lack of action by council 38% Poor collection 15% Health Percentage of respondents who believe this disease Malaria 54% occurs in their area Typhoid 38% Upper Respiratory Tract Infections 15% Eye Infections 8% Skin diseases 8% Diarrhea 8% 8% Worms

*Multiple answers allowed; percentages may exceed 100% ** Only one high income household surveyed relied on both a pit latrine and a private well; in this case they were within 30 m. of each other.

90 Appendix 12: Ruiru Health Data, Page 1 of 7

Ruiru Health Centre Top 10 Disease Causes September 1999-February 2000 and September 2005-February 2006

Sept. 1999-Feb. 2000 Sept. 2005-Feb. 2006 Percent of Total Percent of Total Top Ten Diseases Top Ten Diseases New Cases New Cases Diseases of the Respiratory System 32% Malaria 24% Malaria 27% Diseases of the Respiratory System 22% Diarrhoeal Diseases 9% Diseases of the Skin 9% Diseases of the Skin 7% Diarrhoeal Diseases 9% Intestinal Worms 6% All other diseases 8% All other diseases 5% Intestinal Worms 7% Eye Infections 4% Urinary Tract Infections 5% Rheumatism 3% Accidents 4% Pneumonia 2% Rheumatism 3% Urinary Tract Infections 2% Gonorrhea 2%

91 Appendix 12: Ruiru Health Data, Page 2 of 7

Ruiru Health Centre Number of New Disease Cases, Non-continuous Monthly Data, 1992, 1993

No. Disease Jun-92 Aug-92 Sep-92 Dec-92 Feb-93 May-93 Jun-93 Jul-93 1 Diarrhoeal Diseases 0 325 341 230 86 234 171 226 2 Tuberculosis 266 0 0 0 0000 3 Leprosy 0 0 0 0 0000 4 Whooping Cough 0 0 0 0 0000 5 Meningitis 0 0 1 0 0000 6 Tetanus 0 0 0 0 0000 7 Poliomyelitis 0 0 0 0 0020 8 Chicken pox 0 6 10 5 0230 9 Measles 0 0 8 1 0320 10 Infectious Hepatitis (Jaundice) 0 0 0 0 0000 11 Mumps 2 0 3 2 0 0 4 17 12 Malaria 453 539 575 415 141 265 185 280 13 Gonorrhoea 64 102 105 0 10 23 36 0 14 Urinary Tract Infections 63 178 199 138 81 92 59 0 15 Bilharzia (Schistosomiasis) 0 0 0 0 0030 16 Intestinal Worms 307 505 462 239 57 36 52 0 17 Malnutrition 0 0 0 2 7010 18 Anaemia 0 0 1 4 2130 19 Eye Infections 67 95 102 0 40 65 21 0 20 Cataract 0 0 0 0 0000 21 Ear Infections 52 54 65 23 25 48 23 0 22 Dis. of the Circulatory System 0 0 0 1 1060 23 Dis.of the Respiratory System 1,142 1,853 1,711 936 288 404 229 0 24 Pneumonia 54 85 72 37 3110 25 Abortion 0 0 0 0 0 16 0 0 26 Disorder of Puerperium and Child Birth 0 0 0 0 0200 27 Neoplasms 0 0 0 0 0000 28 Dis.of Blood and Blood Forming Organs 0 0 0 0 0000 29 Mental Disorders 0 0 0 0 0300 30 Dental Disorders 0 0 12 3 0300 31 Dis. of the skin (including ulcers) 455 553 483 366 197 318 214 0 32 Rheumatism, Joint pains, etc 96 210 158 111 43 33 30 0 33 Congenital Anomalies 0 0 0 0 0000 34 Pyrexia of Unknown Origin (PUO) 0 0 0 3 0 2 10 0 35 Poisoning 0 0 0 0 0000 36 Accidents (including fractures, burns, etc.) 140 327 347 208 34 82 47 0 37 Typhoid* NDA NDA NDA NDA NDA NDA NDA NDA 40 All other diseases 0 0 30 16 32 28 18 0 Total New Cases 3,161 4,832 4,685 2,740 1,047 1,661 1,120 523

*Typhoid is not an official entry on the MOH health data chart. In many cases, the typhoid disease classification was written by hand on the Ruiru Health Center chart. In other months, typhoid was not noted on the chart. The SIPA team has noted the months in which typhoid does not appear on the chart by marking the month as “no data available” or NDA. Note: UNAIDS 2003 estimates place Kenya’s prevalence rate for HIV/AIDS at 6.7%. However, HIV/AIDS is not an entry on the chart. Therefore, the data either does not take into account HIV/AIDS cases or they are embedded in other disease classifications.

92 Appendix 12: Ruiru Health Data, Page 3 of 7

Ruiru Health Centre Number of New Disease Cases, Non-continuous Monthly Data, 1997

No. Disease Aug-97 Sep-97 Oct-97 Nov-97 1 Diarrhoeal Diseases 203 221 230 185 2 Tuberculosis 0 0 0 0 3 Leprosy 0 0 0 0 4 Whooping Cough 0 0 0 0 5 Meningitis 0 0 0 0 6 Tetanus 0 0 0 0 7 Poliomyelitis 0 0 0 0 8 Chicken pox 4 9 2 11 9 Measles 0 1 0 3 10 Infectious Hepatitis (Jaundice) 0 0 0 0 11 Mumps 0 0 2 0 12 Malaria 543 479 435 341 13 Gonorrhoea 0 0 2 0 14 Urinary Tract Infections 159 156 127 80 15 Bilharzia (Schistosomiasis) 0 0 0 0 16 Intestinal Worms 124 170 102 102 17 Malnutrition 0 0 0 0 18 Anaemia 3 0 1 0 19 Eye Infections 69 84 120 57 20 Cataract 1 0 0 0 21 Ear Infections 18 18 12 0 22 Dis. of the Circulatory System 0 1 0 0 23 Dis.of the Respiratory System 514 468 410 368 24 Pneumonia 4 8 16 24 25 Abortion 1 1 0 1 26 Disorder of Puerperium and Child Birth 1 2 0 1 27 Neoplasms 0 0 0 0 28 Dis.of Blood and Blood Forming Organs 0 0 0 0 29 Mental Disorders 1 0 4 0 30 Dental Disorders 2 0 1 4 31 Dis. of the skin (including ulcers) 251 230 319 140 32 Rheumatism, Joint pains, etc 102 115 156 45 33 Congenital Anomalies 0 0 0 0 34 Pyrexia of Unknown Origin (PUO) 1 10 0 0 35 Poisoning 0 1 0 0 36 Accidents (including fractures, burns, etc.) 38 58 57 43 37 Typhoid 6 5 NDA NDA 40 All other diseases 23 8 13 4 Total New Cases 2,068 2,045 2,009 1,409

*Typhoid is not an official entry on the MOH health data chart. In many cases, the typhoid disease classification was written by hand on the Ruiru Health Center chart. In other months, typhoid was not noted on the chart. The SIPA team has noted the months in which typhoid does not appear on the chart by marking the month as “no data available” or NDA. Note: UNAIDS 2003 estimates place Kenya’s prevalence rate for HIV/AIDS at 6.7%. However, HIV/AIDS is not an entry on the chart. Therefore, the data either does not take into account HIV/AIDS cases or they are embedded in other disease classifications.

93 Appendix 12: Ruiru Health Data, Page 4 of 7

Ruiru Health Centre Number of New Disease Cases, Non-continuous Monthly Data, 1998

No. Disease Feb-98 Mar-98 Apr-98 May-98 Jun-98 Jul-98 Aug-98 Sep-98 Oct-98 Nov-98 Dec-98 1 Diarrhoeal Diseases 240 220 213 180 211 206 155 225 194 188 180 2 Tuberculosis 0 0 0 1 211 1 1 0 0 0 1 3 Leprosy 00000000000 4 Whooping Cough 00010000000 5 Meningitis 00000010000 6 Tetanus 00000000000 7 Poliomyelitis 00002000000 8 Chicken pox 2 0 5 0 2 0 4 10 20 17 12 9 Measles 53054043306 10 Infectious Hepatitis (Jaundice) 1 2 33 2 0 0 0 1 0 0 0 11 Mumps 4 0 75 1 4 8 0 7 2 9 2 12 Malaria 401 559 510 367 643 472 310 420 367 370 353 13 Gonorrhoea 00001000100 14 Urinary Tract Infections 86 93 79 90 100 23 90 102 88 87 82 15 Bilharzia (Schistosomiasis) 00003000000 16 Intestinal Worms 151 127 115 94 153 87 90 100 129 146 13 17 Malnutrition 15020011000 18 Anaemia 5 6 5 14 3 12 7 3 2 0 9 19 Eye Infections 41 70 51 46 55 45 40 88 91 84 75 20 Cataract 00000012000 21 Ear Infections 24 24 11 11 17 19 17 12 27 18 14 22 Dis. of the Circulatory System 00000000000 23 Dis.of the Respiratory System 450 559 464 361 793 496 316 459 376 386 361 24 Pneumonia 57 28 12 31 29 28 33 24 7 20 4 25 Abortion 00110110011 26 Disorder of Puerperium and Child Birth 05016004013 27 Neoplasms 00000000000 28 Dis.of Blood and Blood Forming Organs 00010000001 29 Mental Disorders 11103000011 30 Dental Disorders 26050034067 31 Dis. of the skin (including ulcers) 239 248 264 204 256 222 154 234 222 243 232 32 Rheumatism, Joint pains, etc 92 123 53 83 67 25 34 58 45 65 36 33 Congenital Anomalies 00001110000 34 Pyrexia of Unknown Origin (PUO) 01321030305 35 Poisoning 00010000001 36 Accidents (including fractures, burns, etc.) 55 72 40 63 17 70 71 45 72 49 56 37 Typhoid 10 15 9 11 20 6 7 NDA 1 18 23 40 All other diseases 26 4 2 4 11 2 14 9 7 7 0 Total New Cases 1,893 2,171 1,946 1,582 2,613 1,724 1,358 1,811 1,657 1,716 1,478

*Typhoid is not an official entry on the MOH health data chart. In many cases, the typhoid disease classification was written by hand on the Ruiru Health Center chart. In other months, typhoid was not noted on the chart. The SIPA team has noted the months in which typhoid does not appear on the chart by marking the month as “no data available” or NDA. Note: UNAIDS 2003 estimates place Kenya’s prevalence rate for HIV/AIDS at 6.7%. However, HIV/AIDS is not an entry on the chart. Therefore, the data either does not take into account HIV/AIDS cases or they are embedded in other disease classifications.

94 Appendix 12: Ruiru Health Data, Page 5 of 7

Ruiru Health Centre Number of New Disease Cases, 1999

No. Disease Jan-99 Feb-99 Mar-99 Apr-99 May-99 Jun-99 Jul-99 Aug-99 Sep-99 Oct-99 Nov-99 Dec-99 Total New Cases 1 Diarrhoeal Diseases 196 160 237 196 182 61 137 44 92 116 120 87 1,628 2 Tuberculosis 000000600010 7 3 Leprosy 000000000000 0 4 Whooping Cough 000010000000 1 5 Meningitis 000000000000 0 6 Tetanus 000000000000 0 7 Poliomyelitis 000000000000 0 8 Chicken pox 0 6 13 14 14 10 8 10 13 24 11 10 133 9 Measles 0 4 13 12 7 5 20 14 2 0 6 2 85 10 Infectious Hepatitis (Jaundice) 0 3 0 1 10 2 8 0 0 0 0 0 24 11 Mumps 2 303 1 1 7 2 4 0 1 0 2 0 323 12 Malaria 308 300 471 375 559 446 434 272 228 253 348 353 4,347 13 Gonorrhoea 0 1 0 0 6 0 101 45 0 83 59 20 315 14 Urinary Tract Infections 80 87 94 92 112 90 81 40 83 69 54 42 924 15 Bilharzia (Schistosomiasis) 0 0 0 0 0 0 0 15 0 0 0 0 15 16 Intestinal Worms 85 124 180 120 155 136 123 77 76 68 80 81 1,305 17 Malnutrition 000000000000 0 18 Anaemia 0 0 3 0 0 36 8 4 0 4 7 12 74 19 Eye Infections 72 87 98 61 106 64 63 31 22 0 0 41 645 20 Cataract 000000130000 4 21 Ear Infections 13 8 0 12 0 8 23 7 10 41 5 9 136 22 Dis. of the Circulatory System 560000040500 20 23 Dis.of the Respiratory System 298 336 447 376 427 885 875 255 236 270 304 231 4,940 24 Pneumonia 0 3 36 37 60 26 36 9 0 0 12 24 243 25 Abortion 000003180010 13 26 Disorder of Puerperium and Child Birth 400000041133 16 27 Neoplasms 000000021000 3 28 Dis.of Blood and Blood Forming Organs 0 0 0 0 0 0 0 1 0 0 0 0 1 29 Mental Disorders 100000000000 1 30 Dental Disorders 058084020020 29 31 Dis. of the skin (including ulcers) 202 179 173 154 173 145 148 25 91 111 111 104 1,616 32 Rheumatism, Joint pains, etc 50 78 83 35 42 7 37 10 11 27 48 39 467 33 Congenital Anomalies 000000030000 3 34 Pyrexia of Unknown Origin (PUO) 10 7 11 0 10 8 3 4 13 0 0 0 66 35 Poisoning 000000000000 0 36 Accidents (including fractures, burns, etc.) 36 47 34 47 36 41 33 55 21 21 146 44 561 37 Typhoid NDA 22 15 4 19 25 25 NDA 5 10 9 NDA 134 40 All other diseases 0 0 6 27 11 120 60 47 19 53 68 157 568 Total New Cases 1,362 1,766 1,923 1,564 1,945 2,124 2,235 991 925 1,156 1,397 1,259 18,647

1999 Population: 109,574, Source: Kenya Census *Typhoid is not an official entry on the MOH health data chart. In many cases, the typhoid disease classification was written by hand on the Ruiru Health Center chart. In other months, typhoid was not noted on the chart. The SIPA team has noted the months in which typhoid does not appear on the chart by marking the month as “no data available” or NDA. Note: UNAIDS 2003 estimates place Kenya’s prevalence rate for HIV/AIDS at 6.7%. However, HIV/AIDS is not an entry on the chart. Therefore, the data either does not take into account HIV/AIDS cases or they are embedded in other disease classifications.

95 Appendix 12: Ruiru Health Data, Page 6 of 7

Ruiru Health Centre Number of New Disease Cases, Monthly Non-continuous data, 2000

No. Disease Jan-00 Feb-00 Mar-00 Apr-00 May-00 Aug-00 Sep-00 1 Diarrhoeal Diseases 107 144 162 107 157 97 81 2 Tuberculosis 0 0 1 0 0 0 0 3 Leprosy 0 0 0 0 0 0 0 4 Whooping Cough 0 0 2 0 0 0 0 5 Meningitis 0 0 0 0 0 0 0 6 Tetanus 0 0 0 0 0 0 0 7 Poliomyelitis 0 0 0 0 0 0 0 8 Chicken pox 9 9 12 12 15 7 3 9 Measles 1 0 0 3 1 1 2 10 Infectious Hepatitis (Jaundice) 0 0 3 1 2 0 1 11 Mumps 0 2 17 8 5 3 1 12 Malaria 280 365 346 284 355 341 283 13 Gonorrhoea 1 30 35 17 40 18 6 14 Urinary Tract Infections 74 89 68 48 75 40 57 15 Bilharzia (Schistosomiasis) 0 2 0 1 0 0 0 16 Intestinal Worms 106 126 180 147 192 112 131 17 Malnutrition 0 0 3 0 0 0 0 18 Anaemia 0 28 29 15 46 8 0 19 Eye Infections 51 58 78 67 60 47 74 20 Cataract 0 0 0 0 0 0 0 21 Ear Infections 13 22 26 14 16 11 19 22 Dis. of the Circulatory System 0 1 6 0 0 0 0 23 Dis.of the Respiratory System 286 399 373 280 422 367 325 24 Pneumonia 12 1 22 20 21 28 13 25 Abortion 1 2 10 1 3 1 1 26 Disorder of Puerperium and Child Birth 0 3 1 1 0 1 0 27 Neoplasms 1 0 1 0 0 0 0 28 Dis.of Blood and Blood Forming Organs 0 2 0 0 0 0 0 29 Mental Disorders 1 0 0 0 0 0 1 30 Dental Disorders 0 1 1 1 6 0 6 31 Dis. of the skin (including ulcers) 148 150 194 137 227 131 169 32 Rheumatism, Joint pains, etc 32 38 54 39 0 35 31 33 Congenital Anomalies 0 0 0 0 0 0 0 34 Pyrexia of Unknown Origin (PUO) 0 0 0 9 9 3 0 35 Poisoning 0 0 0 0 0 0 0 36 Accidents (including fractures, burns, etc.) 27 39 49 58 43 49 33 37 Typhoid 6 6 13 NDA 11 14 28 40 All other diseases 175 176 198 138 215 101 117 Total New Cases 1,331 1,693 1,884 1,408 1,921 1,415 1,382

2000 Population Estimate: 117,573, Source: Columbia University Urban Planning Studio *Typhoid is not an official entry on the MOH health data chart. In many cases, the typhoid disease classification was written by hand on the Ruiru Health Center chart. In other months, typhoid was not noted on the chart. The SIPA team has noted the months in which typhoid does not appear on the chart by marking the month as “no data available” or NDA. Note: UNAIDS 2003 estimates place Kenya’s prevalence rate for HIV/AIDS at 6.7%. However, HIV/AIDS is not an entry on the chart. Therefore, the data either does not take into account HIV/AIDS cases or they are embedded in other disease classifications.

96 Appendix 12: Ruiru Health Data, Page 7 of 7

Ruiru Health Centre Number of New Disease Cases, Non-continuous Monthly Data, 2005-2006

No. Disease Jan-05 Feb-05 Mar-05 Apr-05 May-05 Jun-05 Sep-05 Oct-05 Nov-05 Dec-05 Jan-06 Feb-06 1 Diarrhoeal Diseases 261 295 286 261 355 343 337 280 244 281 289 265 2 Tuberculosis 0 33003214400 3 Leprosy 0 00000000000 4 Whooping Cough 0 00000000000 5 Meningitis 0 00000000000 6 Tetanus 0 00000000000 7 Poliomyelitis 0 00000000000 8 Chicken pox 34 6 7 11 5 10 9 10 25 6 19 6 9 Measles 0 00000000000 10 Infectious Hepatitis (Jaundice) 0 00000000000 11 Mumps 6 11 6 2 0 6 2 1 2000 12 Malaria 821 1,012 1,122 924 1,027 880 1,033 789 775 875 834 807 13 Gonorrhoea 0 00000400000 14 Urinary Tract Infections 66 57 29 42 32 45 88 40 77 59 65 46 15 Bilharzia (Schistosomiasis) 0 00000000000 16 Intestinal Worms 244 233 253 242 305 290 210 170 197 258 178 177 17 Malnutrition 4 10000100000 18 Anaemia 0 000001510001 19 Eye Infections 183 154 157 145 105 104 146 113 127 172 131 96 20 Cataract 0 00000100000 21 Ear Infections 11 40 12 16 9 33 27 12 11 8 15 17 22 Dis. of the Circulatory System 0 00000000000 23 Dis.of the Respiratory System 813 1,023 1,123 1,038 1,147 1,001 1,204 950 852 1,092 906 976 24 Pneumonia 37 123 28 79 53 43 62 150 48 37 65 61 25 Abortion 0 01103101002 26 Disorder of Puerperium and Child Birth 0 01100000101 27 Neoplasms 0 10001100000 28 Dis.of Blood and Blood Forming Organs 0 00000010000 29 Mental Disorders 0 11000022110 30 Dental Disorders 9 5 10 10 8 15 0 3 11 0 3 1 31 Peridental Diseaases 0 00000002010 32 Dental Maloclussions 0 00000402100 33 Other dental disorders 0 00000501000 34 Dis. of the skin (including ulcers) 280 335 278 272 314 330 0 198 222 281 284 279 35 Rheumatism, Joint pains, etc 161 184 107 102 124 47 100 83 118 69 97 59 36 Congenital Anomalies 0 00000000000 37 Pyrexia of Unknown Origin (PUO) 129 4 34 232 10 43 7 49 0 10 48 0 38 Poisoning 0 10000000000 39 Accidents (including fractures, burns, etc.) 21 24 38 38 25 41 22 31 43 42 36 42 40 Typhoid 26 29 10 15 21 18 19 15 7 13 3 10 41 All other diseases 252 335 305 270 283 286 164 197 191 197 116 114 Total New Cases 3,358 3,877 3,811 3,701 3,823 3,542 3,464 3,096 2,962 3,407 3,091 2,960

2005 Population Estimate: 167,227, Source: Columbia University Urban Planning Studio *Typhoid is not an official entry on the MOH health data chart. In many cases, the typhoid disease classification was written by hand on the Ruiru Health Center chart. In other months, typhoid was not noted on the chart. The SIPA team has noted the months in which typhoid does not appear on the chart by marking the month as “no data available” or NDA. Note: UNAIDS 2003 estimates place Kenya’s prevalence rate for HIV/AIDS at 6.7%. However, HIV/AIDS is not an entry on the chart. Therefore, the data either does not take into account HIV/AIDS cases or they are embedded in other disease classifications.

97 Appendix 13: Map of Registered Borehole Locations in Ruiru Municipality

Source: Thika District Office

98 Appendix 14: Contact List, Page 1 of 2

First Name Last Name E-mail Address Title Office Phone Home Phone Address

General Contacts Julius K. Inyingi [email protected] Thika District Public 0733 250 947 Health Officer Engineer Irari Tana Water Board, Nyeri 0733 954 413 Former provincial water office, Nyeri Engineer J.P. Kimani Director, Technical 020 557 131 0722 513 306 NWC, Kampala Rd, Services, Nairobi Water Industrial Area Company Julie M. Kiruri Ministry of Water and 6731597 0721 714126 Athi Water Services Irrigation Thika District Office in Thika Engineer Kibaki Nyeri Water Company 0721 279 928 Lucy Kibui [email protected] Customer Relations 061 203 4623 0733 900 195 Officer, Nyeri Water & Sewerage Company Engineer Silas Muketha National Water & 0722 647 157 Near Public Works, Pipeline Conservation Industrial Area, off Board Uhuru Hwy Kamicheal Nduri Plan International, 21078 or 21081 Thika Health, Water, and Agricutlure Education Engineer Ngare General Manager, Thika Michael Water Company Titus Nzuki [email protected] AMREF,Water and 020 699 4350 0724 528 604 Sanitation Project Office Engineer Onyango [email protected] Personal Assistant to the 0722 922 693 Sammy Member of Parliament

Kabando Wa Kabando [email protected], CEO of the Kenya 020 604 419 or Mombasa Road, [email protected] Association of Hotel 020 602 538 Heidelberg house 2nd Keepers and Caterers floor, Kenya (KAHC) and the Chair of Association of Hotel Nairobi Water Company Keepers and Caterers Erick Waweru [email protected] Community Member 073 577 8843 from Kahawa Sukari, Member of Darubini health NGO inThika Magana Muigai [email protected] Theta Hydro Ltd. (model borehole in Juja) Water and Sanitation Research Maimbo M. Malesu [email protected] ICRAF, Regional Co- 020 52 44 18 or UN Avenue, PO Box ordinator, Global Water 020 52 44 21; 30677-00100, Nairobi Partnership Associated FAX 020 52 44 Program 01 Japheth Mbuvi [email protected] World Bank Water 020 322 6321 World Bank, Kenya Hill Library (need Park, Upper Hill Rd appointment) Malaquen Milgo malaquen.milgo@gtz- Ministry of Water 020 271 9987 or located in Ministry of wsrp.or.ke Library 020 273 0973 Water Bldg, Waji House, 4th floor Mi Hua [email protected] Millennium Project, 020 722 4482; UN Avenue, PO Box Water and Sanitation FAX 020 722 30677-00100, Nairobi Specialist 4490 Chin Ong [email protected] ICRAF, Project 020 524 205; UN Avenue, PO Box Manager, Regional Land FAX 020 52 44 30677-00100, Nairobi Management Unit 01 Norah Osora [email protected] World Bank Public 020 322 6320 World Bank, Kenya Hill Information Center Park, Upper Hill Rd

99 Appendix 14: Contact List, Page 2 of 2

First Name Last Name E-mail Address Title Office Phone Home Phone Address

Athi Water Services Board Contacts Mr. Gitau Deputy District Officer, Thika District Office, AWSB Engineer Joseph Kamau [email protected], Services Planning 020 272 4292 0720 714 766 3rd fl, Africa Re Centre, [email protected] Engineer, AWSB Hospital Rd, Upper Hill John M. Kinya District Water Officer, 0733 729 877 Thika District Office, AWSB Patrick Kinyori [email protected] Chairman, AWSB 020 272 4292 3rd fl, Africa Re Centre, Hospital Rd, Upper Hill Julia Kiruri Surface Water Officers, Thika District Office, AWSB Engineer John Muiruri [email protected] Chief Manager, 020 272 4292 0735 375 695 or 3rd fl, Africa Re Centre, Technical Services, 0725 674 763 Hospital Rd, Upper Hill AWSB Julius Muiruri Water Quality Officer, Thika District Office, AWSB Mr. Mungai Surface Water Officers, Thika District Office, AWSB Juliana Mutua Physical Planning 0670 30184 0720 311 638 Officer, Thika District (soon to be working for Ruiru) Engineer Mwangi [email protected] CEO, AWSB 020 272 4292 0735 375 695 or 3rd fl, Africa Re Centre, Lawrence 0725 674 763 Hospital Rd, Upper Hill Mary Mwangi Ruiru Division Water 0721 806 376 Ruiru Officer, Ruiru Office, AWSB Engineer Naivasha District Officer, Thika District Office, AWSB University of Nairobi, Urban Planning Deptartment Musyimi Mbathi [email protected] Lecturer in Urban & 0721 643 501 Regional Planning, University of Nairobi; led Ruiru studio in Spring 2005 Geoffrey Mogondu [email protected] Master of Urban 0722 696 818 Planning student; thesis on water and Ruiru, Ruiru resident Peter Ngau [email protected], Professor & Chair of 020 271 8548 0722 658 781 UP is on ground floor of [email protected] Dept of Urban & Architecture, Design & Regional Planning, Dev. Bldg on State University of Nairobi House Ave (not U of N main campus) Lilian Otiego [email protected] Master of Urban 0722 309 336 Planning student, thesis on water in Shem O. Wandiga [email protected] Professor, Chemistry 020 311 714 Department, University of Nairobi

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