Inter-regional workshop on:

Strengthening evaluation, regulation and

implementation of household water treatment and

safe storage

Workshop report

Addis Ababa, Ethiopia

3-5 May, 2016

ii

Contents

Summary and key outcomes ...................................................................................................... 1

Background ................................................................................................................................ 2

Workshop proceedings............................................................................................................... 4

Session 1: The big picture: Water and health .................................................................... 4

Session 2: Status of HWTS strategies and policies ........................................................... 5

Session 3: Promoting HWTS: approaches and knowledge dissemination ........................ 6

Session 4: Accelerating access to HWTS: distribution options ........................................ 8

Session 5a: Strengthening evaluation and regulation of HWT performance .................. 8

Session 5b: Strengthening evaluation and regulation of HWT performance .................. 9

Session 5c: Strengthening evaluation and regulation of HWT performance ................ 11

Session 5d: Visit to Ethiopian Public Health Institute (EPHI) laboratory ..................... 11

Session 6: Monitoring and evaluating HWTS use .......................................................... 12

Session 7: HWTS as part of broader water, sanitation and hygiene (WASH) response in

emergencies ........................................................................................................................ 13

Session 8: Way forward: key challenges and solutions ................................................... 13

Appendices

Appendix 1: Workshop agenda ............................................................................................ 16

Appendix 2: List of participants .......................................................................................... 20

Appendix 3: Summary of group discussion on regulation................................................... 23

iii

Abbreviations

EFMHACA Ethiopian Food, Medicine & Health Care Administration & Control Authority

EPHI Ethiopian Public Health Institute

FDA Food & Drugs Authority

GSA Ghana Standards Authority

HWT household water treatment

HWTS household water treatment and safe storage

M&E monitoring and evaluation

NGO non-governmental organization

SDGs Sustainable Development Goals

UNICEF United Nations’ International Children’s Fund

WASH water, sanitation and hygiene

WHO World Health Organization

WSP water safety plan

1

Summary and key outcomes

A workshop on strengthening evaluation, regulation and implementation of household water

treatment and safe storage (HWTS) was convened by the International Network on

Household Water Treatment and Safe Storage (“the Network”) on 3-5 May 2016 in Addis

Ababa, Ethiopia. The Network is co-hosted by the World Health Organization (WHO) and

United Nations’ Children’s Fund (UNICEF). The purpose of the workshop was to review

progress made on implementing national strategies and policies on HWTS, and discuss key

needs to strengthen implementation efforts, as well as national evaluation and regulation of

household water treatment (HWT) products. This report summarizes key discussions points

from the workshop, as well as next steps.

Key discussion issues

HWTS is an important component of the framework for safe drinking-water. Under

the Sustainable Development Goal, monitoring will include indicators on water safety.

HWTS is a component of the drinking-water safety framework, and is an important public

health intervention for improving the safety of water and protecting health among

vulnerable populations.

Implementation of HWTS needs to be strengthened

In general, policies / strategies on HWTS exist, but resource mobilization, improved

coordination particularly at sub-national level and integration with other health

intervention are required to strengthen efforts.

Strong national working groups on HWTS are essential for catalysing progress.

Working groups should serve as a platform through which national stakeholders can meet

and strategize on key issues related to HWTS, and serve as the advocacy and catalysing

agent for:

The development of national standards on performance of HWTS products;

The establishment of regulatory frameworks for HWTS, including strengthening

certification frameworks to include comprehensive criteria on microbiological

effectiveness; and

The engagement of the private sector in policy formulation and programme

implementation.

2

Promotion of HWTS should be balanced with behaviour change.

HWTS implementation strategies should be strengthened to focus on sustained behaviour

change, not ‘pushing’ HWTS products to households.

Tangible approaches for engaging the private sector are needed. Beyond inviting the

private sector to discussion fora, practical incentives such as tax waivers are needed to

encourage manufacturers and distributors to reach wider markets. In addition, customs

authorities are encouraged to recognize HWTS products as health products and apply

similar procedures as other supplies or goods imported for public health purposes.

Commitments and next steps

WHO to continue to work towards strengthening national capacity in evaluation and

regulation of HWTS products, and liaise with countries on prioritization of activities and

next steps

Governments, NGOs, private sector and academia to work together in strengthening

national working groups on HWTS, and work to:

o Adopt WHO performance recommendations for HWT in the development of their

national standards;

o Support countries in undertaking performance evaluation of locally-manufactured

HWTS products;

o Classify of HWT products as ‘health products’ and facilitate waiving of import taxes;

and

o Facilitate accurate coding of HWT devices by the customs agencies, to support the tax

waiving noted above, and prevent products found to not meet performance

requirements from being allowed into countries.

Participating organizations of the Network to support countries in wider implementation

efforts, including knowledge exchange fora, supply chain management and consumer

financing.

Background

Household water treatment and safe storage (HWTS) is an important public health

intervention to improve the quality of drinking-water and prevent water-borne disease. When

effective methods are used correctly and consistently, HWTS can reduce diarrhoeal disease

3

by as much as 45 %1. In order to comprehensively assess effectiveness, WHO in 2014

established the International Scheme to Evaluate Household Water Treatment Technologies

(the Scheme) to independently and consistently evaluate HWT products based on WHO

criteria2. Concurrently, the Scheme also aims to strengthen the capacity of countries to

regulate and evaluate HWT products and seeks to ensure that results of the evaluation are

considered and used by procurement and regulatory authorities.

In addition to effectiveness, achieving tangible health gains from HWTS also depends on

other factors, including the existence of national enabling environments and effective policies

that recognize HWTS amongst other public health interventions, supply chains, affordability,

user preferences, etc. In order to facilitate progress on these fronts, the WHO and UNICEF-

hosted International Network on Household Water Treatment and Safe Storage (“the

Network”) brings together over 140 participating organizations, including representatives of

governments, academic institutions, implementing agencies and the private sector, around the

common goal of reducing water-borne disease through safe water.

All three countries at the workshop (Ethiopia, Kenya and Ghana) have participated in

previous workshops convened by the Network aimed at developing policy frameworks and

national strategies on HWTS in the regions of East Africa3 and West Africa

4. Further, in all

three countries diarrhoeal disease is a significant cause of morbidity and mortality, and

HWTS serves as an important intervention for safety of drinking-water, and have participated

in discussions aimed at identifying how HWTS evaluation and regulation can be

strengthened5,6.

1 WHO (2014). Preventing diarrhoea through better water, sanitation and hygiene: Exposures and impacts in

low- and middle-income countries. Geneva: World Health Organization;

(http://www.who.int/water_sanitation_health/gbd_poor_water/en/). 2 WHO (2011). Evaluating household water treatment options: health-based targets and microbiological

performance specifications. Geneva: World Health Organization

(http://www.who.int/water_sanitation_health/publications/2011/household_water/en/). 3 WHO, UNICEF and UNC (2011). National Household Water Treatment and Safe Storage Strategies and

Integrated Household Environmental Health Interventions: Report of a Workshop for selected countries in East

Africa. Available from: 4 http://www.who.int/household_water/resources/EastAfricaPolicyIntegrationWorkshop2011.pdf?ua=1

WHO, UNICEF and UNC (2013). Household Water Treatment and Safe Storage in West Africa: Report of a

May 2013 Regional Workshop on Household Water Treatment and Safe Storage and Integrated Household-

based Environmental Health Interventions. Available from:

http://www.who.int/household_water/resources/2013AccraReport_Final_forposting.pdf?ua=1 5 WHO, UNICEF and PSI (2013). Evaluating Household Water Treatment Performance and Scaling up Safe-

Drinking Water Solutions: National workshop, Ethiopia. Available from:

http://www.who.int/household_water/resources/EthiopiaHWTWorkshopReport_Feb2013_Final_2.pdf?ua=1 6 WHO (2015). Strategic Meeting of the WHO International Scheme to Evaluate Household Water Treatment

Technologies.

Available from: http://www.who.int/household_water/scheme/schemestrategicmeetingreport-2015.pdf?ua=1

4

The current workshop was therefore to follow up on these efforts, and specifically:

Review status and implementation of national strategies and polices on HWTS,

including existing approaches to addressing HWTS in emergencies;

Share lessons learned in policy formulation and implementation; and

Discuss key needs and solutions in improving HWTS implementation, including:

product performance evaluation and regulation, monitoring and evaluation of use, and

utilizing lessons learned to improve implementation approaches.

The workshop took place over three days, and included over 50 participants from Ethiopia,

Kenya and Ghana, representing national and regional governments, non-governmental

organizations, academics, implementing organizations and manufacturers of HWTS products.

Themes covered on Day 1 of the workshop included: recent evidence on water and health,

and HWTS in the global development agenda; status of national strategies and policies on

HWTS; and HWTS promotion and financing options. Day 2 covered WHO performance

recommendations for HWT and results from Round I of the Scheme, existing approaches to

HWT evaluation and regulation in countries. Day 3 was focused on field monitoring and

evaluation of HWTS, as well as discussions on key needs to strengthen implementation,

regulation and evaluation of HWTS in countries. The workshop agenda is attached in

Appendix 1, and the list of participants and group photograph in Appendix 2.

Workshop proceedings

Opening remarks at the workshop were given by Dr Paul Mainuka (Officer in Charge, WHO

Ethiopia); Dr Samuel Godfrey (Chief of WASH, UNICEF Ethiopia) and Dr Taye Balcha

(Head Office of State Minster, Federal Ministry of Health). Mr Dangew Tadessa (Ministry of

Health, Ethiopia) welcomed participants and led the round of introductions, and Dr Batsi

Majuru (WHO headquarters laid out the objectives of the workshop. The workshop was

divided into sessions, which are summarized below.

Session 1: The big picture: Water and health

The objectives of the session were to provide an overview of recent evidence on water quality

and health, and linkages between HWTS and broader efforts on water safety in the

Sustainable Development Goals (SDGs).

Anna Murray, Tufts University

Ms Murray presented an overview of recent evidence on water quality and health, including

5

the most recent estimates on the burden of disease attributable to inadequate drinking water,

and systematic reviews of the impact of water quality interventions on health. Key points

highlighted were that although global diarrheal disease has been reduced and access to

improved water sources has increased, there is still high disease burden, particularly among

children under 5. New drinking-water targets under the SDGs will consider drinking-water

safety, not just water access, current evidence demonstrates that HWTS can reduce diarrheal

disease among users.

Batsi Majuru, WHO headquarters

Dr Majuru presented on the water safety framework presented in the WHO Guidelines for

Drinking-water Quality7, highlighting concepts relating to water safety management, and the

role of HWTS. Key concepts highlighted were health-based targets and how they relate to the

WHO performance recommendations for HWT technologies8, water treatment methods and

that HWTS is analogous to conventional water treatment; and the consequent need to ensure

that such treatment is effective, and done correctly and consistently by users. Discussions

following the presentation highlighted the importance of safe storage after treatment and

verification of material safety as a part of HWT evaluation.

Session 2: Status of HWTS strategies and policies

The objectives of the session were to: provide overview of existing policies and strategies on

HWTS; update on progress on implementation, including challenges encountered; and

discuss potential solutions to challenges to shared.

Dangew Tadesse, Ministry of Health, Ethiopia

Ethiopia does not currently have a consolidated strategy that comprehensively addresses key

aspects relating to HWTS, but it is included in various public health policies and strategies.

The Health Transformation Plan of Ethiopia(2016-2020) has a target to increase HWTS use

from the current 10 % to 35%, by 20209. The National Water Quality Monitoring and

Surveillance Guideline (in draft), includes indicators on HWTS use, and the Health Extension

Program has been on promoting safe storage. In general, comprehensive water safety

7 WHO (2011). Guidelines for drinking-water quality. Fourth edition. . Geneva; World Health Organization.

Available from: http://www.who.int/water_sanitation_health/publications/dwq-guidelines-4/en/ 8 WHO (2011). Evaluating household water treatment options: Heath-based targets and microbiological

performance specifications. Geneva; World Health Organization. Available from:

http://apps.who.int/iris/bitstream/10665/44693/1/9789241548229_eng.pdf 9 The Federal Democratic Republic of Ethiopia Ministry of Health (2015).Health Sector Transformation Plan,

2016-2020. Available from:

http://www.moh.gov.et/documents/26765/0/Health+Sector+Transformation+Plan/5542a23a-9bc7-46a2-8c1f-

8b32c2603208?version=1.0

6

management including HWTS is not strong, and the key challenges noted are high turnover

of trained professionals, and weak monitoring: health management information systems do

not include HWTS.

Adam Mohammed Ali, Ministry of Health, Kenya

HWTS is addressed as a component of the Environmental Sanitation and Hygiene Strategy of

2007, which has been revised and is due to be launched in late May 2016. The main

components of the strategy are HWTS promotion and M&E. To date, progress has been made

in HWTS promotion as part of wider WASH in schools efforts, and on M&E, where water

safety indicators have been integrated into the health management information system of the

Ministry of Health. Among the key successes are that the national working group on HWTS

remains active and provides input on product selection, and an HWTS training manual has

been developed, though not yet available in print form. Challenges noted are as follows:

Lack of prioritization of HWTS at policy level;

HWTS is viewed only as an emergency intervention, and there is therefore no sustained

financing or clear budgetary allocation from government and development partners; and

Weak integration of HWTS into wider disease prevention strategies.

Kweku Quansah, Ministry of Local Government and Rural Development

Mr Quansah shared an overview of the national strategy for HWTS in Ghana, which

comprises the overall strategy itself, a private sector participation framework, and a scale-up

model. The strategy has seven components: policy and institutional development; technology;

consumer engagement; emergency response; research and knowledge management; financing

and partnerships; and monitoring and evaluation. To date, progress has been made on: policy

and institutional development through development of a drinking-water quality management

framework; consumer engagement, through implementation of a behaviour change

programme; and emergency response, through training of over 200 health officers and

engineers in HWTS, and WSP in 24 districts. While the strategy includes a private sector

participation framework which outlines the sector’s roles, to date there has been little

progress. It was noted that although representatives actively participated in the development

of the national strategy, there has been little engagement with them since.

Session 3: Promoting HWTS: approaches and knowledge dissemination

The purpose of this session was to highlight challenges and lessons learned in HWTS

promotion.

7

Alemayehu Tegegne, Population Services International (PSI) Ethiopia

Mr Tegegne shared an overview of PSI’s promotional strategy for HWTS products. PSI

Ethiopia currently produces and distributes a chlorine disinfectant WaterGuard, under the

brand name WuhaAgar, and distributes the flocculant-disinfectant P&G Purifier of Water.

Distribution is to all nine regions in the country, and promotional methods used include

advertisements, community-wide events, door-to-door promotions, etc. Among the

challenges noted are:

HWTS is largely perceived as an emergency intervention, with little long-term use; and

there is little interest from vendors to stock HWTS products

Long registration process with the regulatory authority, EFMHACA;

Limited access to foreign currency, which hampers imports; and

Presence of contraband products.

Kweku Quansah (Ministry of Local Government and Rural Development)

Mr Quansah shared an overview of a behaviour change programme aimed at promoting

HWTS in communities that is being implemented in Ghana and lessons learned. The

programme is currently being implemented in the five priority regions of the country where

the burden of disease related to WASH is highest. The programme is being implemented as a

component of a broader programme on community-led total sanitation and hygiene, and to

date, over 1, 000 key extension staff have been trained in 5 regions for community level

HWTS promotional activities. With regards to the monitoring, the BASIS (MIS System for

Basic Sanitation) is being used to capture HWTS activities. Key lessons learned are outlined

below:

“Behaviour first” approach has the potential to promote sustained use of HWTS products;

Using other behaviour change communication vehicles to promote HWTS has been

effective and mainstreaming is key for sustained, long term social change; and

Completion and use of harmonized sector management information system and M&E

systems would enhance coordination and regulation and rally relevant partners for scale up.

Paul Earwaker, Centre for Affordable Water and Sanitation Technologies (CAWST)

Mr Earwaker presented an overview of the HWTS Knowledge Base; an online tool which

aggregates information on HWTS developed by CAWST. The tool contains information on a

range of topics related to HWTS, including: technology and product efficacy; monitoring and

8

evaluation; existing projects on HWTS; and implementation approaches. Contributors can

upload information to the Knowledge base can be accessed from www.hwts.info.

Session 4: Accelerating access to HWTS: distribution options

The aim of the session was to jointly develop ideas on private sector engagement, financing

solutions and supply chains to achieve national targets on HWTS.

Hester Foppen (Aqua for All) and Lemessa Mekonta (IRC Wash Ethiopia)

Mrs Foppen introduced a project that is under development that aims to pilot new pathways

for the distribution of HWTS products. The proposed distribution pathways are: health

centres; sanitation business centres; and drinking-water utilities. Lemessa then led the

discussion, in which workshop participants shared their input on the proposed distribution

pathways and the opportunities and challenges each of them present, possible incentives for

their involvement in HWTS distribution, and overall feasibility. The presentation and

discussion generated a lot of interest and debate, with discussions highlighting the pros and

cons of each distribution pathway. Discussion points highlighted that while public facilities

such as health centres may have a wide reach, their experience is in providing public services,

and they may have little experience in the retail service that would ensue from selling HWTS

products. Sanitation marketing business were highlighted as being retail oriented, but may not

have the capacity to provide after-sales support / maintenance.

Session 5a: Strengthening evaluation and regulation of HWT performance

The purpose of this session was to give an overview of the WHO performance

recommendations for HWT and share examples of national regulation of HWT.

Batsi Majuru, WHO headquarters

Dr Majuru shared an overview of the WHO performance recommendations for HWT, the

summary of Round I results from the WHO International Scheme to Evaluate Household

Water Treatment Technologies (“the Scheme”), and capacity building activities. Health gains

from HWT and safe storage can only be achieved when treatment products are effective in

removing pathogens from drinking-water, and are accessible to, and used correctly and

consistently by vulnerable populations. A variety of HWT products – with performance

ranging from little to considerable pathogen removal – are available. The Scheme was

established in 2014 to independently and consistently evaluate the performance of HWT

9

products according to WHO performance recommendations10

. In Round I of the Scheme, ten

HWT technologies, including solar, chemical, filtration and ultraviolet (UV) were evaluated,

and a rapid market assessment of HWT products was conducted. The Round I summary

report 11

details that there are both high performing and poor performing products and that

more needs to be done to strengthen national regulation and evaluation of HWT alongside

effective implementation. Evaluation under the Scheme does not constitute a certification, as

WHO is not a certifying body; this is the prerogative of national regulatory authorities.

Performance evaluation is a component of the product certification process, and through the

Scheme, WHO carries out this service on behalf of countries that would otherwise not have

the resources nor the capacity to rigorously evaluate HWT products. As such, the results of

the Scheme evaluation form the basis on which national regulatory authorities can then

certify or authorize products for sale or distribution within their countries. WHO is working

with national governments to fast track the authorization of products that have been evaluated

the Scheme and to strengthen evaluation, regulation and overall implementation of HWTS.

Anna Murray, Tufts University

Ms Murray shared an example of national regulation of HWT products in Haiti, where Tufts

University and the Centres for Disease Control and Prevention (CDC) have been supporting

the development a certification framework for HWT products12

. The certification framework

developed includes: reviews of product dossiers, verification of existing certifications, review

of efficacy data; verification of product composition (where applicable), and review of

product packaging. The presentation highlighted the importance of strengthening the capacity

of regulatory authorities in conducting similar reviews, and how regulations can be applied to

a wider range on HWT technologies, other than chemical disinfectants.

Session 5b: Strengthening evaluation and regulation of HWT performance

The purpose of this session was for countries to share overviews of their frameworks for

HWT evaluation and regulation.

10

WHO (2011). Evaluating household water treatment options: Heath-based targets and microbiological

performance specifications. Available from:

http://apps.who.int/iris/bitstream/10665/44693/1/9789241548229_eng.pdf 11

WHO (2016). Results of Round I of the WHO International Scheme to Evaluate Household Water Treatment

Technologies. Geneva: World Health Organization. Available from:

http://www.who.int/household_water/scheme/household-water-treatment-report-round-1/en/ 12

Murray A, Pierre‐Louis J, Joseph F, Sylvain G, Patrick M, Lantagne D. 2015. Need for certification of

household water treatment products: examples from Haiti. Tropical Medicine & International Health. 20(4):462-

70.

10

Seyom Wolde, Ethiopian Food, Medicine and Health Care Administration and Control

Authority (EFMHACA); and Almaz Gonfa, Ethiopian Public Health Institute (EPHI)

EFHMACA is mandated to regulate food (including water) and medicine with respect to

products, professionals, premises and practices. EPHI’s food microbiology and food safety

conducts analyses of food and water-related products. There are currently no national

standards for HWT products in Ethiopia. HWT products are required to be registered with

FMHACA before being marketed or used. To date, only chlorine disinfectants and flocculant-

disinfectants have been certified. Currently, the requirements for registration of HWT

products are a dossier evaluation and laboratory testing to verify the safety and material

composition of the product. Among the existing challenges noted are weak supply chains for

laboratory materials required to conduct performance evaluation and absence of certified

laboratories. However, as part of the capacity building activities of the Scheme, WHO is

working with FMHACA and EPHI to expand the scope of the evaluation and registration to

include devices, as well as microbiological performance against bacteria, viruses and

protozoa, and develop national standards for HWT.

Benjamin Murkomen, Ministry of Health Kenya

There are currently no national standards for HWT in Kenya. Products are tested by the

Kenyan Bureau of Standards against faecal coliform and the government chemist for material

safety and verification of product composition. Products are licensed by both the national and

county governments. Following testing by these institutions, the results are then shared with

the technical working group on HWTS for review. Upon approval by the technical working

group, the product is then registered with the Kenyan Regulatory Authority and licensed by

government agencies. Challenges noted are: no harmonized testing protocols amongst labs;

lengthy procedures for licencing of products; and weak field M&E on ongoing performance.

Genevieve Baah, Ghana Standards Authority (GSA)

There are currently no national standards for HWT in Ghana. Products are required to be

certified by GSA, and be registered with the Food & Drugs Authority (FDA). Current

certification requirements are: inspection of facility and premises; dossier review, laboratory

test results; and appropriate labelling. The timeline for product registration is 3 months. As

part of the capacity building activities of the Scheme, WHO is working with FDA and GSA

to expand the scope of the evaluation and registration to include microbiological performance

against bacteria, viruses and protozoa, and develop national standards for HWT.

11

Session 5c: Strengthening evaluation and regulation of HWT performance

The purpose of this session was to identify key needs and potential solutions with regards to

HWT regulation and evaluation. Participants broke up into country groups to discuss the

following questions:

1. What are the benefits to having country-level regulation of HWTS products?

2. What are the difficulties/drawbacks to having country-level regulation of HWTS products?

3. Who should be involved in developing a regulation framework?

4. What are some barriers to creating and implementing a regulation framework?

5. What components, beyond laboratory efficacy testing, would be useful to evaluate for

HWTS products?

The main issues highlighted from the discussion were: weak coordination amongst

stakeholders, lack of capacity to develop or enforce regulations, even if they were to be

established; and the perception that regulations may discourage manufacturers or distributors.

It was also noted that the devolved governmental structures in countries such as Ethiopia and

Kenya where national and regional / county regulatory structures may exist could be difficult

to coordinate. A detailed summary of the discussion points is attached in Appendix 3.

Session 5d: Visit to Ethiopian Public Health Institute (EPHI) laboratory

At the conclusion of Day 2 participants visited the Food & Water Microbiology and

Environmental laboratories at EPHI. The purpose of the visit was to better understand the

existing services provided by the lab and key needs for strengthening capacity in relation to

HWT performance testing. The laboratory faces logistical and infrastructural challenges,

summarized below:

Low output of laboratory grade water, little or no access to materials of test water

preparation and equipment for evaluation of water constituents;

Long material procurement process that spans 6-12 months in order to secure laboratory

materials and equipment, and not all supplies they submit purchase orders for are

guaranteed; and

Frequent electrical power outages that impede work and may compromise stock

microorganisms.

12

Session 6: Monitoring and evaluating HWTS use

The purpose of this session was to provide an overview of current M&E approaches for water

safety and share lessons learned.

Alex Doyen, Vestergaard

Mr Doyen presented on the use of remote sensors to assess the effectiveness of filter use,

based on a study that was conducted in Rwanda13

. The sensors measure how much water is

put in into the filters, how much is filtered put, and frequency of cleaning of the filter.

Anna Murray, Tufts University

Ms Murray gave a presentation on lessons learned from field M&E of HWTS, including key

challenges encountered. The presentation highlighted the need to maintain clarity on the

M&E questions to be addressed, selection appropriate indicators, and structural and

organizational arrangements. Discussions ensuing from the presentation highlighted that

M&E of HWTS is often fragmented, and conducted by the implementing organization with

little or no linkage of the data with government entities responsible for HWTS.

Balew Yibel, Ministry of Water, Irrigation and Energy

Mr Yibel gave a presentation on the status of water quality monitoring and management in

Ethiopia. Currently, four of the nine regions in the country are conducting water quality

monitoring. Ethiopia is also implementing Climate Resilient Water Safety Plans (CR-WSPs),

which also include HWTS as a component. The work is currently being implemented in 12

areas (nine urban and three rural) that serve more than 600,000 people in total. Improvement

actions include both soft components and infrastructure improvements. A number of

challenges were noted, which are outlined below:

Human resources

o Lack of water quality specialists

o Limited capacity to interpret water quality data and recommend necessary corrective

action

Institutions

o Although national standards for water quality are in place, regulatory capacity is weak

and operational staff are unclear on roles and responsibilities of regulatory authority

and service providers

o Lack of accredited reference laboratory for water quality testing

13

Thomas et al. (2013). Use of remotely reporting electronic sensors for assessing use of water filters and

cookstoves in Rwanda. Environmental Science & Technology 47(23).

13

Implementation

o Although the CR-WSP strategy includes HWTS as a component, there is no practical

guidance on how HWTS and WSPs can be integrated

o HWTS is primarily regarded as an emergency intervention

o Low community involvement in risk factor identification and mitigation

Session 7: HWTS as part of broader water, sanitation and hygiene (WASH)

response in emergencies

In this session participants broke into groups to discuss key challenges and potential solutions

in emergency response with regards to HWTS and broader WASH, and discussions were

structured within three broad phases of emergencies: preparedness; response; and recovery.

The main discussion points highlighted were:

Preparedness

o Regular communication and coordination amongst stakeholders outside of emergency

contexts is weak, and there is therefore little opportunity for joint learning and

improvement

o Awareness of HWTS products beyond popular brands chlorine disinfectants and

flocculant-disinfectants is low, and product selection is limited to these technologies

only

Response

o Much of the existing guidance on HWTS in emergencies is very generic, and is difficult

to apply in a more localized context

o Coordination at district or other localized is weak

Recovery

o Limited capacity to follow up and reinforce HWTS use on a more sustained basis

o Post-distribution monitoring is weak

o Public-private sector engagement is weak; little opportunity for reviewing lessons

learned.

Session 8: Way forward: key challenges and solutions

Participants broke into country groups to review lessons learned from the workshop,

challenges faced with regards to HWTS and strategize on follow-up actions. In all three

countries HWTS is addressed either as a standalone strategy (Ghana) or included in other

health strategies / policies (Ethiopia and Kenya). Common challenges shared amongst all

14

three countries are: low resource mobilization; weak coordination at sub-national level; weak

field monitoring and evaluation systems; and weak engagement of the private sector.

Common priority action points from the three countries were to:

Strengthen national working groups on HWTS (e.g. more regular meetings, clear terms of

reference and expected deliverables, and periodically meet with wider stakeholders in

WASH to present on progress made and exchange knowledge);

Develop national standards for HWT;

Develop more comprehensive certification framework for HWTS products, taking into

account microbiological performance; and

Advocate for reduced import taxes / tax waivers for HWTS products.

A fourth group comprising manufacturers and distributors of HWTS products also discussed

challenges faced within the sector and potential solutions. From this group there was

discussion on what ‘engaging the private sector’ means at a practical level. Key challenges

highlighted were that the private sector is largely seen as seeking solely to make profit and is

excluded from decision-making and discussion fora, and this consequently has an impact on

implementation of HWTS, including:

Technology choice and accessibility: An example shared was that chlorine disinfectants

and flocculant-disinfectants are considered as public health products and as such, import

tax waivers for these HWT technologies can be obtained. However, these waivers are not

applicable to other HWT technologies such as filters. Importers of these technologies have

no platform through which they can engage with relevant government officials to obtain

similar waivers, and consequently pay import taxes of between 25-39 %. This ultimately

results in a limited range of HWT technologies being available.

Monitoring and evaluation of field use: data collected by manufacturers or their

implementers is not shared with governments as there are limited platforms / channels of

communication.

The group recommended the following: the private sector should be included in discussion

and decision making fora on HWTS; HWTS is a preventive health intervention, and as such,

HWTS products should be categorized as health products and that national standards for

HWT performance be established.

15

Conclusion

Specific recommendations and commitments are summarized at the beginning of the report.

In closing, Dr Batsi Majuru and Mr Waltaji Kutane thanked participants for their

contributions to the workshop, and highlighted that follow up will be made on the

commitments from the various countries, and shared with the Network. Mr Dangew Tadesse

closed the workshop.

16

Appendix 1: Workshop agenda

WHO/UNICEF International Network on Household Water Treatment and Safe

Storage

Inter-regional workshop on: Strengthening evaluation, regulation and implementation of

Household Water Treatment and Safe Storage

Agenda

Jupiter International Hotel, Addis Ababa, Ethiopia

3-5 May 2016

Workshop objectives

Review status and implementation of national strategies and polices on HWTS, including existing

approaches to addressing HWTS in emergencies;

Share lessons learned in policy formulation and implementation; and

Discuss key needs and solutions in improving HWTS implementation, including: product

performance evaluation and regulation, monitoring and evaluation of use, and utilizing lessons

learned to improve implementation approaches.

Day 1: Tuesday 3 May

08:30-09:00 Registration

09:00-10:00 Opening ceremony and workshop overview

09:00-09:20 Opening remarks Dr Paul Mainuka,

Officer in Charge,

WHO Ethiopia

Dr Samuel Godfrey,

Chief of WASH,

UNICEF Ethiopia

Dr Taye Balcha,

Head Office of State Minster,

Federal Ministry of Health

09:20-09:40 Introduction of participants Dangew Tadessa,

Ministry of Health Ethiopia

09:40-09:55 Workshop objectives and overview Batsi Majuru,

WHO

09:55-10:00 Group photo All

10:00-10:30 Coffee break

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10:30-11:30 Session 1: The big picture: water quality and

health

Moderator:

Kebede Eticha

10:30-10:45 Water quality and health: A look at the evidence Anna Murray,

Tufts University

10:45-11:00 An overview of the drinking-water safety

framework

Batsi Majuru,

WHO

11:00-11:30 Discussion

11:30-13:00 Session 2: Status of HWTS strategies and policies Moderator:

Akosua Kwakye

11:30-11:45 HWTS implementation in Ethiopia: status and key

challenges

Dangew Tadessa,

Ministry of Health

11:45-12:00 HWTS implementation in Ghana: status and key

challenges

Kweku Quansah,

Ministry of Local

Government and Rural

Development

12:00-12:15 HWTS implementation in Kenya: status and key

challenges

Benjamin Murkomen,

Ministry of Health

12:15-13:00 Discussion

13:00-14:00 Lunch

14:00-15:15 Session 3: Promoting HWTS: approaches and

knowledge dissemination

Moderator:

Batsi Majuru

14:00-14:15 Promoting HWTS in Ethiopia: Experiences and

lessons

Alemayehu Tegegn,

PSI

14:15-14:30 The HWTS knowledge base Paul Earwaker,

CAWST

14:30-15:15 Roundtable: Successful approaches to behavior change communication

15:15-15:45 Coffee break

15:45-17:00 Session 4: Accelerating access to HWTS:

distribution options

Moderator:

Solomon Nzioka

15:45-16:00 Pathways for distribution of HWTS Hester Foppen / Lemessa

Mekonta,

Aqua for All and IRC

16:00-16:45 Discussion: Engaging utilities in distribution of HWTS

16:45-17:00 Wrap up

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Day 2: Wednesday 4 May

09:00-09:15 Recap Day 1

09:15-10:30 Session 5a: Strengthening evaluation and

regulation of HWT performance

Moderator:

Kebede Eticha

09:15-09:45 WHO performance recommendations for HWT and

the Scheme

Batsi Majuru,

WHO

09:45-10:00 Strengthening HWT certification: Example from

Haiti

Anna Murray,

Tufts University

10:00-10:30 Discussion

10:30-11:00 Coffee break

11:00-12:30 Session 5b: Strengthening evaluation and

regulation of HWT performance

Moderator:

Waltaji Kutane

11:00-11:15 Evaluating and regulating HWT in Ethiopia:

Experiences and challenges

Seyom Wolde,

FMHACA

Almaz Gonfa,

EPHI and

11:15-11:30 HWT evaluation and regulation in Ghana:

Experiences and challenges

Genevieve Baah,

Ghana Standards Authority

11:30-11:45 HWT evaluation and regulation in Kenya:

Experiences and challenges

Benjamin Murkomen,

Ministry of Health

11:45-12:30 Discussion

12:30-13:30 Lunch and exhibition of HWT products

13:30-15:00 Session 5c: Strengthening evaluation and

regulation of HWT performance

Moderator:

Anna Murray

13:30-14:30 Country group discussion: key needs and challenges

for strengthening HWT evaluation and regulation

All

14:30-15:00 Presentation and discussion of key needs and challenges

15:00-16:30 Learning visit to EPHI laboratory

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Day 3: Thursday 5 May

09:00-09:15 Recap Day 2

09:15-10:30 Session 6: Monitoring and evaluating HWTS use Moderator:

Benjamin Murkomen

09:15-09:30 Monitoring and evaluation of HWTS and using data

to inform improved implementation

Alex Doyen,

LifeStraw

09:30-09:45 Monitoring HWTS use: Lessons from selected

countries

Anna Murray

Tufts University

09:45-10:00 Water quality monitoring in Ethiopia Balew Yebel,

Ministry of Water, Irrigation

& Energy

10:00-10:30 Discussion

10:30-11:00 Coffee break

10:30-12:30 Session 7: HWTS as part of broader WASH

response in emergencies

Moderator:

Kebede Eticha

10:30-11:30 Roundtable discussion: Key needs for strengthening HWTS in emergencies

11:30-12:30 Session 8: Way forward: key challenges and

solutions

Moderator:

Batsi Majuru

11:30-12:30 World café: country group sessions All

12:30-13:30 Lunch

13:30-16:00 Session 8 continued: Way forward: key

challenges and solutions

Moderator:

Waltaji Kutane

13:30-14:30 The shopping bag: Country group reflections on

‘take home’ messages

All

14:30-15:15 Presentation of shopping bags (over coffee) All

15:15-15:45 Workshop evaluation All

15:45-16:00 Closing remarks Dangew Tadessa

17:00-19:00 Closing cocktail at Jupiter International Hotel

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Appendix 2: List of participants

Name Organization Country

Suzzy Abaidoo Ministry of Water Resources, Works and

Housing

Ghana

Genevieve Baah Ghana Standards Authority Ghana

Emmanuel Dzotsi Ministry of Health Ghana

Akosua Kwakye World Health Organization Ghana

Kweku Quansah Ministry of Local Government and Rural

Development

Ghana

Adam Mohammed Ali Ministry of Health Kenya

Doyle Birika Ministry of Health Kenya

Benjamin Murkomen Ministry of Health Kenya

Samuel Wairia Ministry of Health Kenya

Solomon Nzioka World Health Organization Kenya

Alexandar Doyen Vestergaard Kenya

Paul Earwaker Centre for Affordable Water and Sanitation

Technologies

Kenya

Abiy Girma Ministry of Water, Irrigation and Energy Ethiopia

Ashagire Cherinet Regional Health Bureau Ethiopia

Desalegn Gullo SNNR Regional Health Bureau Ethiopia

Umata Negassa Oromia Regional Health Bureau Ethiopia

Dawit Siraw Addis Ababa Regional Health Bureau Ethiopia

Seyoum Wolde Ethiopian Food, Medicine and Health Care

Administration and Control Authority

Ethiopia

Almaz Gonfa Ethiopian Public Health Institute Ethiopia

Kirubel Tesfaye Ethiopian Public Health Institute Ethiopia

Zufan Abera Damtew Federal Ministry of Health, Ethiopia Ethiopia

Goitem Medhien Federal Ministry of Health, Ethiopia Ethiopia

Dagnew Tadesse Federal Ministry of Health, Ethiopia Ethiopia

Solomon Yimer Federal Ministry of Health Ethiopia

Wondeossen Assefa SETEMA Plc Ethiopia

Mesefin Saheles FMOH/GSF Ethiopia

Tadesse Wordofa AAFM&HC Ethiopia

Kebede Eticha World Health Organization Ethiopia

Waltaji Kutane World Health Organization Ethiopia

Kulule Mekonnen World Health Organization Ethiopia

Osman Yiha World Health Organization Ethiopia

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Name Organization Country

Tewolde Birhanu Save the Children International Ethiopia

Bekele Damte Aqua for All Ethiopia

Gashaw Kebede Plan International Ethiopia

Biyazen Lake Bishan Gari PLC Ethiopia

Andrew Smith Desert Rose PLC Ethiopia

Arto Suominean COWASH Ethiopia

Alemayehu Tegegne Population Services International Ethiopia

Admasu Tesfaye Soyar Filter Ethiopia

Demelahi Woylen Tulip Filters Ethiopia

Raju Gondar University Ethiopia

Yirga Ambaw USAID Ethiopia

Melese Bekele World Vision Ethiopia

Yohannes Hagos Day One Response Ethiopia

Gashaw Kebede Plan International Ethiopia

Menassie Kifle Citrus International Trading PLC /Aquatabs Ethiopia

Lemessa Mekonta IRC-WASH Ethiopia

Shibabaw Tadesse Save the Children Ethiopia

Samel Gonfafay United Nations’ Children’s Fund Ethiopia

Tamene Gossa United Nations’ Children’s Fund Ethiopia

Happy Rugogwe Helioz GMBH Austria

Hester Foppen Aqua for All Netherlands

Anna Murray Tufts University United States of America

Batsirai Majuru World Health Organization Switzerland

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Participants on the first day of the workshop

Photo credit: WHO Ethiopia/Biniyam Fisseha

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Appendix 3: Summary of group discussion on regulation

1. What are the potential benefits of having national regulation of HWTS products?

Ghana Kenya Ethiopia (1) Ethiopia (2)

Quality control of

products on the market

Protection of public

health

Make post-market

surveillance easier

Improved knowledge

of HWTS technologies

Reduction in

counterfeits products

Increase product

efficacy

Compliance enhanced

Level ground for

investors

Consumer protection

Improved health /

livelihood

Value for money

Safety of the products

Important for safety,

quality, and efficacy of

products

Creates competition for

supply

Sustainable supply and

distribution

Regulatory agency

should differentiate

between products

which work and don’t

work

Ensures the quality,

safety, and efficacy of

the products

2. What are potential difficulties/drawbacks to having national regulation of HWTS products?

Ghana Kenya Ethiopia (1) Ethiopia (2)

Inadequate human/

material resources

Lack of standards

Lack of political will

Time and money /

Weak enforcement

Capacity (human,

materials, equipment)

Weak coordination

Might discourage

some stakeholders

Regulation doesn’t

solve any problem

3. Who should be involved in developing a regulation framework?

Ghana Kenya Ethiopia (1) Ethiopia (2)

Ministry of Local

Government and

Rural Development

(lead ministry

responsible for

HWTS)

Ministry of Water

Ghana Standards

Authority

Ministry of Health,

Food & Drugs

Authority, Ghana

Health Service

Government

Consumer

Manufacturer

Distributers

GSO

NGOs

Donor groups

Political institutions

Ethiopian Food,

Medicine and Health

Care Administration

and Control Authority

Federal Ministry of

Health

Ethiopian Public

Health Institute

Standards Authority

Ministry of Finance

Ministry of Water,

Irrigation and Energy

Private sector

(manufacturers,

distributers,

importers)

NGOs

UN

Public sector

Private sector

NGOs

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4. What are potential barriers to creating and implementing a regulation framework?

Ghana Kenya Ethiopia (1) Ethiopia (2)

Long procedures in

enacting laws

Lack of control at

unauthorized routes

(borders)

Low knowledge on

HWTS products

Inadequate human

resource capacity

Interferences

(traditional authorities,

politicians)

Low political will

Conflicting interests

with the players

Lack of champion of

HWTS regulation

Expertise / capacity to

implement

Global market

dynamics

Lack of national

standards for HWT

performance, and

comprehensive

regulation

Limited access to

accredited

laboratories

There is no clear

mandate on regulation

of HWTS –

particularly filters

There is no capacity

to perform

performance

evaluation tests

Getting enough

budget to perform the

tests

Tax exemption

5. What components, beyond laboratory efficacy testing, would be useful to evaluate for HWTS

products?

Ghana Kenya Ethiopia (1) Ethiopia (2)

User-friendly

instructions

Field evaluation data

Submission of dossier

from manufacturers

(i.e. composition of

chemical products,

quality control

information)

Instructions / labelling

Clarity / simplicity of

use

Lot number/expiry

date (for chemical

products)

Materials safety

Independent reviews

with clear guidelines

provided to the

Technical Working

Group

Dossier on system

(product information)

User-friendliness

(cultural, beneficiary

perception, ease of

use)

Availability of the

product

Safe storage should be

considered

Robustness of the

product to the local

water (including

durability)

Simplicity of

operation