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Water safety Water safety frameworks in frameworks in
developing developing countries: countries:
science-policy science-policy linkageslinkagesDr Guy Howard, DFIDDr Guy Howard, DFID
Policy and sciencePolicy and science
Policy requires evidence – the role of Policy requires evidence – the role of sciencescience
BUT BUT other factors – social, ethical, other factors – social, ethical, political also importantpolitical also important
SO SO policy often policy often evidence-informed evidence-informed rather than rather than evidence-basedevidence-based
Policy works through formal and Policy works through formal and informal processes informal processes don’t get fixated on policy documentsdon’t get fixated on policy documents
Policy and science – fraught Policy and science – fraught with mis-understandingwith mis-understanding
Scientists think policy-makers do not Scientists think policy-makers do not follow evidencefollow evidence
Policy-makers think scientists Policy-makers think scientists narrow techniciansnarrow technicians
Further complicated when science isFurther complicated when science is Limited in its development in-countryLimited in its development in-country Small number of ‘voices’ dominateSmall number of ‘voices’ dominate Limited operational research of policy Limited operational research of policy
relevancerelevance
Water safety framework – Water safety framework – science and policy in actionscience and policy in actionWater safety framework comprises Water safety framework comprises
(WHO 2004):(WHO 2004): Health-based targetsHealth-based targets Water safety plansWater safety plans SurveillanceSurveillance
Driven by improving public healthDriven by improving public health Also Also allows transparent trade-offs allows transparent trade-offs Applied in BangladeshApplied in Bangladesh
Health-based Health-based targets and targets and
quantitative risk quantitative risk assessmentassessment
Bangladesh contextBangladesh context
In early 1990s reached 97% coverage In early 1990s reached 97% coverage in rural areas (WHO & Unicef 2000) – in rural areas (WHO & Unicef 2000) – contribution to reduced diarrhoeacontribution to reduced diarrhoea
1993 arsenic first detected1993 arsenic first detected Survey (1999-2000) indicates 27% Survey (1999-2000) indicates 27%
tubewells >50tubewells >50µg/l and 46% >10 µg/l µg/l and 46% >10 µg/l (BGS& DPHE 2001)(BGS& DPHE 2001)
Blanket testing shows 29% > Blanket testing shows 29% > 5050µg/l µg/l (about 20% of country total)(about 20% of country total)
Policy contextPolicy context
Technologies identified for use in Technologies identified for use in mitigation mitigation Dug wells Dug wells Rainwater harvesters Rainwater harvesters Pond sand filters Pond sand filters Deep tubewells Deep tubewells Arsenic-removal technologiesArsenic-removal technologies
Surface water use prioritisedSurface water use prioritised Priority given to 1Priority given to 1stst 3 technologies 3 technologies
Others only to be used when these failedOthers only to be used when these failed
Risk substitutionRisk substitution
These policy choices equate to ‘Specified These policy choices equate to ‘Specified technology Health-based targets’technology Health-based targets’
BUTBUT no consideration given to risk no consideration given to risk substitutionsubstitution PathogensPathogens Cynaobacterial toxinsCynaobacterial toxins Other chemicals (natural or anthropogenic)Other chemicals (natural or anthropogenic)
QHRA undertaken to estimate impact QHRA undertaken to estimate impact of these risks and benefits of policy of these risks and benefits of policy choiceschoices
RAAMO method RAAMO method (abbreviated)(abbreviated)
Representative set of main technologies tested Representative set of main technologies tested monsoon & dry season using cluster samplingmonsoon & dry season using cluster sampling
Model developed with output in DALYs for Model developed with output in DALYs for microbial & arsenic risksmicrobial & arsenic risks
3 ‘reference’ pathogens 3 ‘reference’ pathogens Composite model bacteria, cryptosporidium and Composite model bacteria, cryptosporidium and
rotavirusrotavirus Input data from indicator organisms - derived Input data from indicator organisms - derived
relationships to pathogensrelationships to pathogens Arsenic disease burden input data direct Arsenic disease burden input data direct
arsenic measurement and focus on main arsenic measurement and focus on main health outcomeshealth outcomes
Infection withRotavirus, Shigella,
Cryptosporidium
Volume ofwater consumedunboiled locally
[Pathogen] in sewage
Dose of pathogens
[E. coli] in sewage
Ratio[pathogen]:[E. coli]
Ratio[TTC]:[E. coli]
Measured[Arsenic]for option
Measured[TTC]
for option
Predicted[E. coli]
for option
Predicted[pathogen]for option
Cancer of lung, bladder and skin
Measured[TTC]locally
Measured[E. coli]locally
Disease Burden for option
Inputs to or outputs from
the model
Model process steps
Model architecture (Howard et al Model architecture (Howard et al 2007)2007)
Results: Microbial DALYsResults: Microbial DALYs
TechnologyTechnology Dry seasonDry season Monsoon Monsoon seasonseason
Dug wellDug well 1.111.11-2-2 1.341.34-2-2
Deep Deep tubewelltubewell
6.986.98-5-5 1.261.26-3-3
Pond sand Pond sand filterfilter
1.071.07-2-2 1.31.3-2-2
Rainwater Rainwater harvesterharvester
6.486.48-3-3 3.733.73-3-3
0.01
0.1
1
10
100
1000
10000D
W(d
)
DW
(w)
DTW
(d)
DTW
(w)
PS
F(d)
PS
F(w
)
RW
HS
(d)
RW
HS
(w)
STW
Arsenic Mitigation Options
Ars
enic
DA
LY
, 1
0^-6
LCL Median UCL
Results: arsenic DALYsResults: arsenic DALYs
WHO reference level of WHO reference level of riskrisk
GDWQ suggests reference levels of GDWQ suggests reference levels of risk can be used in setting health-risk can be used in setting health-based targetsbased targets
Suggested 10Suggested 10-6-6 DALYs – broadly DALYs – broadly equivalent to 10equivalent to 10-5-5 lifetime cancer risk lifetime cancer risk used in chemical guideline derivationused in chemical guideline derivation
Conceptually elegant, but poses Conceptually elegant, but poses practical problems practical problems E.g real-life considerations of impact of E.g real-life considerations of impact of
diarrhoea & cancerdiarrhoea & cancer
RAAMO findings RAAMO findings reference riskreference risk
Microbial contaminants Microbial contaminants Reference risk not achievable for any Reference risk not achievable for any
technologies year-roundtechnologies year-round Arsenic standard already much higher Arsenic standard already much higher
DALY score than WHO reference riskDALY score than WHO reference risk Not clear how useful the concept of Not clear how useful the concept of
‘reference risk’ is in such ‘reference risk’ is in such circumstancescircumstances
Better to use comparative measures & Better to use comparative measures & aim for best achievable resultaim for best achievable result
Changes in practice & Changes in practice & policypolicy
Chlorination on dug wells and PSFs Chlorination on dug wells and PSFs increasingly standard – overcame previous increasingly standard – overcame previous resistanceresistance
Led to re-emphasis by implementing Led to re-emphasis by implementing agencies on technologies with lower health agencies on technologies with lower health riskrisk
Review of National Policy and Review of National Policy and Implementation Plan now initiatedImplementation Plan now initiated
Water safety plansWater safety plans
Identified as critical to improving Identified as critical to improving water safety from RAAMOwater safety from RAAMO
O&M failures particularly highlighted O&M failures particularly highlighted in relation to microbial qualityin relation to microbial quality
In principle agreement by all major In principle agreement by all major players that should be followedplayers that should be followed
BUT needed locally relevant WSPs with BUT needed locally relevant WSPs with evidence in-country of their evidence in-country of their effectivenesseffectiveness
The process that was The process that was followedfollowed
National conference on water quality National conference on water quality Government, donors & NGOs agree need Government, donors & NGOs agree need
for pilot projects for pilot projects Workshop to develop a set of draft Workshop to develop a set of draft
WSPs for rural technologiesWSPs for rural technologies Govt, donors, NGOs involvedGovt, donors, NGOs involved
Pilot projects to apply WSPs Pilot projects to apply WSPs Consolidation of experience and Consolidation of experience and
revision of WSPsrevision of WSPs
Developing the WSPsDeveloping the WSPs
Generic WSPs Generic WSPs developeddeveloped Cover all water Cover all water
supplies with supplies with particular particular technologytechnology
Developed using Developed using proformas & proformas & existing knowledge existing knowledge and experienceand experience
Systematic Systematic assessment of: assessment of: hazards, hazards, degree of risk, degree of risk, control measures, control measures, monitoring, monitoring, validation and validation and verificationverification
Actions plans Actions plans developeddeveloped
Technologies consideredTechnologies considered
Protected dug Protected dug wellswells
Pond sand filtersPond sand filters Rainwater Rainwater
harvestersharvesters Deep tubewellsDeep tubewells Shallow Shallow
tubewellstubewells
Piped systemsPiped systems From tubewellFrom tubewell From surface From surface
water after multi-water after multi-stage filtrationstage filtration
Gravity-fed Gravity-fed (minor)(minor)
LaterLater Arsenic removal Arsenic removal
systemssystems
Pilot projectsPilot projects
3 NGOs covering 82 communities 3 NGOs covering 82 communities across Bangladesh (also Unicef/GoB)across Bangladesh (also Unicef/GoB)
Every major technology addressedEvery major technology addressed Baseline, intermediate and final Baseline, intermediate and final
water quality assessments water quality assessments undertakenundertaken
Community caretakers supported Community caretakers supported with pictorial monitoring toolswith pictorial monitoring tools
Key findingsKey findings
Reductions in sanitary risks for all Reductions in sanitary risks for all technologiestechnologies
Microbial quality improvedMicrobial quality improved Water handling hygiene practices Water handling hygiene practices
improved improved 12% reduction in diarrhoeal disease 12% reduction in diarrhoeal disease
in one pilot projectin one pilot project Greater caretaker accountabilityGreater caretaker accountability Pictorial tools found usefulPictorial tools found useful
Water quality risk grading Water quality risk grading schemescheme
Count per Count per 100ml100ml
CategoryCategory CommentsComments
00 AA Very low riskVery low risk
1-101-10 BB Low riskLow risk
11-10011-100 CC Intermediate riskIntermediate risk
101-1000101-1000 DD High riskHigh risk
>1000>1000 EE Very high riskVery high risk
0
5
10
15
20
25
30
35
40
45
50
Baseline Final
Dug wells: water quality
Low & v.low
Medium
High & v.high
Evidence to practiceEvidence to practice
All major water rural programmes All major water rural programmes committed to WSPscommitted to WSPs
Moved into 2Moved into 2ndnd edition – regular edition – regular interactionsinteractions
Capacity support offered via ITN-Capacity support offered via ITN-BUET (training, consultancy)BUET (training, consultancy)
See See www.buet.ac.bd/itnwww.buet.ac.bd/itn
Key lessonsKey lessons
Bangladesh showed possible to get Bangladesh showed possible to get wide stakeholder buy-inwide stakeholder buy-in
Important to get all major players Important to get all major players agreed on single set of products and agreed on single set of products and approachesapproaches
Need to develop more standardised Need to develop more standardised approachesapproaches More cost-effectiveMore cost-effective Consistency and coherenceConsistency and coherence
SurveillanceSurveillance
Surveillance protocol developed and Surveillance protocol developed and approved by GoBapproved by GoB
Limited but practicalLimited but practical Emphasis on cost-effective survey Emphasis on cost-effective survey
methodsmethods Very difficult to implementVery difficult to implement
Funding for monitoring scarce and Funding for monitoring scarce and veryvery limitedlimited
ImplicationsImplications
RAAMO & WSPs showed could get RAAMO & WSPs showed could get change in policy and practicechange in policy and practice
BUTBUT also highlighted informal as also highlighted informal as well as formal policy processeswell as formal policy processes Formal policies relative recent so no Formal policies relative recent so no
immediate change likelyimmediate change likely Water & Sanitation Program now Water & Sanitation Program now
leading process of formal policy leading process of formal policy reviewreview
Future challengesFuture challenges
Climate change and impacts on Climate change and impacts on water supply and sanitationwater supply and sanitation
DFID/WHO funding joint work DFID/WHO funding joint work Decadal forecasting to 2020 and 2030Decadal forecasting to 2020 and 2030 Assessment of technology susceptibilityAssessment of technology susceptibility
Focus on ‘hotpsots’ and longer-term Focus on ‘hotpsots’ and longer-term policy implicationspolicy implications
ConclusionsConclusions
Bangladesh water safety frameworkBangladesh water safety framework Good illustration of policy-science Good illustration of policy-science
interactionsinteractions Uncertainty could be managed provided Uncertainty could be managed provided
transparent and quantifiedtransparent and quantified Evidence based practice importantEvidence based practice important Highlighted value of informal as well as Highlighted value of informal as well as
formal policy processesformal policy processes This type of approach needs wider This type of approach needs wider
replicationsreplications