No water, no electricity but lots of hope: WaterAid UK visits a hospital in Malawi

31 January 2019
WaterAid/Chipiliro Kansilanga

Across the continent of Africa, 42% of healthcare centres are without clean water, decent toilets and good hygiene. When that’s coupled with electricity outages, it puts pressure on staff, and threatens the wellbeing of patients. Lis and Elizabeth from WaterAid UK spent the night at a district hospital in Malawi, to experience for themselves this challenging environment.

When the sun goes down and the lights don’t come on, a darkness falls over huge swathes of Malawi. The beautiful hills, mountains, open plains and plateaus plunge into darkness. 

In Malawi, one in three people live without clean water, and more than half the population has no decent toilet. The situation in healthcare facilities is equally worrying, with one in five having no clean water and more than half lacking decent toilets. One such facility is Ntchisi District Hospital. 

It’s 87 kilometres north of the capital Lilongwe and serves up to 315,900 people. Among them, thousands of women go to the health centre for obstetric care every year. Each month, Ntchisi’s staff see approximately 450 births and, sadly, 15 neonatal deaths and one maternal death.

I arrived with the WaterAid Malawi team, and my WaterAid UK colleague Elizabeth just before sunset. We were there to spend the night at Ntchisi District Hospital, to meet the staff and patients. As staff let us step into their routine for just one evening, we would experience being in a hospital without a reliable water supply and limited toilets. 

Globally, Malawi is among the countries with the highest maternal and neonatal mortality rates. A national policy to bring expectant mothers into healthcare facilities to give birth with support from a skilled birth attendant is designed to save lives. But the reality for the women includes floors for beds, full pits for toilets (if there are any at all), and no clean running water to drink or wash with. And, on the day we arrived to stay, no electricity either.

A power cut

The empty corridors reverberated to the sound of a single generator, too weak to power anything more than the delivery room, a theatre and to light and warm the nursery. We walked on in the darkness, our torch offering glimpses of murals depicting hygiene and maternal advice. But without clean water, decent toilets and good hygiene, infections can spread fast in a healthcare setting. Working without running water puts both staff and patients at risk. But here the hospital stands, and work it does, 365 days a year.

In the middle of a 12-hour power blackout, a nurse briefs the WaterAid team on how the maternity ward is run without electricity, clean water or decent toilets.
WaterAid/Chipiliro Kansilanga
In the middle of a 12-hour power blackout, a nurse at Ntchisi Disctrict Hospital briefs the WaterAid team on how the maternity ward is run without electricity, clean water or decent toilets.

Dealing with hygiene and infection

We visited an postnatal ward which was divided into two sections, lit only by regimented rows of candles down the centre and along the walls. It was hard to get a sense of how many women were here, but it was obvious the ward was working at a level well beyond its original capacity. Such a difficult situation in which to deliver safe and quality healthcare to new mothers. 

Staff told us they worked fast to discharge the women as quickly as possible, because the chance of infection grew the longer they remained. Without regular running water and other essentials like decent toilets and waste management, hygiene practices are compromised, increasing the risk of healthcare-associated infections. In the end, the hospital has to allocate more resources to manage illnesses that could have been avoided and are in some cases so severe they lead to death.

In the maternity ward, expectant women and their guardians sleep in the dark, aided by candlelight, in Ntchisi District Hospital, Malawi, October 2018.
WaterAid/Chipiliro Kansilanga
In the maternity ward, expectant mums and their family members sleep in rooms lit only by candlelight.

Unreliable water supply

On paper, Ntchisi District Hospital has piped water, indoor toilets and waste management facilities. But the reality is entirely different when functionality and reliability of these provisions are considered.

“Well, the system is there, but sometimes the problem is the supply. Sometimes we have water, sometimes we don’t,” explained James Mtonga, Environmental Health Officer and Water, Sanitation and Hygiene Coordinator for the hospital. When there is no piped water, the nearest borehole (which was broken down at the time of our visit) is a 10-minute walk away. Hospital staff as well as patients and their guardians walk the distance almost every day.
Under normal circumstances, the hospital is supplied by a water utility company which relies on the national electricity supply to operate. When there is no electricity, the utility’s back-up does not pump enough water and there’s not enough to supply the hospital. Sometimes at Ntchisi, they go for days without water – because of the blackouts. In the worst of circumstances, Ntchisi District Hospital has had to use one of its four ambulances just to collect water.

The human cost

This is just part of what has become normal for health centres and hospitals across Malawi, and it’s a situation repeated in other countries too. Staff work within circumstances we find hard to imagine – and this has become their reality. Later, we would find out this was one of those evenings when a mother was lost and this became very real to us, too. She’d given birth at home prematurely to her eighth child. Already unwell with an underlying condition, she hadn’t recovered from the blood loss. Arriving by motorbike several hours later, she had died.

Bringing voices together

Towards midnight, Elizabeth spent some time with the expectant mums. As she spoke to them about her experience of being a mum in Scotland, they asked questions about how they could bring about change for Malawians too. Every so often, she would hear the low cries and moans of a woman in labour. The labouring women were barely audible, really, just as they are in the decision-making processes surrounding the resourcing of health facilities such as Ntchisi. Given the opportunity, however, women across the world are lifting their voices up and demanding to be heard – showing that what is accepted as normal can, in fact, change.

Just before she left the expectant mothers to sleep, prayers were said, and the women shared a song about perseverance. It was about the prophet Job, the suffering he endured and how he kept his faith in God. Out of all the sounds we heard that evening – the gentle voices of staff steadily explaining their situation, the warning sounds issued by equipment signalling dangerously low oxygen levels in a new baby, his rattling breath – it would be this singing that made us look to the future. The women can demand change and when they bring their voices together, it is a powerful sound. 

You can listen to the song below:

Finally, the dawn brought light back to Ntchisi, and so a new day’s routine begins, as always, with the walk to collect water from the nearby borehole. 

Elizabeth McKernan from WaterAid Scotland helps carry water back to Ntchisi District Hospital from the nearest borehole
WaterAid/Chipiliro Kansilanga
Elizabeth McKernan from WaterAid Scotland helps carry water back to Ntchisi District Hospital from the nearest borehole.

At the beginning of 2019, the Deliver Life project – made possible with UK aid from the British people – will complete three years of work focused on health centres and communities in three regions across Malawi. Building on this success, a new project supported by the Scottish Government and Scottish Water has just begun supporting an additional four healthcare centres across Machinga District. 

Since Lis and Elizabeth visited Ntchisi, the hospital has received a bigger generator to help it cope with the blackouts which continue. WaterAid Malawi has committed to improving access to clean water, decent toilets and good hygiene in 150 healthcare centres across the country, including Ntchisi – directly supporting 75 and influencing government and other partners to reach the rest – by 2023.