Combined household water treatment and indoor air pollution projects in urban Mambanda, Cameroon and rural Nyanza, Kenya ppt

WHO/SDE/02.11
Englishonly
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Combinedhouseholdwatertreatmentandindoorair
pollutionprojectsinurbanMambanda,Cameroonandrural
Nyanza,Kenya
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Geneva2011
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Photocredit(BruceNandShaheedA,2009)
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Combinedhouseholdwatertreatmentandindoorairpollutionprojectsinurban
Mambanda,CameroonandruralNyanza,Kenya

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WHO/SDE/WSH/02.11
Englishonly


Combinedhouseholdwatertreatmentandindoorair
pollutionprojectsinurbanMambanda,Cameroonandrural
Nyanza,Kenya






ReportofamissiontoMambanda,CameroonandNyanza,Kenya
Carriedoutfrom10to18December 2009
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Authors
AmeerShaheed
Consultant,Water,SanitationandHealthProgramme,WorldHealthOrganization,Geneva
NigelBruce
Consultant,InterventionsforHealthyEnvironments,WorldHealthOrganization,Geneva

Editor
MaggieMontgomery
TechnicalOfficer,Water,SanitationandHealthProgramme,WorldHealthOrganization,
Geneva


Acknowledgements
Theauthorsthanktheprojectofficersandhealthpromoters,
governmentofficials,small‐
scalebusinesspeopleandhouseholdrespondentsinCameroonandKenyawhoofferedtheir
timeandexpertisetoinformthisevaluation.Inaddition,appreciationisextendedtoall
thosestakeholderswhohelpedinitiatethesehouseholdenvironmentalhealthintegration
projectsandcontinuetocarryoutthisimportantwork.
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TABLEOFCONTENTS

EXECUTIVESUMMARY 6
1.BackgroundtoRFP 6
2.EvaluationTermsofReference(ToR)andmethods 6
3.CountryReports 7
4.Overallstrategicissuesandrecommendations 16
5.Nextsteps 17
1.INTRODUCTION 20
1.1Projectoverview 20
1.2EvaluationTermsofReference 20
1.3Visitschedule 21
1.4Evaluationmethods 21
1.5Briefreviewofliterature 21
1.5.1Effectivenessof
HWTS 21
1.5.2Effectivenessofimprovedsolidfuelstoves 22
2.COUNTRYREPORT–URBANMAMBANDA,CAMEROON 24
2.1Countrybackground 24
2.2Projectorganizationandmanagement 24
2.3Educationandproductpromotion 27
2.4Interventionefficacy,effectivenessandefficiency 28
2.4.1Householdwatertreatment 28

2.4.2Impr ovedstoves:reductionofhouseholdsolidfuelairpollution 32
2.5Financeand
loanarrangements 35
2.6Addedvalueofintegrateddelivery:synergies 35
2.7Recommendedareasforfurtherresearch 37
2.8Scaling‐up 38
2.8.1Locallevel 38
2.8.2Largerscale(city–national) 39
2.9Discussionandconclusions 40
2.9.1Conclusions 40
2.9.2Data 43
2.9.3Finalcomments 44
3.COUNTRYREPORT–RURALNYANZA,KENYA 45
3.1Countrybackground 45
3.2Project
overview 46
3.3.Projectorganisationandmanagement 48
3.4Education(health),productpromotionandfinance(loans) 49
3.5Interventionefficacy,effectivenessandefficiency 52
3.5.1Householdwatertreatment 52
3.5.2Impr ovedstoves:reductionofhouseholdsolidfuelairpollution 55
3.7Evaluationresearch 62
3.8Scaling‐upandintegrationwithgovernment 63
3.9Discussionandconclusions 65
4.SYNTHESISOF
EXPERIENCEFROMCAMEROONANDKENYA 68
4.1Projectfundingandorganisation 68

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4.2Products 68
4.3Educationandpromotion 69
4.4Sellingofproducts 69
4.5Sustainabilityandscalingup,exitstrategy 70
4.6Synergy 70
4.7Researchandevaluation 70
5.RECOMMENDATIONANDNEXTSTEPS 71
5.1Specificrecommendationsforcountries 71
5.1.1Cameroon 71
5.1.2Kenya 72
5.2Strategicrecommendations 73
5.3Follow‐upWorkshop 74
5.4Issuesforfurtherresearch 74
5.5
Futureimplementation 75
6.REFERENCES 76
ANNEX1Visitschedule(December2009) 78
ANNEX2Evaluationtopics/questions 79
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
ABBREVIATIONS

ACMS AssociationCamerounaisedeMarketingsociale(SocialMarketing
AssociationofCameroon)
ALRI AcuteLowerRespiratoryInfection
AQG AirQualityGuidelines

GTZ GesellschaftfürtechnischeZ usammenarbeitung(GermanTechnical
Cooperation)
HAP HouseholdAirPollution
HHE HouseholdEnergy
HWT Householdwatertreatment
HWTS Ho useholdwatertreatmentandsafestorage
IAQ IndoorAirQuality
ITN Insecticidetreatednets
LP Liquefiedpetroleum
JMP WHO/UNICEFJointMonitoringProgram
MMS MambandaMultiStove(Cameroon)
NGO Non‐governmentalOrganization
NICHE NyandoIntegratedChildHealthandEducationProject
PCIA PartnershipforCleanIndoorAir
PSI PopulationServicesInternational
RFP Requestforproposals
SWAP SafeWaterandAIDSProject(KenyanNGO)
SWAp Sector‐wideapproach(KenyanGovernment)
UNICEF UnitedNationsChildren’sFund
WG WaterGuard®(“Sur’Eau”inFrench)
WHO WorldHealthOrganization
6
EXECUTIVESUMMARY
1.BackgroundtoRFP
In2007,theWorldHealthOrganization(WHO)issuedarequestforproposals(RFP)onthe
integrationofIndoorAirQuality(IAQ)andHouseholdWaterTreatment(HWT)atthe
householdlevelinAfrica.Globally,theburdenofill‐healthinAfricaduetounsafedrinking‐
water,inadequatesanitationandpollutedindoorair
standsoutprominently.AmongAfrican
childrenunder5yearsofage,18%ofalldeathsareduetodiarrhoea,and17%topneumonia


(UNICEF/WHO,2009).Around40%ofthesepneumoniadeathscanbeattributedtoindoor
airpollution,andapproximately88%ofdiarrhoeadeathstoinadequatewater,sanitation,
andhygiene

(WHO,2007).

Theaimsofthisinitiativewere:

1. Toexplorewhetherornotitispossibletoachievesynergiesandeconomiesofscaleby
linkingHWTandIAQinterventions
2. Toexaminethepotentialforexpansionandscalingupintheimplementationofprojects
combiningtheseinterventions
3. To
documentintegrationmodelsfortheseinterventions
4. Toexaminetheadded‐valueofintegratingthesetwoapproaches,inawaythat
contributestoanimprovementinhealthoutcomes,aswellassustainabilityandadoption
ofuse.

Followingappraisaloftheproposalsreceived,twoprojectswereselected,oneinurban
Douala,
Cameroon,thesecondinruralNyanza,Kenya.Abriefoverviewofeachprojectis
providedinthecountryreportsectionsinthemainreport.

2.EvaluationTermsofReference(ToR)andmethods
WHOprojectsupportintheoverallmanagementplanmadeprovisionsforanevaluationvisit
toeachcountry.ThesewerecarriedoutinDecember2009bytwoWHOConsultants,Mr
AmeerShaheed(CameroonandKenya)andDrNigelBruce(Kenya),withthefollowingToR:

1. Preparebackgroundinformationandcompilecontextualinformation

ontheareas/study
communitieswithrespecttowatersupply/quality,householdfueltypeandsupply/IAQ
(subjecttoavailability)andrelatedhealthdata(diarrhoea,acutelowerrespiratory
infection(ALRI))
2. Toconductafield‐visittothetwoprojectsinCameroonandKenya,andperformabasic
evaluation
3. Prepareacomprehensive
factualaccountofprojectactivitiesandoutputs,describingthe
experienceofresidents,projectstaffandotherrelevantkeyinformants(e.g.local
government,partnerorganizations)concerningprojectdelivery,achievements,problems
andissues,andconcerningfutureprospectsforthiscombinedenvironmentalhealth
approachtargetedathouseholds.Particularemphasisshouldbegiventoassessing
the
addedvalueoflinkingdrinking‐watersafetyandindoorairquality.



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Themethodsusedfortheevaluationdrewontechniquesofrapidappraisal,involving(i)
reviewofDocumentation(allavailableprojectdocumentation,countrystatisticaldata,
relevantpublishedpapersandreports;(ii)Interviewswithkeyinformants(projectstaff,
residents/usersoftheproductsandservices,andotherstakeholders),and(iii)Observation
(projectmanagementand
procedures,households,photographs).Interviewswererecorded
bymanualnote‐taking,andres ponsessynthesizedusingasimpleformofframework
analysis.ThebackgroundpaperintheRFPbyClasenandBiran

(2007)whichproposed
criteriaonpotentialsynergiesandantagonisms,alsocontributedtostructuringthe
evaluation.

3.CountryReports
CAMEROON
Localsituation
Cameroonisacountryof18.2millionpeople.Meanlifeexpectancyatbirthis50/52years
(m/f),andunder‐5mortalityis149/1000livebirths.Diarrhoeaaccountsfor16.4%ofunder‐5
deaths,andpneumonia,for20.4%

(WHO,2009).Accordingto2008figures,anestimated
92%ofurbanCameroonhasaccesstoan"improved"drinking‐watersourceasdefinedbythe
WHO/UNICEFJointMonitoringProgramme(WHO/UNICEF,2010).This doesnotg uarantee
safewaterhowever,andalargeproportionofsuchsourcesmaybesubjecttocontamination
,
especiallythroughunsafewaterhandlingandstorage

practices.Additionally,56%ofurban
areaslackaccessto“improved”sanitation(WHO/UNICEF,2010).Regardingurbanfueluse,
approximately52%consistsofwoodandsawdust,25%ofLPGgas,5%ofcharcoal,and13%
ofkerosene(WHO,2010).

TheprojectwasspearheadedbytheGermanTechnicalCooperation(GTZ)inCameroon,in
Mambanda,asemi‐formalsettlementinDouala,Cameroon'slargestcity.Situatedonan
island,accesstowaterislimited,andgroundwaterisbrackish,containingheavyiron
deposits.Furthermore,thepoorsystemofpipelinesandmanagementoftreatmentplants
resultsincontaminated,unsavoury,andinsufficientdrinking‐water.Fueluseconsisted
primarilyof
woodandsawdust,andtoalesserextent,charcoalandLPgas.

Projectactivityandachievements
Projectobjectives
Theprojectpilotedamethodofintegratingthedeliveryofawatertreatmentdevicewith

improvedstoves.Itwassetuptoinvestigatethepotentialaddedvalueofcombining
environmentalhealthinterventions.
Itshealthaimswere“toreducechildmorbidityand
mortalityfromdiarrhoealandrespiratorydiseases”

(GTZ,2008).GTZalsosawthisasan
opportunitytofollowfromtheirearlieractivitiesinwater,sanitation,andhygienein
Mambanda.

Projectfunctioning
Theprojectwascoined“SmokeandDrinking‐water”,whichsawthejointimplementationof
awatertreatmentproduct“WaterGuard®”(WG)andanimprovedstove“Mambanda
MultiStove”
ineightblocksofthesettlement.WGisasodiumhypochloritesolutionusedfor
disinfectingdrinking‐wateratthepoint‐of‐use,popularinmanyAfricanandAsiancountries
andemergency‐reliefoperations.TheMambandaMultiStove(MMS)isauniqueimproved
stove,designedbyGTZ,aimingtoreduceindoor‐air‐pollution
andefficientlycombust


8
multipletypesoffuel.TheprojectwassettorunfromJune2008toNovember2009.Itwasin
successiontoGTZ’searlier“WaterandSanitation”project(2006‐2008),inthecontextof
whichwell‐chlorinationandsanitationinterventionswereconductedinseveralpartsof
Douala,includingMambanda.

Projectstructure
TheGTZenvironmenthealthofficerinDoualawastheoverallprojectcoordinator.He
employedtwoprojectmanagers,whowereinchargeofallfieldactivities.TheAssociation
CamerounaisepourleMarketingSocial(ACMS),anot‐for‐profitorganisation,providedWG

andsocialmarketingexpertisetotheproject.Localweldersweretrained
byGTZtoproduce
theMMS.Theprojectteamincludedfourlocalg roups:(1)watervendors,whosoldwaterat
communalpumpsalongwithbothinterventionproducts;(2)localshopkeeperswhosold
WG;(3)communityworkerswhoengagedwiththebeneficiariesandsoldbothproducts;and
(4)localhealthcentre
staff.

Expectedoutputs
Ofthetargetpopulation,90%wasexpectedtohaveaccesstosafedrinking‐waterand60%to
beusingfuelefficientstovesbytheendoftheproject.Theintegratedapproachwas
expectedtobringoverallefficiency,particularlyincostandtime.Theyexpected
improvementsincommunity
healtheducation,andgreaterownershipoftheproject
amongstbeneficiaries.

Evaluationresults
Itisimportanttonotethatthefocusofthisevaluationwastostudythepotentialfor
integratedhouseholdinterventions,asopposedtotheeffectofthespecificinterventionsin
question.Theevaluationwasconductedbyrapidappraisal
methods,includingkeyinformant
interviews.AllquantitativedatawasobtainedfromstudyingreportssubmittedbyGTZafter
ourevaluation.

Aseriesofevents–mostlybeyondthecontroloftheprojectmanagers–affectedtheproject
overitscourse.Thisledtosomedifficultiesintheinterpretationofavailabledata
onthe
projectimplementationandimpacts,issueswhicharediscussedfurtherinsection2.2.Dueto
this,andtoafocusthatwasmoregearedtoassessingintegrationperse,ourconclusionsand
recommendationsdrawsubstantiallyonthevisit,withsupportfromreportsanddatawhere

thisisavailable.

The
followingarekeyresultsthatemergedfromtheevaluationexercise:

Communityresponse
Therewasclearsupportfortheinterventionamongstthestudygroupandneighbouring
residents.Bothbeneficiariesandprojectimplementersfoundtheintegration ofhealth
interventionstobeefficientandeffective.Asignificantlyraisedawarenessoftheprojectand
generalhealthwasreported.Thegreatestcomplaintregardedstoveprices,whichweretoo
expensiveformostmembersofMambanda,andsoldbestwhensubsidized.





9
Implementerbenefits
Themainimplementerbenefitsincludedconsolidatingawarenesscampaigns,
implementationanddatacollection,reachingagreatertargetaudienceandpromoting
preventiveactionforbothALRIanddiarrhoeawithasingletheme(thekitchen).

Targetpopulationbenefits
Twoproductsbeingpromotedatonce(timesaved),amoreconsolidated/holistic
understandingof
healthandapotentiallymoreenduringmessagewerethekeybenefitsto
theprojectbeneficiaries.

Trainedcommunityworkers
Thetrainedlocalcommunityworkers,whopromotedandsoldtheproductsdirectlyto

households,playanimportantroleingeneratinginterestanddemandfortheproducts .
Theyimpartedafeelingoffamiliarity
andtrust,andbridgedthedividebetween
implementersandcommunity.

Quantitativeimpact
Theshortdurationofthispilotstudydidnotallowforcollectingsufficientdatatoquantify
theimpactonhealthfromtheinterventiontechnologies.Itwasalsonotpossibleto
numericallydemonstrateanincreaseinsalesanduptake
specificallyduetothesynergy.
Therewaslittledataoncompliance,hardmeasuresofuptakeorof‘treatment’effects(e.g.
chlorineresiduals,airpollutionmeasurements),orhealthimprovementsinrelationtoeither
product.However,reporteduseofWGforwatertreatmentrosefrom1to34%forthe
interventionhouseholds,
andtherewasanincreasefrom1to12%inMMSstoveusein
thosesamehouseholds.Duringtheproject220stovesweresoldtoindividualslocatedinthe
interventionareawhile442weresoldtoindividualsoutsidetheintervention.Althoughthe
reasonsforgreatersalesoutsideMambandahavenotbeen
specificallyinvestigated,
anecdotalaccountsindicatethatthestoveswereunaffordableinMambanda,evenwiththe
30%subsidy.However,wealthierhouseholdsoutsideMambandacouldaffordthestoves
andfoundthemtechnologicallysuperiortootherstovesonthemarket.

Discussion
Thecombinedapproachofenvironmentalhealthinterventionswasreceivedwellby
implementers
andbeneficiariesalike.Keygainsnotedbyimplementersincludedefficiency
onseveralfronts(e.g.numberofcommunityinterventions,time,cost),andimprovements
throughconsolidatedpromotion.Keydifficultiesaroseinrespectofaffordabilityofthe
interventions(principallythestove),funding,andinmanagingprojectsustainabilityinthe

faceofchallenginglocal
circumstances.PricewasanimportantbarriertothesaleofMMS,
whichneverthelessbenefitedfromconsiderableawarenessandinterest.Theprojectwould
havebenefittedfrommoresystematicanddetailedmonitoringandevaluation.

Inconsideringthedeliveryofcombinedinterventions,wefoundananalysisofmotivational
factorstobeimportant.The
indoorairqualitycomponentoftheinterventionsawperceived
benefitssuchasefficientfueluse,acleanercookingenvironmentandvisiblesmoke
reduction.Useofwatertreatmentontheotherhandseemedmoreduetoaraised
awareness,andhealth‐andhygiene‐basedbehaviourchange.Thesetwointerventions,with
differentmotivations,
werepackagedunderacommontheme:thekitchen.Thistheme


10
workedwellinthegivensetting,andeffectivelyjoinedthetwointerventions.Recognizing
motivationalfactorsandfindingeffectivepromotionalmessages/bannersthusseemedtobe
apertinentconsideration.

Oneofthemostimportantlinksinrespectofbehaviourchange,impartingeducation,and
puttingtheoryintopractice,wastheroleofthe
localcommunityworkers.Theircredibility
andknowledgeofthelocalareawasessentialtoeffectivelytargetindividuals,valuesand
behaviours.Theyalsoformedanimportantlinkbetweenthecommunity,projectteam,and
otherstakeholders.Ofmostinterest,theworkerswereallassociatedwitha“brand”of
sorts,knownas“MamiPegna”.
“MamiPegna”(roughlytranslatedas“MotherIdeal”)
representedavillagewomanwhoembodiedvirtue,andgoodlivingpractices(e.g.hygiene,
health,andwithconnotationsofgoodmorals).Thecommunityworkerswereidentifiedas

MamiPegna,andworecustomizedt‐shirtswithherlogo(seeSection2),andwerewell‐
known
acrossMambanda.Thisunifyingconceptwasaneffectivemechanismtobindboth
(andseveralother)interventionstogether.

Thespecificimpactofthetechnologiesthatwerepromotedrequiresfurtherinvestigation,
asdatacollection,extenuatingcircumstances,andtimewererestrictingfactors.Fromour
analysis,greaterawarenessanduptakeofbothproductswasobserved.
Interviewsrevealed
greaterhealthawareness,andhygienepractices.Beneficiariesreportedimprovedhealth
fromusingWG,andweregenerallysatisfiedwiththeproductdespitetheill‐fittingbottle
caps(discussedfurtherinSection2.3).Indeed,themajorityofcommunitymembers
interviewedindicatedawishtohavecontinued,andforgreateraccess
tosuchproducts.
Althoughpricewasamajorbarrier,theversatilityandtechnologicalvalueofthestovemade
itparticularlypopular,withafewstovesevenbeingsoldoutsideDouala.

Regardingnextstepsforinvestigatingintegratedmodels,twoprioritiesemergedin
particularfromtheMambandawork.Thefirstwasto
carryoutfurtherassessmentsofsuch
projects,designedtoteaseoutspecific“addedvalue”ofjointprojectsoverseparateones.
Thesecondwastoclearlydefinethescopeofintegratedinterventionprogrammesand
identifytheirspecificcomponents,determiningthespecifictypesandnumberof
interventionsthatwouldbeappropriateforgiven
settings.

Thisprojectalsoillustratedtheimportanceofdevelopingworkablegovernanceframeworks
forscalinguphousehold‐andcommunity‐levelprojects.Theseneedtoincludearolefor
governmentalongsidemultiplestakeholders(includingprivatecompanies)downtothe
communitylevel.Itisalsoimportanttoconsiderdifferentfinancialmodelstomake

suchan
integratedapproachsustainableforallpartiesinvolved(notablysuppliersandlow‐income
end‐users).

PrincipalrecommendationsfortheMambandaproject
Themajorbenefitsofthissynergisticapproachareapplicabletoarangeofenvironmental
healthinterventionsatthehouseholdlevel.Thefollowingarespecificrecommendationsfor
improvingand
scalingtheprojectinMambanda.Inordertoexpandactivities,thefollowing
threemajorrecommendationsaregiven:




11
 Overallfollow‐up/projectre‐establishment
Anassessmentofthecurrentsituation,giventhecessation(atthistime)ofthe
projectwouldbeanappropriatefirstaction.Initialtaskswouldincludeascertaining
whichofthepartnerorganizationsarestilloperational,otheravailablepartners,and
thestatusoftheformerMambandawater
andsanitationcommittee.

 Supportforalocalwater,sanitation,andindooraircommittee
Approachestoinvolveallstakeholdersinaviablemannerarerequired.Forits
duration,thecommunitycommitteeseemstohavebeensuccessful.Giventhe
householdleveloftheseinterventions,suchamodelmaystillbeappropriate.
The
activeparticipationoflocalgovernmentwouldalsobeafactortoinclude,together
withotherhigher‐levelsupport.


 Resourcemobilization/financialmechanisms
Alongwithgovernance,financeisanimportantelementtosustainability.Solutionsto
maketheinterventionfinanciallyviableareneeded.Inaddition,reducingthecapital
costtothe
householdswhileprovidingongoingincentivestolocalimplementersand
suppliersiscrucial.

FutureassessmentstofurtherinvestigatetheissuesexploredinCamerooninclude:
 CompliancewithWG,usingmeasurementsofchlorineresiduals
 MMSuptake(includingdemographicsofinterventionhouseholds)
 EfficacytrialsofMMSincludingemission,householdairpollution
levelsandfuel
efficiency,andpossiblealterationstoimproveperformanceandreduceair
pollution.
 EpidemiologicalstudiesforbothWGandMMSusers(withappropriatecontrol
groups),asalongertermevaluationobjective.


KENYA
Countrysituation
Kenyaisacountryof38.8millionpeople,ofwhich68%areclassifiedas
rural(WHO/UNICEF,
2010).Neonatalmortality(33/1000livebirths )andunderfive‐mortality(128/1000live
births)arestillrelativelyhighanddiarrhoeaandpneumoniaarethepredominantcausesof
deathinyoungchildren(WHO,2010).Thesetwoillnessesareresponsibleforaround16%
and17%ofthesedeaths,respectively,in2004

(UNICEF/WHO,2009).

ThemostrecentJMPdataindicatesthatinruralKenyaoverhalf(52%)ofhouseholdshad

accessto"improved"watersourcesin2008,whichissubstantialincreasefrom30%in1990
(WHO/UNICEF,2010).ThemostrecentfiguresfromtheWHOhouseholdenergydatabase
showthatin2003almostall
(96%)ofruralhomesusedsolidfuelsforcooking,mostofwhich
iswood(85%),withsomecharcoal(10%)(WHO,2011).Lessthan5%ofthesesolidfuelusers
havestoveswhichventsmokethroughachimney.

Giventhissituationwithrespecttohealthstatusandtowaterandenergy
accessinKenya,
togetherwiththeimportanceofbothsafewaterfordiarrhoeapreventionandreductionof
solidfuelsmokeexposureforpneumoniaprevention,effectiveinterventionsaddressingboth


12
oftheseproblemsarehighlyrelevant.Thepotentialofsuchprogrammesforscalingupisof
vitalimportance,ifinitiativessuchastheprojectevaluatedherearetomakeasubstantial
contributiontoreducingthepopulationdiseaseburdenarisingfromunsafewaterandsolid
fueluse.

Kenyaprojectactivityand
achievements

Projectobjectivesandexpectedoutputs
ThefollowingobjectivesandoutputswerestatedintheSWAPprojectRFPapplication:


Goal:
Thegoaloftheprojectistoreducetheriskofdiarrhealdiseasesandrespiratoryinfectionsby
motivatingtheuseofhouseholdwatertreatment(HWT)productsandinnovativestovesfor
improvementofindoorairquality(IAQ)inruralKenyanvillages.


Objectives:
 DemonstratetheintegrationofHWTandIAQinto10of60villagesenrolledinanongoing
programmotivatingthepurchaseanduseofhealthinterventionsthroughsocialmarketing,
communitymobilization,andmicrofinance
 MotivatepurchaseandregularuseofHWTproducts:
a) IncreaseuseofHWTproductsfrom15to40%ofhouseholdsin10intervention
villages
b) Pre‐filtrationofwaterwithsimplesandfiltersinbucketsin25%ofhouseholdsin10
interventionvillagesrelyingonturbidsources
 Motivatethepurchase,production,installation,andadoptionofIAQtechnologies(eitherthe
RocketStove orJikoKisasaStove)in30%ofhouseholdsin10interventionvillages
 Evaluateprogrammaticapproaches,adoptionprocesses,andaspectsrelatedtothe
maintenanceandcontinueduseoftheinterventions.


Projectstructure
TheprojectisrunbyaKenya‐basedNGO,theSafeWaterandAIDSProject(SWAP),basedin
Kisumu.AlthoughtheworkofSWAPcoversmostofNyanzaprovince(andapartofwestern
Kenya),thecurrentprojectisrestrictedtoNyandodistrict,southofKisumu,borderingLake
Victoria.Twomaincomponentstotheprojectareactivityevaluatedhere:

1. Thedeliveryofeducationandproducts(severalwatertreatmentandstorage
products,improved‘Upesi’stoves,insecticidetreatednets,andotherproducts
includingnutritionalsupplements)tohouseholds,usingacommercialmodelthat
allowsamodestprofitmarginforthe
vendors/educators.
2. AnevaluationstudymanagedbyCDCandSWAPstaff,theNyandoIntegratedChild
HealthandEducationProject(NICHE),covering60villagesofNyando,ofwhich10
receivedpromotionoftheintegratedHWTSandHHEinterventions.Theresearch

componentincludessurveysandbi‐weeklysurveillance,withassessmentof
interventionuse,
waterquality(chlorineresiduals,microbiology),indoorairquality,
andthemainhealthoutcome(diarrhoea).



13
Thisisawell‐managedproject.Itreliesonvendors,usingasustainablecommercialmodel
supportedbylow‐interestloansandinnovativeeducationalmethodstoempowerlow‐
incomehouseholdswithknowledgeabouthowvariousproductscanimprovehealthof
families,andencouragesadoptionthroughexample.

Projectfunctioningandachievements
The
vendors,localmembersofthecommunitiesdrawnfromHIVsupportgroupsandother
communityselfhelpgroups,areessentiallyrunningsmall‐scalebusinessoperations
facilitatedby(relatively)low‐costloans,andarekeytothefunctioningandsuccessofthis
project.Theyworkthroughcommunitymeetingsandschools,andalsodirectly
byhouse‐to‐
housevisits,whilesomealsosellincommunitykiosksandpharmacies.TheSWAPvendors
areofferedtrainingonsafewaterandbusinessskillstohelpthemtobecomemoreefficient
inmanagingtheirsmallscalebusinessesincludingsellinghealthproducts.

Thepromotionofproductsiscommerciallysustainable
asthesearesoldatcostwithasmall
mark‐upforthevendors,althoughthisisepisodicallycompromisedbyfreehandoutsby
otheragenciesofwatertreatmentproductsduringfloodsandothercrises.Overall,this
appearstobeaneffectiveandrobustmodelforsustainabledelivery.LikeallsuchNGO
‐led

activitieshowever,itwasnotentirelyclearhowwellthissystemwould‘survive’ifSWAP
fundingandkey,highlycompetentpersonnelwerenolongermanagingtheprogramme.
Vendorsareverycommitted,andrecognizecommunitydemand,butareunsurewhether
theywouldstillbeabletoaccesstheproducts.The
productsthemselveshavethepotential
toimpactonarangeofhighprioritydiseaseconditionsforchildsurvivalinKenya,namely
pneumonia(Upesistoves),diarrhoea(arangeofHWTSproductsandhand‐washingsoaps),
malaria(ITNs)andunder‐nutrition(Sprinkles).

Watertreatmentandstorage
TheHWTSproductscanbeexpected
tobeefficacious,buteffectivenessdependson
complianceineverydayuse.Furtherdataanalysisisneededtocompletethepicture,but
resultsavailabletodateshowcomplianceacrosstheNICHEareatobemoderate,reachingat
best66%reporteduseand57%confirmedbychlorineresidualtestinginthe10integrated

projectvillagesamongimprovedstoveusers.Onthebasisofthesedata,theprojecthas
reached(andexceeded)thestatedgoalforHWTS.

Thislevelofcompliancemayhoweverberelativelygood,intermsofwhatcanbeachievedin
practicewithHWTS.Althoughcomplianceappearstobehighestwhere
combined
interventionshavebeenpromotedandadopted,thisneedsfurtheranalysis,adjustingfor
socio‐economicandotherconfoundingfactors.Itisalsoimportanttotakeintoaccountthe
effectofparticipationinastudywithfrequenthomevisitswhichmayinflatecomplianceina
non‐sustainableway.

Improvedstoves
The
authorsarenotawareofanypriorstudiesoftheefficacyoftheUpesistoves,specifically

intermsofHAPreductionsinideal(‘test‐house’)circumstances.However,resultsfrom
testingofindoorairpollutionlevelsinthecurrentproject(repeatedearlyin2010)
demonstrateverymodestreductionsinPM
2.5
of10‐20%atbest.However,strongerevidence
ofsavingsinfuelwoodofnearly30%wasreported.Basedoneverydayexperienceinthe


14
project,however,thesestovesappeartobewell‐likedandwell‐used,andarereportedto
savewood,reducesmokeandtheconsequentirritation,cough,headaches,etc.,aswellas
thelevelofsootinthekitchen.Womenhavere‐organisedtheirkitchensinresponsetothis,
bringingpotsandother
utensilsmuchclosertothestove.Thereasonsforthisinconsistency
betweenfieldexperience(reportedreductionsinsmokeandirritation)andtestfindings(for
PM
2.5
)arenotclear,asreductionsinambientkitchenPM
2.5
ofsomewherearound40‐50%(at
least)mightbeexpectedgiventhereportedimprovementsinthekitchenenvironment.The
projectteamusedanestablishedprotocolandequipmentformakingthemeasurements.

Informationonthenumbersofstovesadoptedineachcommunity,andhencelevel(%)of
uptake,wasnotreported
acrossthestudyareaoravailabletous(althoughthesedatashould
beavailabletotheproject).Itisthereforenotpossibletocommentonwhetheradoptionhas
metthetargetsetintheprojectobjectives.Whileeffectivenessofthestovesremainsopen
toquestionandwillbefurtherassessed
oncethenewmeasurementresultsareavailable,

themodelofpromotionandsaleofacook‐stoveproductthatiswell‐likedandusedisan
importantachievementandofvalueforthefutureoftheproject.

Synergies
TheapproachofcombiningthepromotionanddeliveryofHWTSandHHE
productsmetwith
acrosstheboardpositiveresponses.Itappearsmorecost‐effectivethanifthesame
productswerepromotedthroughseparateprogrammes.Combineddeliverymayalso
achievehighercompliance,butthisdoesneedfurtheranalysis.Therewerenosubstantive
concernswithanyofthecriteriaidentifiedfromthebackgroundreview
paper.

Impactonhealthoutcomes
Analysisoftheresultsoftheimpactsoftheinterventionsondiarrhoeaandpneumonia
incidenceisawaited.Itcanbeexpectedthatthereportedlevelofcompliancewithwater
treatmentwouldhavesomeimpactondiarrhoea,particularlywherethehigherlevelshave
beenreached.On
theotherhand,theverymodestreductioninPM
2.5
levelsrecordedforthe
Upesistovewouldnot(ifconfirmed)beexpectedtoleadtosubstantialreductionsinriskof
pneumonia.

Sustainabilityandscalingup
Withrespecttothetwolinkedissuesofsustainabilityandscaling‐uptheoutcomeofthe
evaluationalsoispositive,althoughbothdependtosome
degreeatleastontheexistence
andmodusoperandiofSWAP.Thevendorsspokentosaidthattheywerecommittedto
continuingtheirwork,evenifSWAPceasedoperations,butonlyiftheycouldstillobtainthe
products.FromtheperspectiveoftheSWAPmanagement,thevendorsarestilldependent

on
SWAP’ssupportwithtraining,followupvisits,supplyofproducts,motivatingthemwith
incentivesandsoon.SWAPitselfisalsostilldonordependent,andhasrecentlydevelopeda
businessplantoraiseitsownincome.However,giventhefactthatSWAPoperatesasimilar
methodologyacrossitswholearea
ofoperationsfordeliveringthewatertreatment,ITNs
andother(original)setofproducts,itdoesseemreasonabletoassumethatdeliveryofthese
plusthestoveswouldalsobepossibleacrossthismuchlargerarea.

Todate,scalingupoftheimprovedstovesacrossthiswiderareahasbeen
veryslow,dueto
theneedtoscaleupproduction,andalsofortrainingofinstallers.Considerationalsoneeds


15
tobegivennowtotheimplicationsoftheresultsoftheUpesistoveevaluation,since
althoughthestoveiswell‐liked,affordableandclearlysavesfuel,thereductionsinkitchen
PM
2.5
areunsatisfactoryintermsofthehoped‐forhealthbenefits.Theprojectneedsto
examinealternativestoveoptionsforthispurpose,whichcouldbepromoted,atleast
initially,alongwithcontinuedpromotionoftheUpesi.Despitethisquestionregardingthe
mosteffectiveandappropriatestovetechnology,itdoesseemthat
thereispotentialtoscale
upthedeliveryapproachacrossaconsiderablylargerpopulation.

Coordinationwithgovernmentandotheragencies 
In2009,SWAPjoinedHENNET,anationalnetworkingorganizationforNGO’sandFaith
BasedOrganizationwhichwasestablishedin2005andhas77members.Themissionof
HENNETisto

stimulatelinkagesandstrategicpartnershipsamonghealthNGO’s,
Governmentandprivatesectorinordertoenhancetheirresponsestowardshealthneedsof
Kenyans.Thisfunction,togetherwiththerecentelection(December2009)ofSWAPtothe
boardofdirectors,meansthatHENNETcouldmakeavaluablecontributiontosupportingco‐
ordinated,
scaledupdelivery.

PrincipalrecommendationsfortheKenyaproject
 OncompliancewithHWTS,itwillbeimportanttoconductcarefulanalysistoexamine
thisstratifiedbysocio‐economicstatus,andforoverallestimatestoincludeadjustment
forconfounding.
 BasedontheresultsoftheUpesievaluationstudies,other
stoveoptionsshouldnowbe
evaluatedpriortoscalingup,probablyinadditiontocontinueduseoftheUpesiforthe
immediatefuture.Furtheradviceshouldbesoughtonthequestionofhowlargea
reductioninPM
2.5
willbedeemed‘acceptable’forthispurpose:somefurtherdiscussion
ofthismatterisincludedundergeneralstrategicrecommendations,below.Any
alternativestoveswillneedtestingofbothsuitability(includingaffordability)and
performanceintermsofPM
2.5
reduction,andfuelefficiency.
 Theteamshouldobtain/calculatepopulation‐baseddataonuptakeanduseofUpesi
stoves,acrossthe10villagesoftheintegratedstudyareainitially,butalsomake
provisionforassessingstoveuptakeacrossthewholeNICHEstudyarea.
 Aneedwasidentifiedbythe
projecttodevelopadditionalproductioncentresforUpesi
stoves.Thisshouldbereviewedinthelightoffuturescalingupandpromotionplansfor
thisstove.

 Carryoutfurtherassessmentofvendorstocksandconstraintsonobtainingstocks,andif
necessaryidentifywaystoaddressanylimitations.
 Keeppricing
underreview,andassess–withappropriatecautions‐thepossibilityof
arrangingsomeformoftargetedsubsidyforpoorerfamilies.Investigatesomeformof
‘assetacquisitionpackage’forhouseholds.
 [Unlessalreadybeingdone]Documenteducationandproductuseinschools,andassess
theimpactsonbehaviour,andifpossible,
healthoutcomes.
 GiventheapparentlystrongpotentialforscalingupthedeliverymethodsusedbySWAP,
anoptionappraisalforscalingupshouldbedevelopedinvolving,SWAP,other
organisations/agencies,HENNET,andrelevantgovernmentministries.

AdditionaldetailedrecommendationsandsuggestionsareincludedinSection5.1.2


16
4.Overallstrategicissuesandrecommendations
Theexperiencefromthesetwoprojects,incontextofwiderpolicyonaddressingwaterand
airquality,raisessomegeneralstrategicquestionsforwhichrecommendationsaremade.

 Thepositiveexperiencefromthesetwoprojectsconcerningtheapparentlyclearbenefits
ofdeliveringHWTSandHHEinterventionsinanintegratedway
hasimportant
implicationsforfutureprogrammes.Specifically,thekeystrategicquestioniswhether
integrateddeliveryshouldbethenorm,ratherthan,asatpresent,theexceptionand
onlyseeninafewinnovativeprojects.InadditiontoHWTSandHHE,integrateddelivery
canencompassawiderangeofprioritypublichealth
issues,includingmalaria,nutrition,
HIV/AIDS/TB,familyplanning,water,andhygienepromotion,withconsiderablepotential

foraddressingMillenniumDevelopmentGoals,particularly4and5,amongothers.These
arecriticalquestionsfornextstepswiththiswork,andoneoftheprincipaljustifications
forholdingaworkshoptoconsolidateandcriticallyassess
experiencefromthesetwo
projects,andideallyinputadditionalrelevantexperience.

 Inbothcountries,thesituationinrespectofaccesstosafewatersupplyisverypoor,and
giventhissituation,HWTSclearlyhasanimportantparttoplayinpublichealthpolicy.
Thispointwasclearlymadeby
theWR(Kenya),DrDavidOkello,notleastduetotheslow
paceofworkonprovidingaccesstosafedrinking‐water,eveninurbanareasinthat
country,andthecontinuinghighincidenceofcholera.Itwouldseeminevitablehowever,
thatveryactivepromotionofHWTScouldatthesame
timereducetheimperativeto
makesubstantiveprogresswiththeprovisionofsafe,treatedwatersuppliesto
communitiesandhouseholds.ThistensioncouldbeaddressedbysettingplansforHWTS
promotioninthecontextofclearandambitioustargetsandtimescalesfortreatedwater
supplytotheareasandcommunities
concerned.Ifthislinkagewasthenorm,progress
withbothpointofuseandcommunitytreatedsupplies,couldbeassessedtogether.

 Identifying,implementingandscalinguphouseholdenergyinterventionsthatarehighly
effectiveintermsofreducingHAPlevelsandexposure,andareaffordableandpractical
forthelarge
numbersofpoorhomesmostaffectedbythisissue,remainsachallenge.
Thisishighlightedbythecurrentproject(specificallyinKenyawheredataonreductions
inPM
2.5
areavailable),butithasbeenacommonexperience.Ifthismatterisnottobea
seriousbarriertoprogressinmanylessdevelopedcountries,itisimportanttoconsider

adopting,asmainstreampolicy,aphasedapproachtoachievingreductionsinHAP.In
thisscenario,initialinterventionswould,in
additiontobeingaffordable,safer,morefuel
efficientandwell‐likedbyusers,alsoprovidequitesubstantialbutnotnecessarily
optimalexposurereduction.Optimalexposurereductionswillbedefinedbyairquality
guidelines(seebelow).BasedontherepeatedevaluationoftheUpesistoveinKenya,
reductioninthe48‐hr
kitchenPM
2.5
concentrationisaround10‐20%atbest,which–in
thecurrentstateofknowledge–isconsideredinsufficientforobtainingusefulhealth
benefits.Thismatterwillhoweverbethetopicforfurtherconsiderationandexpert
advicetotheproject.Unfortunately,todate,theHAPreductionwiththeMMSstove
in
Cameroonhasnotbeenstudied,andthisshouldbedoneassoonaspossible.Thereis
someencouragementforthispragmatic,phasedapproachfromtheexposure‐response
analysisfromRESPIREtrialinGuatemala(Smithetal.,2011),whichshowsthata50%
reductioninexposureresultedinausefulreduction
inchildALRIrisk,eventhough


17
residualexposurelevelsarestillhighincomparisonwithWHOairqualityguidelines
(AQG).Withthisapproach,however,itmustbestressedthatonethicalandequity
grounds,thestandardsoughtandlonger‐termtargetmustbethesame(low)levelsfor
all,andthatthesetargetsmustbederivedfrom
theWHOAQGs.
5.Nextsteps
Workshop
Theevaluationplansfortheprojectsincludedtheoptionofafollow‐upworkshop,with

resourcestosupportthis.Thiswouldbeveryvaluableforreflectingontheexperience
reportedhere,andplanningalonger‐termstrategytopromoteandevaluatethecombined
deliveryofenvironmentalhealthinterventionsatthe
householdlevel.Thisproposalhadthe
supportofDrDavidOkello(WRKenya).Planningforthisworkshopwillbe carriedout
followingconsultationbasedonthisreport.

Publicationanddissemination
ThisevaluationreportwillbemadeavailablethroughtheWHODepartmentalwebsites
(WSH,PHE).Ajointsetofweb
pagesonintegratedapproacheswouldbeausefulresource.
Inadditiontoprojectreports,scientificpublicationswillbeavailableinduecoursefromthe 
NICHE/SWAPprojectinKenya.Itwouldbevaluableinthemeantimetobuildonthe
experienceoftheseprojects,thisevaluation,andthebackgroundpaperby
ClasenandBiran
(2007),toprepareapublicationtoraiseawarenessofpotentialbenefitsofintegrated
delivery,experiencetodate,andfuturedirectionsforpolicyandresearch.

Keyresearchquestions
Thefollowingareasforfurtherresearchareproposed.Thefollow‐upworkshopwillprovide
agoodopportunitytoidentifyand
prioritiserequirementsforfurtherresearch,andthe
preparationphaseshouldincludefurtherconsultationonthesequestions.

 Inwhatsituationsareintegratedapproachesmoreorlesssuitable?Shouldintegrated
deliverybethenorm,orrestrictedtospecialsituations?Arethereparticular
advantagesinareaswithhighlystressedfueland/orwater
supplies,orwhereclimate
changeadaptationwillbeespeciallydemanding?
 Whattypesofinterventions(e.g.HWTSproducts,improved

stoves/ventilation/cleanerfuels,insecticidetreatedmosquitonets,handwashing
soaps,nutritionalsupplements,condoms,contraceptivepills,sanitarytowels)
improvedaremostappropriateforintegrateddelivery)?Arethereother
interventionsinthehouseholdsetting
aimedatpriorityhealthissues,notconsidered
bytheseprojects,whichcouldorshouldbeincluded?
 Doesintegra teddeliveryresultingreatereffectiveness,andeconomicefficiency,in
respectof(i)complianceand(ii)healthimpacts?Whatresearchmethodsandstudies
designswillbemostappropriate?Seefurtherdiscussionof
thisbelow.
 Whatistheroleofthehealthsysteminco‐ordinating,managinganddelivering
integratedprogrammesforimprovingthehouseholdenvironment,giventhemulti‐
sectoralnatureoftheproblemsandthefrequentinvolvementofNGOs,andother
agencies/donors?
 Whatarethemosteffectivemodelsforintegrateddelivery,
includingconsiderationof
theroleoflocalmarketsystems,andinvolvementofcommunitiesandusers?


18
 Whatfinancingarrangements,e.g.loans,subsidies,etc.,areneededtosupport(i)
deliveryand(ii)users,andwhatapproachestomanagingthesearemosteffective.
Thesequestionsmaynotdifferfromsimilarquestionsforotherexamplesof
deliveringproductsandservicesinpoorcommunities,althoughtheneedtosupply
and
adoptacombinationofproductsmayraisedifferentissues.
 Whatadditionalissuesforscalingupneedtobeconsideredforintegrated
approaches,overandabovethosepertainingtoscalingupofothercommunityhealth 
anddevelopmentprojectsandprogrammes?


Issuesinevaluatingtheaddedvalueofintegratedinterventions
The
assessmentofwhetherornot‘synergies’fromtheintegrateddeliverybring‘added
value’intermsofhealthimpacts(andtheinputs,processandoutputsthatultimatelyleadto
healthimpacts),iscomplex.Robustquantificationofaddedvalueforhealthoutcomes–true
‘interactions’resultingfromthebenefitsofreducingdiarrhoeaand
respiratory(and
potentiallyother,e.g.malaria)morbidityatthesametime–wouldbeverycomplexand
expensive,andlikelyrequiresomeformoffactorialstudydes ignthatverysignificantly
distortdeliverymechanismsandhencemayhavelittlerelevancetoactualeffectiveness.A
moreefficientandpracticalapproachmaybe
tothoroughlyassessprocess(efficiency,
benefitstosupply,businessopportunities,usersperspectives,etc.),aswellascompliance
withtheinterventions,andoverallchangesinmorbidityrates.

Nationalpolicyframework
Considerationneedstobegiventohowinnovationinandadoptionofintegratedapproaches
tohouseholdenvironmentalriskrelatestonational
policy.Thiswillincludetheformulation
ofnewpolici es,theadjustmentofexistingpoliciesandtheharmonizationofpoliciesin
differentsectors.Thiscouldalsobeusefullylinkedtohouseholdhorticulturalwaterusefor
foodsecurity.Thewholerangeofenvironmentalhealthandnutrition interventionsatthe
householdlevelshouldbe
coveredbysuchapolicyframework,andleadtonational
guidelinesforcertificationandqualitycontrolaswell.

6.References

ClasenT&BiranA.ExploringthePotentialSynergiesofHousehold‐basedInterventionsto
 ImproveDrinkingWaterQualityandIndoorAirQuality:aConceptNote.2007,

LondonSchoolofHygieneandTropicalMedicine,London.
GTZ.PilotProjectProposal:Integratingpoint‐of‐usewaterqualityinterventionswith
 interventionsto
improveindoorairqualityinthequarterofMambanda,Cameroon.
 GermanTechnicalCooperation,2008,Duola,Cameroon.
Smith,Ketal.RESPIRE:Arandomisedcontrolledtrialoftheimpactofreducinghouseholdair
 pollutiononchildhoodpneumoniainGuatemala.Forthcoming,Lancet,2011.
UNICEF/WHO.Diarrhoea:whychildrenarestilldying
andwhatcanbedone.UnitedNations
 Children’sFund,2009,NewYork.
WHO/UNICEF.ProgressonSanitationandDrinking‐water:2010Update.WorldHealth
 Organization,2010,Geneva.
WHO.CombatingWaterborneDiseaseattheHouseholdLevel.WorldHeal thOrganization,
 2007,Geneva.
WHO.WorldHealthStatistics2009.WorldHealthOrganization,2009,Geneva.



19
 />WHO.Globalhouseholdenergydatabase.
/>
[Accessed9February2011].






20
1.INTRODUCTION

1.1Projectoverview
In2007,anRFPwaspreparedbyWHOforproposalsintegratingIndoorAirQuality(IAQ)and
HouseholdWaterTreatment(HWT)projectsatthehouseholdlevelinAfrica.Ataglobal
level,Africasuffersmostfromtheenvironmentalrisksofunsafedrinking‐water,inadequate
sanitation,andpollutedindoorair.
Africanchildrenrepresentthegreatestriskgroupinall
thesecases,withapproximately677,000deathsduetounsafewater,sanitationandhygiene
and500,000deathsduetoindoorsmokein2004,thelatestyearofavailabledata(WHO,
2009).Theaimsoftheprojectwere:

 Toexplorewhetheror
notitispossibletoachievesynergybetweenlinkingHWTand
IAQinterventions
 Toexaminethepotentialforexpansionofimplementationofsaidjointprojects
 Todocumentintegrationmodelsfortheseprojects
 Toexaminetheadded‐valueofintegratingthesetwoinitiatives,inawaythat
contributes
toanincreaseinhealthimpact,aswellassustainabilityandadoptionof
use.

InconsultationwithAFROandCountryOffices,twoproposalswerechosen,onein
Cameroon,andtheotherinKenya.TheCameroonpilotproposalwassubmittedbythe
HealthProgrammeoftheGermanTechnicalCooperation(GTZ).Fuel‐
efficientstovesand
point‐of‐usechlorinationmethodshavebeenintroducedintoanongoingWATSANprojectin
Mambanda,aninformalsub‐quarterofDoualaaccommodatingover1250households.The
WATSANactivitiesincludewell‐chlorination,latrine‐building,healtheducation,aswellas
wastewaterandsolid‐wastemanagement.Thesecondproposalwassubmitted
bytheSafe
WaterandAIDSProject(SWAP),anNGOreceivingsupportfromtheCentersforDisease

Control(CDC).SWAPproposedtointegrateIAQandHWTSin10outof60villagesenrolledin
theNyandoIntegratedChildHealthandEducation(NICHE)projectinNyanzaprovince,
Kenya.NICHEisa
projectattemptingtoincreaseaccesstowatertreatment,nutritional
products,andinsecticidetreatednets.

Thepilotshadatimeframeof18months,fromJune2008toNovember2009.Itwas
envisagedtoholdafollow‐upmeeting/internalevaluation/workshopattheendofthis
period,theobjectivesandactivitiesofwhichare
thesubjectofthisdocument.
1.2EvaluationTermsofReference
Theevaluationoftheseprojects,carriedoutbyWHOConsultants(ASandNB)inDecember
2009,hadthefollowingobjectives:

1. Compileanddescribebackgroundandcontextualinformationonareas/study
communitiesinrespectofwatersupply/quality,householdfueltypeand
supply/IAQ
(subjecttoavailability),andrelatedhealthdata(diarrhoea,ALRI,etc)

2. Toconductafield‐visittothetwoprojectsinCameroonandKenya,andperformbasic
evaluation


21

3. Prepareacomprehensivefactualaccountofprojectactivitiesandoutputs,including
photographs,describingtheexperienceofresidents,projectstaffandotherrelevantkey
informants(e.g.localgovernment,partnerorganizations)concerningprojectdelivery,
achievements,problemsandissues,andfutureprospects.Particularemphasiswillbe
giventoassessingwhataddedvalue

isgainedbylinkingwaterandindoorairquality.
1.3Visitschedule
RefertoAnnex1.
1.4Evaluationmethods
Evaluationwasbasedonrapidappraisalmethods,incorporating:

 Reviewofdocumentation(dataandreportsoncountries/settings,projectreports,
otherrelevantsources)
 Interviewswithkeyinformants,includingproject,communityand
otherswith
relevantexperienceandperspectives
 Observation,dairylog,photographs.

Foralistofmainheadingfortheinterviewschedulesusedfor(i)projectstaff/agencies,etc.,
and(ii)communitymembers,SeeAnnex2.Interviewswererecordedintheformofnotes,
andanalysed/compiledusingbasicFrameworkAnalysis,usingheadingsinformedbythe
initialobjectives,andrefinedbythemesemergingfromtheinterviews.

ThebackgroundpaperintheRFPbyClasenandBiran(2007),whichproposedcriteriaon
potentialsynergiesandantagonisms,wasusedtostructureassessmentinthecurrent
evaluation.
1.5Briefreviewofliterature
1.5.1EffectivenessofHWTS
The
roleandeffectivenessofwaterqualityinterventions,particularlyatthepoint‐of‐use,
havebeensubjecttomuchdebate.Toencompassthescopeofthedebate,thissectionwill
focusonrecentsystematicreviews.Drawinguponthreedifferentsystematicreviews,
Cairncrossetal(2010)wrotethemostrecentpaperonthe
comparativevalueofwater,
sanitation,andhygiene.Overall,waterqualityinterventionsresultedin36‐48%reductionsin

diarrhoealdisease.Furthermore,household‐basedinterventionsresultedina43‐44%
reduction(Cairncrossetal,2010).Themajorcriticismtotheseresults,aswithmuchofthe
water‐qualityrelatedhealthevidence,is
thatmostresultsarebasedonself‐reported
diarrhoealdisease,whichcouldbepartlyorwhollyduetobias.Ofthe35trialsreviewedby
Cairncrossetal(2010)onlyfourwereblinded,andthesefourhadresultedinalowoverall
diarrhoealreductionofonly7%.Thus,theauthorsconcluded
that17%ismorerealistic
diarrhealdiseasereductionforwater‐qualityinterventions.OthercritiquesofHWTSinclude
itsrelianceonsustaineduptakeandcorrectandconsistentuse,whichhasnotbeen
satisfyinglyprovenintheliterature(CairncrossandSchmidt,2009).However,despite
skeptiscism,thereisstrongevidenceintheliterature
supportingpositivehealtheffectsof
HWTSwithupto60%reductionsindiarrhoea(Clasen,2009;Fewtrelletal.,2005).The


22
appropriateplaceforHWTSneedstobefound,withinthewiderframeworkofwaterand
sanitationinterventions.Regionalfactors(e.g.waterandculture),sourcewaterquality,local
burdenofdisease(i.e.whetherdrinkingwateristhemajorcauseofdiarrhoeainaparticular
location)areexamplesofvariablestobestudied.
Furtherworkisalsoneededtosupport
sustainedandcorrectuseoftreatmenttechnologies,includingresearchonimplementation
modelsandtechnologyperformanceevaluation.
1.5.2Effectivenessofimprovedsolidfuelstoves
Theassessmentofstoveeffectivenessrequiresconsiderationnotonlywhethertheimproved
deliversonHAPreductionandotherpotentialbenefits
suchasfuelsavings,butalsowhether
itisacceptabletousers,ismaintainedandremainsineverydayuse.Itisusefultodistinguish
efficacy(whataninterventiondeliversinidealcircumstances)fromeffectiveness(whatit

doesinrealisticsituations)andefficiency(whetheritdoessocost‐effectively).Thesefactors
are
consideredintheoverallreport,butthefocusinthissectionisonhoweffectivethe
interventionsareinpracticeinreducinglevelsofHAPinthehome,andforpersonal
exposures.

Impactofinterventionsonhouseholdpollutionandpersonalexposure
OnwaytoreduceemissionsandhenceHAPlevels
andpersonalexposureistoimprovethe
completenessofcombustion.InEastAfricacheapimprovedstoveswithoutflues,burning
eitherwood(e.g.theUpesi)orcharcoal,arepopularandarereportedtoreducekitchen
pollutionbyimprovingcombustion,althoughfew(ifany)measurementsareavailableto
supportthis.Thecurrent
KenyanstudydoesincludemeasurementofPM
2.5
(Section3).Flue‐
lesswoodstovesoftheRockettype,whichusean'elbow'combustionchambertoimprove
combustion,arebeingintroducedinanumberofAfricancountries.Theseareclaimedto
deliverlargeremissionreductions,butformalevaluationisawaitedandtheyaremore
expensivethantheUpesi.The
mostencouragingnewdevelopmentinbiomasscombustion
technologyisthegasifierstove,whichusessecondarycombustion,withorwithouttheaidof
forcedventilationusingasmallfan.Varioustypeofthesestoves,whicharerapidlygaining
popularityinChinaandIndia,canburneither(finelychopped)'raw'biomass,orprocessed

(pelletized)biomass,anddeliveremissionlevelsofPM
2.5
closetothoseofLPGstoves(KirkR
Smith,personalcommunication).Theyarehoweverquiteexpensive(US$40‐75),andthere
istodateverylimitedexperiencewithuseinverypoor,ruralcommunities.


Thesecondapproachtoreducingemissionsintothehomeistoattachaflue,orarrange
a
hoodwithachimney.Improvedstoveswithflueshavebeenpromotedextensivelyinseveral
Asiancountries,althoughmanyhavebeenfoundtobeinpoorconditionafterafewyears.
SomestudiesfromIndiahaveshownvariableandsometimesmodestorminimalreductions
inpollution.Forexample,Laxmichimney
stovesinhomeslocatedinMaharasthra,India
resultedina24%reductionofPM
2.5
anda39%reductionofCO,whileasukhadchimney
stoveintheBundelkhandregionofIndiareducedkitchenconcentrationsofPM
2.5
andCOby
44%and70%respectively

(Chengappaetal.,2007).Similarexperiencewithfluedstoveshas
beenreportedfromLatinAmerica.PlanchastovesinGuatemala(madeofcementblocks,
withametalplateandflue)canreducePMby60to70%,andbyasmuchas90%whenwell
maintained.Typical24‐hourPMlevels(PM
10
,PM
3.5
,andPM
2.5
havebeenreported)with
openfiresof1,000–2,000g/m3havebeenreducedto300–500g/m3,andinsomecases
lessthan100g/m
3
.


(Alabalaketal.,2001).


23

HAPreductionsstudiedinthreeprovincesofChinafound24‐hrkitchenPM
4
foralltraditional
stovetypesof268µg/m
3
,and152µg/m
3
forallimprovedstovetypes.Althoughasignificant
reduction,mosthomeswerestillabovetheChinesenationalHAPairqualitystandardof150
µg/m
3
PM
10
(Edwardsetal.,2007).Evaluationwascomplicatedbycomplexityoffueltypes
inregularuse,changeswithinandbetweenseasons,andmultiplestovetypeuse(improved
andtraditional)forvariouspurposes.

InstallationofhoodswithfluesforhighlypollutedKenyanMasaihomesresultedin
reductionsin24‐hourmeanPM
3.5
of75%frommorethan4,300g/m
3
toabout1,000g/m
3


(Bruceetal.,2002).Althoughalargeproportionatereduction,thepost‐interventionlevels
werestillveryhigh,duetothecontinueduseoftraditionalstoves,andtheveryenclosed,
poorlyventilatedtraditionalhomes.

Wherestudied,personalexposurehasbeenfoundtoreduceproportionatelylessthanarea
pollution.Thus,inthe
KenyanMaasaistudy,a75%reductionin24‐hourmeankitchenPM
3.5

andCOwasassociatedwitha35%reductioninwomen’smean24‐hourCOexposure.Similar
proportionatereductionswerefoundforwomenandchildrenusingwoodstovesin
Guatemala.AstudyofpersonalparticulateexposureinGuatemalanchildren<15months
reportedmean10‐to12‐hourPM
2.5
levelsof279g/m
3
foropenfiresand170g/m
3
for
planchastoves,a40%difference(Naeheretal.,2000).

Insummary,forimprovedsolidfuelstovestodeliververysubstantialreductionsinlevelsof
HAP,theseneedtohaveawellconstructed,cleanandfunctioningflue,orutilizesecondary
combustiontoreduceemissionsatsource.Flueshoweveraddconsiderably
tocost,and
mustbemaintainedandcleaned.Gasifierstovesarealsorelativelyexpensiveforthe
populationsconcerned,usuallyneedspeciallypreparedorprocessedfuel,andexperiencein
termsofsuitabilityforpoorruralpopulationsrequiresfurtherassessment.Inorderto
ensureverysubstantialreductionsinoverallpersonalexposure,either

clearfuels,or
sustaineduseoflowemissionbiomassstoveswillbeneeded–althoughthelatterisstillthe
subjectofongoingevaluation.









24
2.COUNTRYREPORT–URBANMAMBANDA,CAMEROON
2.1Countrybackground

TheRepublicofCameroonhasapopulationof18.2millionpeople.Doualaisthelargestcity
inthecountry,andthecommercialcapital.Mambanda,wheretheprojectunderevaluation
wasimplemented,isasemi‐formalsettlementintheBonaberiregionofDouala.Mambanda
reflectsthediversityoftherestofthe
country,withAnglophoneandFrancophone
householdsdistributedacrossit,andgreatdisparitybetweenthefewrichfamiliesandthe
poormajority.

Accesstodrinking‐waterislimited;beinganisland,Bonaberigroundwaterisbrackishand
containsheavyirondeposits.Furthermore,thepoorsystemofpipelinesandmanagementof
treatmentplants
resultsincontaminated,poor‐tastingandinsufficientdrinking‐water.These
localissuesarealsoreflectedinthehealthindicatorsforthecountryasawhole.Diarrhoeal
diseaseaccountsfor16.4%ofunder‐5mortality,andpneumoniafor20.4%(WHO,2009).

Additionalstatisticsonwater,sanitation,andhouseholdfuelforurban
Cameroonareshown
inTable2.1.

Table2.1Water,sanitation,andfueluseindicators‐Cameroonurbanareas(WHO/UNICEF,2010)

Urban 92%Accessto"improved"
drinking‐watersources
Total 74%
Urban 56%Accessto"improved"sanitation

Total 47%
Dung 1.7‐5.4%
Cropwastes <1%
Sawdust Notreportedseparately
Wood 47.9‐67.1%
Charcoal 2.4‐4.6%
Kerosene 8.8‐13.5%
Biogas <1%
LPG 22.5‐30.0%
Mainhouseholdfuelforcookingand
heating%(WHOenergydatabase)


Electricity <1%
2.2Projectorganizationandmanagement
Abriefoverviewofthestructureandmanagementfollows.Detailedassessmentsofproject
andfinancialmanagementprocedureswerenotpartoftheprincipalaimsofthisevaluation.
Furtherinformationcanbefoundinprojectsreportsandwiththeindividualparticipant
organizations.


TheGermanTechnicalCooperation
(GTZ)spearheadedtheproject,coined"Smoke&
Drinking‐water".ItwassettorunfromJune2008toNovember2009,butdueto
administrativeissuesonlybeganinlateAugust2008,runningatotalof15months.The
projectsucceededthetwo‐year"WaterandSanitation"intervention (2006‐2008),whichwas
