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Regional Workshop for Southern Africa on Household Water 

Treatment and Safe Storage and Integrated Household‐based 

Environmental Health Interventions 

 

 

June 2012 

Maputo, Mozambique 

 

Coordinated by the World Health Organization and the United Nations Children’s Fund with communications support from 

The Water Institute at the University of North Carolina 

 

 

 

   

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Acknowledgements 

This Southern Africa regional workshop was an initiative of the International Network on Household 

Water Treatment and Safe Storage. The HWTS Network was launched in 2003 by the World Health 

Organization and is now co‐hosted by both WHO and the United Nations Children’s Fund. The Network 

brings together nearly 140 organisations in a mission to reduce the incidence of diarrhoeal disease by 

increasing access to clean water through the use of household water treatment and safe storage. 

Ana Candido, from the Government of Mozambique’s Ministry of Health (Ministério da Saúde) hosted 

and officially opened the workshop, held at the VIP Grand in Maputo, Mozambique June 20‐22, 2012. 

Other Mozambican government officials included Mauricete Angelo, Ministry of Health; Chelsea Langa, 

Ministry of Health; Rosa Maerdoenda, Ministry of Health; Ana‐Paula Cardoso, Ministry of Health; Elisa 

Adelaide Tembe, Ministry of Health; Maria Nivalda Lázaro, Ministry of Health; Salma Xavier, Ministry of 

Health; Teresa Pereira, Ministry of Health; Isabel Tauzene, Ministry of Health; Julieta Felicidade, Ministry 

of Public Works & Housing; Gilberto Azania Langa, Ministry of Public Works & Housing; Cristo Antonio 

Dos Santos, Ministry of Public Works & Housing; Jordi Gallego, Ministry of Science & Technology; Jaime 

Muchanga, Administração de Infra‐estruturas de Água e Saneamento; Virginia Muianga, Inspecção 

Nacional de Actividades Económicas; Alberto Muando Júnior, Centro de Higiene Ambiental da Cidade de 

Maputo; and Quermildo Finiasse Aliginar, Centro de Formação Professional de Agua e Saneamento. 

The following Malawi government officials attended: Humphreys Masuku and Young Samanyika, from 

the Ministry of Health, and McLawrence Mpasa from the Ministry of Water Development and Irrigation. 

Zambia government officials included Mibenge Chilekwa, Ministry of Health; Elizabeth Chafwa, Ministry 

of Health; and Douglas Sing’anga, Ministry of Local Government and Housing. 

The workshop was organised by local and international officials from the WHO and UNICEF and 

facilitated by Maggie Montgomery of WHO and Michael Forson of UNICEF. Special thanks to Wouter 

Maenhout, Sebastião Nkunku, Vainess Mfungwe and Isabel Bombe in the WHO Mozambique office for 

handling workshop logistics. Ryan Rowe of the Water Institute at the University of North Carolina at 

Chapel Hill provided communications and other organisational support to the workshop proceedings 

and served as rapporteur. 

Workshop speakers included the following: Greg Allgood, Procter & Gamble; Ana Candido, Mozambique 

Ministry of Health; Elizabeth Chafwa, Zambia Ministry of Health; Iulian Circo, Population Services 

International; Michael Forson, UNICEF; Lorelei Goodyear, PATH; Henk Holtslag, Independent consultant; 

Lilian Lehmann, Innovations for Poverty Action; Humphreys Masuku, Malawi Ministry of Health; Maggie 

Montgomery, World Health Organization; Tim Neville, Vestergaard‐Frandsen; Edema Ojomo, Water 

Institute at UNC; Ryan Rowe, Water Institute at UNC; Albert Saka, Zambia Keeper’s Foundation and 

Douglas Sing’anga, Zambia Ministry of Local Government and Housing. 

In all, over 60 participants from nearly 40 organisations in eight countries attended the workshop and 

contributed to the discussions.   

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Table of Contents 

Acknowledgements ....................................................................................................................................... 2 

Table of Contents .......................................................................................................................................... 3 

1.  Purpose of the workshop and this report ............................................................................................. 4 

2.  Summary of Recommended Practices .................................................................................................. 4 

3.  Opening remarks, objectives and outputs ............................................................................................ 5 

4.  International HWTS perspective: challenges and opportunities .......................................................... 6 

5.  Status of HWTS National Policies and the Enabling Environment ........................................................ 7 

6.  Examples and lessons learned in implementing HWTS ........................................................................ 8 

7.  Good Practices in Integrating HWTS with Health Efforts...................................................................... 9 

8.  Sustainability and Reaching the Most Vulnerable .............................................................................. 10 

9.  Monitoring and Evaluating HWTS in the Home .................................................................................. 11 

10.  Evaluation and Regulation of HWT ................................................................................................. 12 

11.  Preparation and presentation of draft National Action Plans ........................................................ 13 

12.  Translating plans into action and identifying needs ....................................................................... 14 

13.  Conclusion ....................................................................................................................................... 14 

References .................................................................................................................................................. 16 

Annex 1 – Agenda ....................................................................................................................................... 18 

Annex 2 – Concept Note ............................................................................................................................. 22 

Annex 3 – List of participants ...................................................................................................................... 26 

 

 

   

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1. Purpose of the workshop and this report 

Achieving tangible results in the scaling‐up of household water treatment and safe storage (“HWTS”) and integration into primary prevention programmes depends, in large part, on the existence of national enabling environments and effective policies. The workshop held in Maputo, Mozambique in June 2012 provided an opportunity for government officials from Malawi, Mozambique and Zambia to connect with other professionals working in the region and share their experiences in developing strategy for HWTS and its implementation. The first half of the three‐day workshop focused on examples of national strategies, linking HWTS to key national policies and best practices in implementation and integration. The second half focused on tools for improving outcomes and impact and allowed participants to collaborate on developing tnational action plans.  The World Health Organization (WHO) and UNICEF‐hosted International Network on Household Water Treatment and Safe Storage (the “Network”) has adopted a target to have 30 countries establish policies on household water treatment by 2015. This workshop is part of a global effort on incorporating HWTS into relevant national water and health policies and strengthening evaluation and regulation of HWTS. In 2011, the Network organised a similar regional workshop involving Ethiopia, Kenya, Rwanda, Tanzania and Uganda; the report from that workshop is available online.1 Other regional workshops are currently in the planning stage.  The purpose of this report is to record the outcomes and outputs of the Maputo workshop discussions and provide a reference guide for attendees as they develop and implement action plans and strategies to support the scaling up of HWTS in their countries. Workshop proceedings are available online at:  http://waterinstitute.unc.edu/hwts/events/2012_maputo. 

2. Summary of Recommended Practices 

In reference to the workshop objectives, the following practices were identified as important elements in developing national strategies for scaling up HWTS. These recommended practices are not prescriptive but merely a guide for stakeholders considering how to best implement HWTS in their own specific environments and contexts.  National policy structures and regulation 

Include HWTS, where appropriate, into broader national policies on health, water and development rather than creating a stand‐alone policy 

Designate one specific ministry as the lead agency for HWTS issues 

Develop national targets on use of HWTS, especially among vulnerable groups, as a basis for assessing impact 

                                                            1 Report and proceedings of the East Africa regional workshop are available at http://waterinstitute.unc.edu/hwts/events/entebbe2011.  

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Consider adopting WHO recommendations on the microbiological performance of household water treatment options (WHO, 2011a) for the regulation and setting of standards on HWTS technology options 

 Policy formulation, implementation and monitoring & evaluation 

Ensure policy goals and strategies are clear and consistent especially in overlapping areas 

Develop national guidelines on implementation to guide efforts in targeting vulnerable groups and areas where safe water is not available as well as promoting and measuring consistent, correct, and exclusive use  

Include HWTS in national emergency preparedness and response plans and pre‐position appropriate quantities of HWTS options 

Monitor and evaluate programmatic outcomes and outputs, guided by the Toolkit for monitoring and evaluating HWTS (WHO & UNICEF, 2012) 

Utilise mobile technology platforms for distributing vouchers, tracking use and sales, and encouraging behaviour change 

Advocate among appropriate ministries and national stakeholders the value of HWTS in specific settings  

Track cost‐effectiveness data and make results available to policy‐makers and funders of HWTS efforts  

 Ministerial collaboration and scaling‐up of HWTS 

Encourage inter‐ministerial collaboration through appropriate mechanisms such as an inter‐agency group convened by  the lead ministry on HWTS 

Establish technical working groups, committees and / or task forces (as a subset of an inter‐ministerial group) to bring stakeholders and government officials together to review policy, make recommendations, and act on specific, time‐bound and measurable tasks 

Include HWTS in national public health and WASH programmes, such as maternal and child health, nutrition and HIV‐related prevention and care, etc. 

Collaborate with regional counterparts to share best practices, identify common challenges and possible solutions 

3. Opening remarks, objectives and outputs  

The workshop was officially opened by the host, the Mozambique Ministry of Health. In addition, country representatives from WHO and UNICEF and the workshop co‐facilitators provided initial remarks. They noted the importance of this workshop in aiding the establishment of policies that can increase access to safe drinking‐water for those most at risk.  The representatives pledged their support for government officials and other stakeholders in developing national action plans on HWTS with a particular focus on integration into existing national public health and WASH programmes.  

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The workshop had three main objectives2:  

(1) Examine national policy structures and regulation concerning HWTS (2) Share tools for and lessons learned in policy formulation, implementation, and monitoring 

and evaluation (3) Identify mechanisms for fostering ministerial collaboration and scaling‐up HWTS  The workshop had four desired outputs: 

(1) Compilation of workshop presentations on a compact disc and made available online (2) Report of the workshop summarizing the discussions and lessons learned (3) Formulation of draft national action plans on HWTS (4) Momentum for participants to follow‐up and engage with the International Network on 

Household Water Treatment and Safe Storage  The approved agenda, workshop concept note and list of participants are presented in annexes 1, 2 and 3, respectively. 

4. International HWTS perspective: challenges and opportunities 

In the first sessions, participants heard presentations from Maggie Montgomery (WHO), Michael Forson (UNICEF), Lilian Lehmann (Innovations for Poverty Action) and Edema Ojomo (Water Institute at the University of North Carolina (“UNC”)). The following section summarises the presentations and the ensuing discussion.  Some of the main challenges currently facing the global advancement of HWTS are the lack of (or inadequate) national strategies and targets, limited monitoring and evaluation, and in certain cases insufficient support from governments for scaling up of the intervention. In order to realise the full potential of the health impact of HWTS, policy‐makers and implementers must place greater emphasis on including HWTS in broader health and water programming and ensure correct and consistent use of HWTS. Furthermore, in order to actually achieve those health gains, users must drink only (or exclusively) water that has been appropriately treated.     WHO recently published a survey and associated report which provided insights into existing mechanisms of government support (WHO, 2012). For example, HWTS is increasingly being included in maternal and child health programmes in order to reduce childhood diarrhoeal morbidity and mortality. Other supportive government actions listed include development of guidelines on HWTS (48%) and the creation of taskforces to address HWTS (46%).  A sizable proportion of countries have also reduced and/or eliminated tariffs on imported HWTS products (22%), often categorizing HWTS as “essential medicines” in order to reduce the cost barrier of such products.   

                                                            2 The workshop objectives and outputs differ from those listed in Annex 2 due to subsequent input from the workshop’s Local Organising 

Committee. 

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Key tools that can assist in addressing these challenges are a new monitoring & evaluation toolkit (WHO & UNICEF, 2012) and microbiological performance recommendations for evaluating HWT (WHO, 2011a).  Both WHO and UNICEF advocate for the integration of HWTS into higher‐level national policies, such as those on primary health care, drinking‐water quality and strategies for reducing child mortality, rather than creating a specific policy on HWTS. However, it is recommended that a specific ministry be assigned responsibility for overseeing national implementation of HWTS. Meanwhile, UNC, UNICEF and PATH are developing a definition of “enabling environment for HWTS” and identifying levers for (such as demand for HWTS) and barriers (such as the cost of the product to the user) to the advancement of HWTS and where reform and investment are needed.  At the World Water Forum held in Marseille, France in March 2012, global targets and commitments for HWTS were agreed to help guide sector stakeholders and provide a means by which to measure global progress. These targets and commitments are listed at:  http://waterinstitute.unc.edu/hwts/events/2012_marseille. 

5. Status of HWTS National Policies and the Enabling Environment 

In the second session, presentations were given by Humphreys Masuku (Malawi Ministry of Health), Elizabeth Chafwa (Zambia Ministry of Health) and Ana Candido (Mozambique Ministry of Health). The following section summarises these presentations and the ensuing discussion.  

In Malawi, HWTS is endorsed as a key response measure to emergency situations. However, it is not specifically identified as an essential routine measure where drinking‐water may be contaminated. Implementation guidance for stakeholders is also lacking. Malawi’s national network of community health workers is a key strength that allows for community‐based promotion. The government of Malawi has a national programme to mass produce and distribute chlorine stock solution at the community level as part of cholera prevention and control efforts. In addition, the Ministry of Health has been involved in pilot efforts over the last five years to examine whether or not maternal health services can be an effective platform for reaching pregnant women with an integrated health message on family planning, exclusive breastfeeding, HIV prevention and care, and water‐related hygiene (including HWTS).  In the pilot districts the combination of hygiene kits with antenatal care has resulted in a nearly 30‐fold increase in household water treatment practices three years after the intervention (Wood et al, 2011; Loharikar et al, 2012).  Such a sustained increase has not been documented in stand‐alone household water treatment efforts. In addition, it resulted in a 15% increase in delivery in health centres and postnatal checks (Sheth et al, 2010) which are indicators of improved maternal and child health. Given these encouraging results the Government of Malawi now seeks to expand the programme.  In Mozambique, the Ministry of Health is responsible for sanitation and hygiene promotion at the community level whereas the Ministry of Public Works and Housing (Ministério da Obras 

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Públicas e Habitação) works on infrastructure development. Although HWTS is not entrenched in national policy it is recognised as contributing to government goals on access to safe drinking‐water and diarrhoeal disease reduction efforts. These ministries and others such as the Ministry of Education and Culture (Ministério da Educação e Cultura) and the Ministry of Environmental Affairs (Ministério para a Coordenação da Acção Ambiental) have processes in place to collaborate and coordinate their actions and a decentralised government devolves implementation to the provincial and district level allowing for customisation of HWTS for local context. For example, the Ministry of Public Works and Housing is currently conducting work with the small water operators in the rural areas. The operators drill boreholes and the Ministry of Health is working to ensure the treatment of such water.  In Zambia, there is a fairly comprehensive policy framework overseeing water and sanitation in rural, peri‐urban and urban areas. The Ministry of Health is responsible for overseeing HWTS which includes activities such as monitoring of water quality, training of environmental health officials, health promotion and education activities and research efforts. The government’s priority is in addressing outbreaks of water‐related disease such as cholera, dysentery and typhoid to which HWTS is a key response mechanism. The Ministry of Health envisions two immediate areas of activity: development of a national action plan and formation and dissemination of implementation guidelines on HWTS. 

6. Examples and lessons learned in implementing HWTS 

In this session, participants heard examples of implementation approaches and the lessons learned from these experiences. Presentations were given by Tim Neville (Vestergaard‐Frandsen), Henk Holtslag (Independent Consultant) and Albert Saka (Zambia Keepers Foundation) and are summarised along with the discussion below. 

 First, participants heard that carbon credits have been used as a viable financing option for a large household water treatment effort in Western Kenya which has reached 900,000 households with high performing membrane filters.  Implementing organisations are increasingly looking to carbon credits as a possible funding mechanism. Carbon credits are based on a “pay for performance” model approach which requires demonstration of use before any credits are issued. Government involvement in such efforts is important in order to ensure incentives are aligned to maximise the benefits to users and achieve health impacts.  Secondly, there is an increasing range of HWTS options available to households. Participants heard about examples such as Aquaprove and Silverdyne. In addition the Tulip Filter is a low‐cost ceramic filter which is being introduced in Malawi and Mozambique by independent entrepreneurs. A greater variety of product options allows users to comparison‐shop and select the product that best meets their needs and preferences. Improved consumer satisfaction could lead to increased uptake, more correct and exclusive use of HWTS when drinking‐water quality is sub‐optimal.   

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Thirdly, there is scope for both cost recovery approaches and smart subsidies for vulnerable groups. If structured appropriately, each can contribute to the development of a commercial market while enhancing sustainability and ensuring access for those who are unable to pay but still need to treat their drinking‐water.  Finally, an examination of solar disinfection (SODIS) implementation in Zambia concluded that ensuring regular bottle supply, continued community promotion, involvement of local leaders and integrating key messages about WASH education in schools were important elements for long‐term uptake and use. 

7. Good Practices in Integrating HWTS with Health Efforts 

HWTS has been integrated with a variety of other health efforts such as HIV‐related care, school‐based WASH programmes, nutrition and maternal health services. Greg Allgood (Procter & Gamble) and Lorelei Goodyear (PATH) discussed their experiences in this area. Two of the practices discussed are summarised below. Additional experiences are outlined in their workshop presentations.3  Distribute and promote appropriate HWTS products among people living with HIV Increasing access to appropriate HWTS, along with appropriate training, social marketing and interpersonal support improves the uptake of the practice and can reduce the risk of diarrhoea, which is one of the leading causes of death among people living with HIV (“PLHIV”). By reducing diarrhoea the absorption of important (and expensive) HIV‐related medications can be increased, allowing implementers’ programme funds to be more effective in improving the health of PLHIV. Inclusion of HWTS in HIV prevention and care programmes is becoming policy in some countries, such as Kenya and Uganda (Government of Kenya, 2002; Government of Uganda, 2010).   Use HWTS and related water and health products as incentives for service uptake In Malawi, chlorine products and flocculant/disinfectant sachets are distributed for free to pregnant women as part of a package of water‐related hygiene products (soap, oral rehydration salts and buckets for storing drinking‐water). Women must visit antenatal care clinics to receive the “water hygiene kit” and are told they will receive free refills when they return for follow‐up visits, deliver their baby at the health centre and for a post‐partum check. The intervention aims to increase uptake of maternal health services and reduce maternal mortality and water‐related disease among the mothers and their families. The intervention takes advantage of the “teachable moment” where the impending birth is a significant motivating factor for the expectant mother to learn more about protecting her health and that of her unborn baby. Early results indicate service uptake is indeed increasing (Sheth et al, 2010) and the Government of Malawi is now considering an expansion of the program.  

                                                            3 Greg Allgood’s workshop presentation is available at: http://waterinstitute.unc.edu/files/2012_maputo/2012Maputo_Day1_12_Allgood.pdf. http://waterinstitute.unc.edu/files/2012_maputo/2012Maputo_Day2_04_Circo.pdf. Lorelei Goodyear’s presentation is available at: http://waterinstitute.unc.edu/files/2012_maputo/2012Maputo_Day1_13_Goodyear.pdf. 

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More good practices for stakeholders such as advocacy groups, donors, governments and policty‐makers, implementers and researchers are reflected in the commitments agreed at the Marseille gathering on HWTS, available here: http://waterinstitute.unc.edu/hwts/events/2012_marseille.   An additional resource is a forthcoming WHO & UNICEF policy brief on the integration of HWTS in HIV prevention and care. This is expected to be published in 2013. 

8. Sustainability and Reaching the Most Vulnerable 

This panel discussion aimed to shed light on improving sustainability of HWTS and reaching the most vulnerable: two key challenges to enabling scaling up and maximising health impact of the intervention. Panelists included Lorelei Goodyear (PATH), Douglas Sing’anga (Zambia Ministry of Local Government and Housing) and Humphreys Masuku (Malawi Ministry of Health). This section provides a summary of their inputs and the audience feedback.  Although sustainability was not defined, most discussants referred to it in the context of financing. Key issues included identifying the most vulnerable, improving uptake of the desired behaviour and the question of how much (vulnerable) users should pay. There was general agreement that free or subsidised distribution of HWTS should be targeted to specific groups and products which are designed for user needs and preferences are likely to have higher uptake.   On identification, groups mentioned included the chronically ill and the extremely poor without access to safe drinking‐water (further defined as the lowest income quintile of the population). Others mentioned people living in rural and peri‐urban areas where access to safe drinking‐water may be less than in urban areas. The Network, in its meetings and workshops, has also referred to other groups such as people living with HIV, people affected by conflict or disasters, orphans, children under the age of five and pregnant women.   On behaviour change and lack of correct and consistent use, some participants suggested that HWTS implementers could learn from approaches such as Participatory Hygiene and Sanitation Transformation (PHAST) and Community‐Led Total Sanitation (CLTS).  What is needed in evidence‐based approaches to trigger psychological factors correlated with use of HWTS. These are contextual and need to be examined in each setting. Other participants cautioned against the use of the CLTS notion of shame to trigger uptake of HWTS. PSI suggested that their work with the so‐called “bottom of the [economic] pyramid” had revealed that the most important marketing message is not about product options or information about health impact; it is about cost. The poorest of the poor are more concerned with managing limited cash flow and prioritising their expenditures and thus messages need to be appropriately tailored.  On financing and user payments, micro‐financing can serve as a method for improving affordability of products for lower income population, although the poorest of the poor may still have difficulty participating in the market. Product design is important in appealing to the 

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needs and preferences of users. Smart subsidies are one means of reaching the lowest quintile. Participants seemed to agree that commercial models are appropriate but that vulnerable groups should be isolated for smart subsidies and other means of financing assistance such as cash transfers or vouchers which can support local markets and businesses, such as those used by PSI in its work in Mozambique. Others also cautioned against setting up parallel supply chains for HWTS products which can be detrimental to long‐term sustainability of a commercial market and are more costly and less efficient than using existing local private enterprise supply channels. 

9. Monitoring and Evaluating HWTS in the Home 

During this session, Maggie Montgomery (WHO), Lilian Lehmann (Innovations for Poverty Action) and Iulian Circo (Population Services International) spoke about recent developments and innovations in monitoring and evaluating HWTS.  Collecting household‐level data continues to pose challenges: social desirability bias, water quality testing, and inconsistent or incorrect use make it difficult to link implementation efforts with health impact. Scarce amounts of time and financial resources, language barriers and limited access to technology are some of the challenges implementing organisations may face in disseminating their work in a timely and relevant manner. Two innovations may help address these issues.  Since the occurrence of the workshop, WHO and UNICEF launched a toolkit which may make it easier for implementing organisations to design monitoring and evaluation efforts, to determine what data to collect, how to collect it and how to analyse and use it to improve programmes (WHO & UNICEF, 2012). The new toolkit for monitoring and evaluating HWTS programmes provides 20 harmonised and globally relevant indicators for assessing household practices and water quality and will help to improve the inter‐reliability of data collected and help improve comparability between programmes.   Advances and increased access to mobile technology have also made data collection easier. Examples include Water for People’s FLOW project4 and Innovations for Poverty Action use of mobile technology to monitor the deployment of its community‐based chlorine dispensers5. More and more organisations are also using SMS messaging for data collection and behaviour change strategies. PSI is using this method to reach pregnant women in Mozambique with reminder messages about the importance of health practices such as HWTS or breastfeeding.6 There are also other numerous other applications of mobile technology for the WASH sector (Pacific Institute, 2012).  

                                                            4 Water for People’s FLOW (Field Level Operations Watch) project FLOW combines data on the operational status of water sources around the 

world and is then displayed in an online map to indicate whether the water source is functional or is in need of repair. Learn more at: http://www.waterforpeople.org/programs/field‐level‐operations‐watch.html.  5 IPA uses mobile devices to collect data from the chlorine dispensers and relay it to a database. Lilian Lehmann’s workshop presentation is available at: http://waterinstitute.unc.edu/files/2012_maputo/2012Maputo_Day2_03_Lehmann.pdf.  6 PSI’s reminder message strategy is detailed in Iulian Circo’s workshop presentation. Available at: http://waterinstitute.unc.edu/files/2012_maputo/2012Maputo_Day2_04_Circo.pdf. 

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10. Evaluation and Regulation of HWT 

The WHO has recently published criteria and guiding principles for evaluating the microbiological performance of household water treatment options (WHO, 2011a). The document classifies products into three levels of performance (highly protective, protective and interim) based on their ability to reduce the three main classes of diarrhoeal‐disease causing pathogens: bacteria, viruses and protozoa.  These recommendations have been disseminated to WHO country offices and government ministry officials worldwide and WHO can provide technical support to countries for the adoption or adaptation of the document. In addition, plans are underway to establish an international evaluation scheme for household water treatment products. The objectives of the scheme are to promote and coordinate independent testing and evaluation of household water treatment products based on WHO performance criteria and support governments in a number of evaluation related functions.  In Malawi, a Catalogue of Standards has been developed by the Malawi Bureau of Standards (Malawi Bureau of Standards, 2011). It does not currently include standards on household water treatment products and such products are assessed on an ad‐hoc basis by government officials. With respect to drinking‐water, the Catalogue includes standards regarding control and surveillance of drinking‐water networks (MS 678), public water quality sampling (MS 682) and bottled water quality (MS 699). Furthermore, Malawi does not have an independent regulator to assess and ensure compliance with these standards. The Ministry of Health has indicated plans to meet with the Malawi Bureau of Standards to discuss the adaptation or adoption of the WHO performance recommendations (WHO, 2011a).  In Mozambique, the Ministry of Health is responsible for the task of monitoring the water quality. Currently, the Government refers to the Regulation on Water Quality for Human Consumption (Regulamento sobre a Qualidade de Água para o Consumo Humano), a ministerial decree issued in September 2004. This regulation was drafted by a multi‐sectoral team and is based on the WHO Guidelines for Drinking‐water Quality (WHO, 2011b). At the time of the workshop, the regulation was being reviewed and stakeholder feedback was encouraged. In Mozambique, all HWTS products are subject to an evaluation by the Ministry of Health. The Aquatest project is assessing the reliability of a low‐cost water quality test to identify those source waters that are most contaminated and to target mitigation measures. All these technologies that come into the country legally, they are actively subjected to this kind of evaluation by the MOH.  In Zambia, the Bureau of Standards is engaging a consultant to develop standards and a process for assessing microbiological performance in order to verify household water treatment product manufacturers’ claims. The recent WHO recommendations on performance will be 

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used as a basis for developing the standards. Zambia currently refers to the WHO Guidelines for Drinking‐water Quality (WHO, 2011b) as the basis for setting its own national guidelines.    In all the countries, the introduction of products which may or may not meet international standards is a problem. Government officials asked about looking to their regional counterparts (South Africa, Ethiopia and Kenya were specifically mentioned) for advice on developing, monitoring and enforcing product standards. Another challenge cited was the lack of investment in monitoring source water quality as part of a national drinking‐water quality surveillance system. 

11. Preparation and presentation of draft National Action Plans 

On the second and third day of the workshop, breakout sessions were scheduled and participants were given the opportunity to join a country team of their choice and contribute to the development of the draft national action plans. The objective of preparing these draft national action plans was to provide a framework for making decisions and identifying priorities in the scaling up of HWTS and allow various stakeholders to have a voice in the decision‐making process.   The breakout sessions produced drafts of varying degrees of ambition and complexity. Each working group was assigned a moderator / facilitator to guide the discussion and natural leaders tended to emerge from the group. It was obvious that some participants came well‐prepared and with a high level of knowledge of relevant national policies and circumstances which helped contribute to a thoughtful and informed discussion. In some cases, participants expressed frustration that some senior decision‐makers from their countries did not attend but this did not prevent the development of the draft action plans. Participants were encouraged to take ownership of the process and then lobby internally for the priority actions they had identified. In addition, the process was useful in identifying information needed to make better decisions, such as the need for preparing and distributing a briefing note to all workshop participants on the policy context in each country to allow for discussions to be better informed and focused on potential gaps.  Session moderators observed that improving the baseline level of knowledge about national policies and circumstances may help to improve the productivity of such breakout sessions in the future and it was agreed that for future workshops, a brief policy landscape review paper would be prepared in advance.  During the afternoon of the final day of the workshop, representatives from each of the Malawi, Mozambique and Zambia teams presented the draft national action plans they had developed within their working groups and invited feedback from other workshop participants. This exercise provided an opportunity for constructive criticism and sharing of ideas between the teams.  

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Following the country presentations, national teams were invited to submit their draft national actions plan to WHO and UNICEF for review and receive seed funding to support initial steps in moving the plans toward action. At of the timeof publication of this report, both Malawi and Zambia had submitted proposals and received seed funding. Mozambique is currently in the process of revising their national action plan proposal.  The final proposals from Malawi and Zambia can be viewed online at the workshop website: http://waterinstitute.unc.edu/hwts/events/2012_maputo. 

12. Translating plans into action and identifying needs 

The major needs in terms of translating the national plans into action are financial resources and effective implementation models.  In addressing these challenges, governments and donors should differentiate between strategies for reaching vulnerable groups and the rest of the population in need. For the former, both donor funds and government support are needed to reach those for whom health impact will be greatest but the ability to pay and access HWT products through the private market is often low. For the latter, for‐profit models may be more appropriate to maximise long‐term sustainability and achieve scale for large numbers of people. During the workshop, government officials expressed a desire for data on the costs, benefits and cost‐effectiveness of the proposed interventions and implementation models to better inform decision‐making.  In translating plans into action, in the short‐term governments should both identify specific vulnerable groups and prioritise their outreach in order to improve equity of access to clean water and improved health outcomes. Concurrently, governments should also act to improve the enabling environment to facilitate contributions by the private sector and NGOs to scaling up access to HWTS, while recognising that this may take political will, sustained support and close regulation over several years or more before the commercial market becomes competitive. Structuring national action plans in this way provides a roadmap to helping those who need it urgently while achieving development goals sustainably – this targeted approach will help in mobilising financial resources. Meanwhile, donors and implementing organisations can assist by proactively sharing program implementation costs with others and collaborating to identify the most cost‐effective options that can be recommended to government officials.  Through communications activities, the International Network on Household Water Treatment aims to provide assistance in the implementation of national action plans. The Network aims to share knowledge and build capacity through a diversified offering of webinars, online content, workshops and activities of the Network working groups. In so doing, it hopes to facilitate decision‐making by stakeholders on policy, programming and research. The Network welcomes ideas and contributions from all of its members in order to achieve these goals. 

13. Conclusion 

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The workshop provided an important opportunity not only for national country teams to develop draft action plans, but also for a diverse group of stakeholders working on HWTS in the Southern Africa Region to share ideas and gain inputs into overcoming specific challenges in funding, implementing and sustaining use of HWTS.  Numerous lessons were learned in respect of the workshop objectives. These are outlined in section 2 of this report and are intended to provide a quick reference guide of recommended practices as stakeholders seek to support the scaling up of HWTS at the national level.  Malawi and Zambia are now implementing their revised action plans and Mozambique is revising the draft plan developed at the workshop.  The implementation of such action plans will serve as an important measure of success of the workshop and for improving upon future national strategy development efforts.    

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performance recommendations. Geneva, Switzerland, World Health Organization. 

http://www.who.int/water_sanitation_health/publications/2011/household_water/en/index.html.  

WHO. 2011b. Guidelines for Drinking‐water Quality, 4th edition. Geneva, Switzerland, World Health 

Organization. Available at: 

http://www.who.int/water_sanitation_health/dwq/guidelines/en/index.html.  

WHO. 2012. Status of national household water treatment and safe storage policies in selected 

countries. Geneva, Switzerland, World Health Organization. 

http://www.who.int/entity/household_water/WHOGlobalsurveyofHWTSPolicies_Final.pdf  

WHO & UNICEF. 2012. Monitoring and evaluation toolkit for household water treatment and safe 

storage programmes. Geneva, Switzerland, World Health Organization. 

http://www.who.int/household_water/resources/toolkit_monitoring_evaluating/en/index.html 

17  

Wood, S., Foster, J. & Kols, A. (2012). Understanding why women adopt and sustain home water 

treatment: Insights from the Malawi antenatal care program. Journal of Social Science & Medicine 

75(4):634‐642. Available at: http://www.ncbi.nlm.nih.gov/pubmed/22051403.  

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Annex 1 – Agenda  

Final Agenda

National HWTS Policies and Integrated Household Environmental Health Interventions in Southern Africa

VIP Grand Hotel

Maputo, Mozambique 20-22 June 2012

Day 1: National household water treatment and safe storage (HWTS) policies, regulations, and best practices implementation 8:00 – 8:30 Registration of participants and initial workshop evaluation 8:30 – 8:50 Introductions and welcome remarks

D Kertesz, WHO Mozambique R DeBernardi, UNICEF Mozambique

8:50 – 9:00 Official opening of the workshop

A Candido, Mozambique Ministry of Health 9:00 – 9:15 Workshop objectives, expected outputs, and joint action plan

M Montgomery, WHO 9:15 – 10:30 International HWTS perspective: challenges and opportunities

Global status and key challenges regarding use and sustainability by L Lehmann, Innovations for Poverty Action

Global survey on national policies and way forward by M Montgomery, WHO

International HWTS Network objectives and activities by M Forson, UNICEF

Review of enabling environment for HWTS by E Ojomo, Water Institute at UNC

10 minute presentations followed by 35 minutes of discussion moderated by M Van der Velden, UNICEF Mozambique.

10:30 – 10:45 Coffee/tea break and group photograph 10:45 – 12:30 Status of HWTS National Policies, Government Efforts and Enabling Environment

Malawi by H Masuku, Malawi Ministry of Health Zambia by E Chawfa, Zambia Ministry of Health Mozambique by A Candido, Mozambique Ministry of Health 10 minute presentations followed by 75 minute discussion with speakers and participants moderated by S Nkunku, WHO Mozambique.

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12:30-12:45 Obligatory UN security briefing for all international participants

Rogerio Mabica, Security Assistant UN Department of Safety and Security

12:45 – 13:30 Lunch 13:30 – 13:35 Brief energizer activity 13:35 – 14:15 Examples and lessons learned in implementing HWTS

HWTS at Scale; Community and user interface in Western Province, Kenya by T Neville, Vestergaard-Frandsen

Low cost filters-failures, successes, and way forward by H Holtslag, Advisor low-cost technologies

Lessons learned in implementing solar disinfection in Zambia by A Saka, Keepers Zambia Foundation

10 minute presentations followed by 20 minute discussion with speakers and participants moderated by M Forson, UNICEF HQ.

14:15 – 15:00 Best Practices in Integrating HWTS with Health Efforts

Integrating HWTS with HIV/AIDS and nutrition efforts by G Allgood, Procter & Gamble

Combining HWTS with antenatal care in Malawi by L Goodyear, PATH

10 minute presentations followed by 20 minute discussion with speakers and participants moderated by M Montgomery, WHO.

15:00 – 15:15 Coffee/tea break 15:15 – 16:15 Sustainability and Reaching the Most Vulnerable

L Goodyear, PATH; D Sing’anga, Zambia Ministry of Local Government and Housing and H Masuku, Malawi Ministry of Health

60 minute roundtable discussion moderated by S Godfrey, UNICEF Mozambique

16:15 – 16:30 Wrap-up

W Maenhout, WHO Mozambique 16:30 – 17:00 De-brief with facilitators/hosts (UNICEF/WHO/MoH/MoPW) 17:00 – 18:00 Evening cocktail for participants

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Day 2: Tools for improving outcomes and impact 7:45 – 8:00 Sign-in

8:00 – 8:15 Summary of Day 1 and Agenda for Day 2

Ryan Rowe, UNC 8:15 – 10:00 Monitoring and Evaluating HWTS in the Home

WHO/UNICEF Toolkit on M&E by M Montgomery, WHO Technology’s role in facilitating evaluation by L Lehmann, IPA Monitoring HWTS implementation by I Circo, PSI

Mozambique 10 min presentations followed by 5 minute Q&A followed by 75 minute roundtable discussion. Moderated by M Forson, UNICEF.

10:00 – 10:15 Coffee/tea break 10:15 – 11:15 Evaluation and Regulation of HWT

The Zambia Perspective by D Sing’anga, Zambia Ministry of Local Government and Housing

WHO global health-based criteria for evaluating HWT and country examples of evaluating/regulating HWT by M Montgomery, WHO.

15 minute presentation followed by 45 minute moderated roundtable discussion with Y Samanyika, Malawi Ministry of Health, G Allgood, Procter & Gamble; D Sing’anga Zambia Ministry of Local Government and Housing and T Neville, Vestergaard-Frandsen. 45 minute roundtable discussion moderated by L Lehmann, IPA.

11:15 – 12:30 Group work on action plans 12:30 – 13:30 Lunch 13:30 – 15:00 Brief energizer activity and group work on draft action plans 15:00 – 15:15 Coffee/tea break 15:15 – 16:15 Continued group work on draft action plans

16:15 – 16:30 Wrap-up of day’s activities

H Kubwalo, WHO Malawi 16:30 – 17:00 De-brief with facilitators/hosts (UNICEF/WHO/MoH/MoPW)

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Day 3: National action plans for HWTS 7:45 – 8:00 Sign-in

8:00 – 8:15 Summary of Day 2 and Agenda for Day 3

M Forson, UNICEF

8:15 – 10:00 Finalize draft action plans and presentations 10:00 – 10:15 Coffee/tea break 10:15 – 12:30 Presentation of National Draft Action Plans

Malawi by a group member Mozambique by a group member Zambia by a group member 15 min presentations with each followed by 30 minute moderated

discussion. Moderated by H Kubwalo, WHO Malawi 12:30 – 13:30 Lunch 13:30 – 13:45 Brief energizer activity and workshop evaluation 13:45 – 15:00 Translating plans into action and identifying needs

Communications for learning and capacity development by R Rowe, UNC

Mobilising resources: From microcredit to large funds by L Lehmann, IPA

10 min presentations followed by 5 minute Q&A and then open discussion. Moderated by W Maenhout, WHO Mozambique

Open discussion on translating plans into action

Moderated by W Maenhout, WHO Mozambique 15:00 – 15:30 Group discussion on timelines, key contacts, and commitments

Moderated by M Forson, UNICEF HQ

15:30 – 15:45 Wrap-up and conclusion of workshop M Montgomery, WHO; W Maenhout, WHO Mozambique; M

Forson, UNICEF Mozambique Ministry of Health and Public Works and

Housing 15:45 – 16:00 Next steps with facilitators/hosts (UNICEF/WHO/MoH/MoPW)

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Annex 2 – Concept Note  

International Network for Household Water Treatment and Safe Storage (INHWTS)

REVISED DRAFT Concept Note and Proposed Workshop Agenda

National HWTS Policies and Integrated Household Environmental Health Interventions in Southern Africa

Maputo, Mozambique

20-22 June 2012 Summary This concept note provides the objectives, expected outputs and arrangements for a proposed regional workshop “National HWTS Policies and Integrated Household Environmental Health Interventions" to be held in Maputo, Mozambique. The workshop will be jointly hosted by WHO and the United Nations Children Fund (UNICEF) in conjunction with national governments and stakeholders. Background In light of recent efforts in Southern African countries to integrate HWTS into health programmes, the workshop would provide a timely forum to share lessons learned and work towards scaling-up initial efforts. For example, in several Districts in Malawi (Blantyre1, Machinga2, and Salima Districts) the Ministry of Health is working directly with health and development partners to integrate hygiene kits, which include household water treatment, with antenatal care. Initial results indicate that the effort has resulted in sustained improvement of water treatment practices as well as increased uptake of antenatal services3. Furthermore, in Zambia health facilities are integrating household water treatment and hygiene behaviour change with HIV/AIDS prevention and conselling efforts. Achieving tangible results in the scaling-up of HWTS and integration into critical public health programmes depends, in large part, on national enabling environments and policies. Therefore, the workshop would provide an opportunity to strengthen national policies to support effective implementation. Such efforts are in-line with international targets on establishing national HWTS policies which have been articulated in the Strategy of the International Network on Household Water Treatment and Safe Storage4 (the “Network”) and have been adopted by the World Water Forum 2012. 1 The work in Blantyre and Salima Districts was sponsored by USAID in collaboration with UNICEF, the Ministry of Health, and Population Services International (PSI). 2 The work in Machinga was carried about by the Clinton Health Access Initiative (CHAI), US Centers for Disease Control (CDC), PATH in direct partnership with the Ministry of Health. 3 Wood, et al. Understanding why women adopt and sustain home water treatment: Insights from the Malawi antenatal care program. Social Science and Medicine. 2011: 1-9. 4 WHO/UNICEF (2011). International Network on Household Water Treatment and Safe Storage. Funding and Strategy Proposahttp://www.who.int/household_water/resources/NetworkStrategyMar2011.pdf

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Participating organizations in the Network have identified Mozambique as a suitable host for such a regional workshop for several reasons. Both the WHO country office and the Government are supportive of HWTS and organizations working on HWTS in Mozambique have expressed a desire to host such a meeting. Maputo is well equipped in regards to meeting and lodging facilities to accommodate participants from neighbouring countries. Finally, while the Network has hosted several meetings in East African countries, it has not yet hosted a meeting in Mozambique. Thus, this workshop provides the opportunity to broaden Network links to national efforts and vice versa. Goal To strengthen national policies, strategies, and regulation of HWTS to support effective implementation and integration with other household environmental health interventions. Specific Objectives

Provide an overview of current national policy structures and regulation concerning HWTS in workshop countries;

Identify strengths and challenges of the institutional environment and identify specific mechanisms for scaling-up (i.e. HWTS targets, inclusion of HWTS in national efforts to prevent and treat childhood diarrhoea, HIV/AIDS & TB, respiratory disease, etc);

Share lessons learned in policy formulation and implementation and Strategize on overcoming challenges to scaling-up and sustaining HWTS use

through the development of draft national action plans

Participants Representatives are expected from all stakeholder groups, while keeping the workshop to a manageable size of approximately 50 participants. Participants will be invited from three countries actively working on HWTS and contributing to the Network (Malawi, Mozambique and Zambia). Participants will include national and regional government officials from the Ministries of Health, Water (or equivalent), Public Works, Education and other as relevant, WHO, UNICEF, and organizations implementing household water management in Southern Africa. This may include private sector (e.g. P&G, Vestergard Frandsen), NGOs (PATH, PSI), development agencies (USAID, US CDC), representatives from the informal sector and academic institutions as relevant. A particular focus will be given to those organizations working on integrated interventions and delivery approaches. Method of Work

1) Identification of relevant background documents and a short briefing note on HWTS national policy development, as well as a brief overview of implementation and integration activities in Malawi, Mozambique and Zambia.

2) Convening a three-day workshop which will include: National status of HWTS presentations from government officials Examples of implementation approaches, monitoring and lessons learned from

implementers, government and donors;

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Small working group sessions addressing specific challenges regarding delivery of integrated interventions, supporting and monitoring sustained use and innovative financing mechanisms;

Draft national plan of action for implementing national HWTS policies and scaling-up integrated household environmental health interventions;

Discussion of implementation of WHO recommendations on evaluating HWT5; and

Discussion of use of WHO/UNICEF HWTS monitoring and evaluation indicators and tools6.

Expected Outputs

To meet the specific objectives, as listed above; National plans of action for implementing HWTS policies and scaling-up

integrated household environmental health interventions; Increased capacity for ongoing information sharing in the region; and Report back to the Network on progress of national plan of action

(approximately three months after at the Annual Network meeting in October 2012).

Key agenda items The following presents key agenda items. A more detailed agenda will be developed by the local organizing commitment with support from WHO and UNICEF. Day 1: National HWTS policies, regulations, and best practices in integration

Brief opening remarks by officials from Ministry of Health, WHO, UNICEF Status of HWTS in national policies and strategies in Malawi, Mozambique and

Zambia Regulation and technology evaluation-global and national efforts Landscape of current HWTS practices and efforts to promote hygiene behaviour

change Sharing lessons from integrated efforts in the Southern Africa

Day 2: Integrated efforts and scaling-up

Continued discussion of integrated efforts, especially in addressing needs of vulnerable groups (small children, malnourished, people living with HIV/AIDS)

Effective monitoring and evaluation of HWTS, including water quality monitoring at the household level

Group work in teams on national action plan Day 3: Action plan for Scaling-up HWTS

Group work on action plan

5 WHO, 2011. Evaluating household water treatment options: Health based targets and microbiological performance specifications. June 2011. Geneva, Switzerland. http://www.who.int/water_sanitation_health/publications/2011/household_water/en/index.html 6 WHO/UNICEF, 2012. Monitoring and evaluation household water treatment and safe storage toolkit. Draft 2. (Currently under peer review).

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Presentation of action plans, follow-up actions and discussion Resource mobilisation and next steps

Workshop conclusion and follow-up

At the conclusion of the workshop, national teams will be tasked to revised their draft action plans based on input gained during the workshop and from appropriate counterparts in their home Ministries. Once revised and submitted these teams will receive 3,000 USD from WHO/UNICEF to facilitate implementation of the plan. This may involve hosting a national/regional meeting on one particular item of focus or conducting an assessment in the field.

During the workshop and afterwards, brief surveys will be administered to participants to gauge their satisfaction and knowledge gained. The purpose of the evaluation will be to improve future workshop design and aid in continuing work with the participants. Finally, a workshop report will be published by the Network documenting the key proceedings and workshop outcomes. The report will be meant to serve as a reference for both workshop participants and the wider global audience of Network participating organizations engaged in HWTS policies development and integration. The report will be made available on the WHO HWTS website where other relevant materials are located including a report from a similar regional workshop held in Uganda in 2011 involving Ethiopia, Kenya, Rwanda, Tanzania and Uganda.7

7 WHO/UNICEF, 2011. Report of a workshop for countries in East Africa: National Household Water Treatment and Safe Storage Strategies and Integrated Household Environmental Health Interventions. http://www.who.int/household_water/resources/en/

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Annex 3 – List of participants 

Name Country Organisation

1 Lilian Lehmann Kenya Innovations for Poverty Action

2 Humphreys Masuku Malawi Ministry of Health

3 Young Samanyika Malawi Ministry of Health

4 McLawrence Mpasa Malawi Ministry of Water Development & Irrigation

5 Hudson Kubwalo Malawi World Health Organization

6 Monica Villanueva Malawi United States Agency for International Development

7 Chelsea Langa Mozambique Ministry of Health – Department of Environmental Health (DSA)

8 Ana Candido Mozambique Ministry of Health – DSA

9 Ana-Paula Cardoso Mozambique Ministry of Health – DSA

10 Rosa Maerdoenda Mozambique Ministry of Health – Epidemiology

11 Elisa Adelaide Tembe Mozambique Ministry of Health – HIV/AIDS

12 Maria Nivalda Lázaro Mozambique Ministry of Health - National Laboratory for Water and Food Hygiene (LNHAA)

13 Mauricete Angelo Mozambique Ministry of Health – LNHAA

14 Salma Xavier Mozambique Ministry of Health – LNHAA

15 Teresa Pereira Mozambique Ministry of Health – LNHAA

16 Isabel Tauzene Mozambique Ministry of Health – LNHAA

17 Julieta Felicidade Mozambique Ministry of Public Works and Housing – National Directorate of Water (DNA)

18 Gilberto Azania Langa Mozambique Ministry of Public Works and Housing – DNA

19 Cristo Antonio Dos Santos Mozambique Ministry of Public Works and Housing – DNA

20 Jordi Gallego Mozambique Ministry of Science and Technology

21 Jaime Muchanga Mozambique Administração de Infra-estruturas de Água e Saneamento (AIAS)

22 Virginia Muianga Mozambique Inspecção nacional de actividades económicas

23 Alberto Muando Júnior Mozambique Centro de higiene ambiental da cidade de Maputo

24 Quermildo Finiasse Aliginar Mozambique Centro de formação professional de agua e saneamento

25 Wouter Maenhout Mozambique World Health Organization

26 Sebastião Nkunku Mozambique World Health Organization

27 Samuel Godfrey Mozambique UNICEF

28 Matteus Van der Velden Mozambique UNICEF

29 Delfim Nhassevele Mozambique UNICEF

30 Tania Loforte Mozambique Samaritan's Purse

31 Helder Ntimane Mozambique Plan International  

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Name Country Organisation

32 Iulian Circo Mozambique PSI Mozambique

33 Osorio Bento Mozambique Navaza Water Filters

34 Antoninho Chitseve Mozambique Class-A

35 Virginia Arranz Mozambique Bosque y Comunidad

36 Gloria Moreira Mozambique World Health Organization

37 Artur Matavele Mozambique WaterAid

38 Fernando Mubai Mozambique PAMODZI

39 Didacienne Mozambique ACORD

41 Tim Doyle Mozambique US Centers for Disease Control & Prevention

42 Sr. Agostinho Fernando Mozambique World Vision

43 Gaspar Maiquita Mozambique Ministry of Education

44 Tomas Impaia Mozambique IRD

45 Khalid Azam Mozambique FEZTP

46 Laurent Roquier Mozambique Wash Consultant / Antenna Technologies

40 Frank Olesen Mozambique / South Africa Vestergaard Frandsen

47 Henk Holtslag Netherlands Independent Consultant

48 Bruce Wylie South Africa South Pole Carbon

49 Maggie Montgomery Switzerland World Health Organization

50 Michael Forson USA UNICEF

51 Greg Allgood USA Procter & Gamble

52 Ryan Rowe USA Water Institute at the University of North Carolina

53 Lorelei Goodyear USA PATH

54 Tim Neville USA Vestergaard Frandsen

55 Edema Ojomo USA Water Institute at the University of North Carolina

56 Mibenge Chilekwa Zambia Ministry of Health

57 Elizabeth Chafwa Zambia Ministry of Health

58 Douglas Sing’anga Zambia Ministry of Local Government and Housing

59 Albert Saka Zambia Zambia Keepers Foundation

60 Dr. Daniel Kertesz Mozambique WHO, Country Representative

61 Dr. Roberto De Bernardi Mozambique UNICEF, Deputy Representative

Participant email addresses are available upon request to hhwater@who.int or hwtsnetwork@unc.edu.