WHO/SDE/02.11 Englishonly   Combinedhouseholdwatertreatmentandindoorair pollutionprojectsinurbanMambanda,Cameroonandrural Nyanza,Kenya                 Geneva2011   1 1  Photocredit(BruceNandShaheedA,2009)  Combinedhouseholdwatertreatmentandindoorairpollutionprojectsinurban Mambanda,CameroonandruralNyanza,Kenya ©WorldHealthOrganization2011 Allrightsreserved.PublicationsoftheWorldHealthOrganizationcanbeobtainedfrom WHOPress,WorldHealthOrganization,20 AvenueAppia,1211Geneva27,Switzerland(tel.: +41227913264;fax:+41227914857;e‐mail:bookorders@who.int ).Requestsfor permissiontoreproduceortranslateWHOpublications–whetherforsaleorfor noncommercialdistribution–shouldbeaddressedtoWHOPress,attheaboveaddress(fax: +41227914806;e‐mail:permissions@who.int). Thedesignationsemployedandthepresentationofthematerialinthispublicationdo not implytheexpressionofanyopinionwhatsoeveronthepartoftheWorldHealth Organizationconcerningthelegalstatusofanycountry,territory,cityorareaorofits authorities,orconcerningthedelimitationofitsfrontiersorboundaries.Dottedlineson mapsrepresentapproximateborderlinesforwhichthere maynotyetbefullagreement.  Thementionofspecificcompaniesorofcertainmanufacturers’productsdoesnotimplythat theyareendorsedorrecommendedbytheWorldHealthOrganizationinpreferenceto othersofasimilarnaturethatarenotmentioned.Errorsandomissionsexcepted,thenames ofproprietary productsaredistinguishedbyinitialcapitalletters.  AllreasonableprecautionshavebeentakenbytheWorldHealthOrganizationtoverifythe informationcontainedinthispublication.However,thepublishedmaterialisbeing distributedwithoutwarrantyofanykind,eitherexpressedorimplied.Theresponsibilityfor theinterpretationanduseof themateriallieswiththereader.InnoeventshalltheWorld HealthOrganizationbeliable fordamagesarisingfromitsuse.                  2 2   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    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.       3 3  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 4 4 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   5 5  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.  7 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