Optimising the Monitoring and Assessment of

Rural Water Supplies

Jamie Bartram

September 1996

Submitted in Part-fulfillment for the Degree of

Doctor of Philosophy
(c) Jamie Bartram, 1996
 Abstract

Access to a safe, reliable water supply is essential for development and for health. In
rural areas there is a shortfall in water supply, infrastructure failure is common and
community-management , although often ineffective, predominates.

Water supply monitoring is poorly-focused upon information needs for management

and often originates from a regulatory-enforcement ethic little applicable to rural
areas .

This work critically appraises water supply service monitoring and assessment. It
focuses upon piped supplies outside the established market economies and examines a
series of case studies which are geographically and organisationally diverse to assess
the contribution of monitoring to abatement of health risks.

A conceptual framework is presented for five linkages, determined by the information

product user, between information from monitoring and improved water supply
services.

Monitoring and assessment are shown to influence water supply service quality and
two information-action linkages - concerning overview assessments for policy
development and prioritisation of major interventions - are shown to be effective.
Monitoring programmes are poorly-optimised to 'drive' these. Two linkages
(concerning external operation and maintenance and regulatory enforcement) are
ineffective or inapplicable. Monitoring supportive of community management is
potentially effective but present trends and policy orientations militate against its
application.

The effectiveness of information-action linkages and further evidence from the case
studies are used to explore implications for information generation. These include
advantages of adopting stratified two-stage sampling, combining 'served' and 'un-
served' populations and addressing both accessibility and quality issues. Further
implications are discussed with respect to information for management, policy,
legislation and regulations and institutional aspects.

Some of this work has been published previously by the author and has been widely
accepted, becoming the underlying structure of the second edition of WHO
'Guidelines for Drinking-water Quality Volume 3: Surveillance and Control of
Community Supplies ' of which the author was technical coordinator and a major
contributor.
 Acknowledgments

The author owes a debt of thanks to the many individuals and institutions which have,
in different capacities, supported the work described in the case studies presented in
this thesis. They are too numerous to cite individually. It is hoped that this work will
contribute to furthering the cause in which they are involved.

Particular thanks are due to Prof D Stubbs and Dr Richard Helmer, co-supervisors, for
their patience and for maintaining faith in eventual completion.

Three further individuals have contributed in different ways and at different stages of
development of this work and the author would like to recognise them individually.
Dr B Lloyd was a close colleague throughout the early stages. The many discussions
we had exploring the boundaries and context of the subject which ranged between the
practical and the moral and ethical did much to assist in the development of a context.
He should also be recognised for strongly promoting the inclusion of institutional
aspects in the work described here. Thanks are also due to Dr David Wheeler for
being a consistent source of constructive criticism and providing the foil to the above
and to Mr Guy Howard for acting as a valuable sounding board and for occasional
prolonged discussion.

Finally , thanks are due to Jane, for believing this could be finished even when I did
not and to Joe, born half way through the work, for thinking it was a nice idea I was
writing a book even when it kept us apart.
 Contents

Volume I
Page Number

Section 1: Introduction 1
1.1 Water and Health 7
1.1.1 Scale of impact of water supply on health 8
1.1.2 Nature of the relationship between water and
human health 11
1.1.3 Relative importance of different aspects of drinking
water supply services for health 15
1.1.4 Indicators of water supply service quality 18
1.2 Problem Statement 20
1.2. l The rate of system failure 21
1.2.2 Rates of investment 22
1.2.3 Changing roles in water supply 23
1.2.4 Community management 25
1.2.5 Information for sector management 26
1.2.6 Monitoring and assessment 28
1.3 The Study 30
1.3.l Purpose of the study 30
1.3.2 Nature of work undertaken and structure of the
thesis 32

Section 2: A Conceptual Framework for the Linkages Between

Monitoring and Assessment Information and
Improved Water Supply 34
2.1 Overview Assessment 36
2.2 Prioritisation of Major Interventions in Existing Water
Supplies 39
2.3 Support for Operation and Maintenance by Formal Water
Supply and Construction Authorities 41
2.4 Enforcement of Standards 44
2.5 Support to Community-based Management 46

Section 3: Testing the Information-Action Linkages 49

3.1 Overview Assessment 50
3.2 Prioritisation of Major Interventions in Existing Water
Supplies 66
3.3 Support for Operation and Maintenance by Fonnal Water
Supply and Construction Authorities 76
3.4 Enforcement of Standards 84
3.5 Support to Community-based Management 91
Section 4: Data Acquisition 101
4.1 Indicators of Water Supply Quality 102
4.1.1 Coverage l 02
4.1.2 Continuity l 08
4.1.3 Quantity 110
4.1.4 Quality 114
4.1.5 Cost 116
4.1.6 Conclusions regarding indicators of preference 117
4.2 Approaches to Data Acquisition 117
4.2.1 General approach 119
4.2.2 Community selection 122
4.2.3 Within-community sampling frames 124
4.2.4 Seasonal problems with water quality data 127
4.2.5 Sampling frames for water quality sampling 128
4.3 Data Collection 132
4.3.1 Sanitary inspection and interview 133
4.3.2 Water quality analysis 136

Section 5: Information 146

5.1 Information for Decision-makers 146
5.2 Data Presentation and Decision-aids 149
5.2.1 Interpretation and presentation of data concerning
water quality 150
5.2.2 Combined indices of service quality 151
5.3 Information Management Systems 155

Section 6: The Organisational Context 159

6.1 Implications for Policy 160
6.1.1 Present trends in policy 160
6.2.2 The impact of monitoring and assessment upon
policy 162
6.2 Legislation and Regulations 165
6.3 Institutional Frameworks 172
6.3.1 Sectoral and inter-sectoral coordination 173
6.3.2 Institutional responsibility for monitoring and
assessment 177
6.3.3 Training and human resource development 180

Section 7: Summary of Conclusions 187

References 192
Volume JI: Annexes 227

Annex 1 Egypt: Status assessment for Egypt 227

Annex 2 Nepal: Monitoring in an NGO rural water 237

supply project in rural Nepal

Annex 3 Pakistan I: An NGO rural water supply 243

project in Pakistan

Annex 4 Pakistan II: Status assessment for Pakistan 251

Annex 5 Peru I: A governmental programme for monitoring 264

and improvement of rural water supplies in Peru

Annex 6 Peru II: Water supply assessment by a self-help 272

development association in rural Peru

Annex 7 Romania: A governmental assessment of rural 277

water supply Romania

Annex 8 Yemen: Status assessment for Yemen 279

Annex 9 Colombia: Environmental monitoring and institutional 285

roles in post-disaster development in Colombia
 Abbreviations

CAH Consejo Aguaruna y Huambisa (Peru)

CPE Continuing Professional Education
COOPOP Cooperacion Popular (literally ·popular cooperation', a Peruvian
Government initiative supportive of rural communities)
DISABAR Direccion de Saneamiento Basico Rural (Directorate of Basic Rural
Sanitation), Peru.
DITESA Direccion Tecnica de Saneamiento Ambiental (Technical
Directorate for Environmental Sanitation, Peru)
EEAA Egyptian Environmental Affairs Agency
EHAP Environment and Health Action Plan
EPA Environment Protection Agency
EPC Environment protection Council (Yemen)
ESA External Support Agency
FAO United Nations Food and Agricultural Organization
GAREW General Authority for Rural Electricity and Water (Yemen)
GDEH General Directorate of Environmental Health (Yemen)
HACCP Hazard Assessment Critical Control Point
HIPH Higher Institute of Public Health (University of Alexandria)
HRD Human resource development
IDWSSD International Drinking Water Supply and Sanitation Decade
IUCN International Union for the Conservation of Nature
KWSB Karachi Water and Sewerage Board
lpd litres per person per day
NEHAP National Environment and Health Action Plan
NIH National Institute for Health
NGO Non-governmental organisation
NOPWASD National Organisation for Potable Water and Sanitary Drainage
(Egypt)
NWSA National Water and Sanitation Authority (Yemen)
ORDEV Organisation for the Reconstruction and Development of the
Egyptian Village (an Egyptian Government Agency)
PCRWR Pakistan Council for Rural Water Resources
PCSIR Pakistan Council for Scientific and Industrial Research
PEPA Pakistan Environmental Protection Agency (federal)
PEPC Pakistan Environment Protection Council
PHC Primary Health Care
PHED Public Health Engineering Department (Pakistan)
SENAPA Servicio Nacional de Agua Potable y Alcantarillado (National Water
Supply and Sewerage Service), Peru.
UN United Nations
UNCED United Nations Conference on Environment and development (Rio
de Janeiro, June 1992)
UNDP United Nations Development Programme
UNEP United Nations Environment Programme
UNICEF United Nations Children's Fund
WB World Bank
 Section 1:

Introduction

'The maintenance and improvement of health should

be at the centre of concern about the
environment and development '
(WHO, 1992a p xiii).

The availability of an adequate, safe water supply has important implications for
economy, social development and health and for the stability of cultures and
civilisations (Engelman and LeRoy, 1993). It is regarded as one of the most vital of
all resources by virtually every community world-wide; but is paradoxically
associated with much illness and death (Lane, 1996). Achievements in water resource
management generally - and in drinking water supply and quality in particular -
underlie the unprecedented increase in economic and social welfare in many
developing countries (World Bank and UNDP, 1995) and improvements in water
supply and sanitation are a proven way of improving the living conditions of the poor
(Anon, 1990a; Anon, 1992b ). Inadequate water availability will prevent or at least
greatly hinder development (Kaul and Mathiason, 1982), patterns of demand related to
phases of development are recognised (Orloci, 1985) and it is suggested that without
sufficient water, economic development becomes virtually impossible and conflict
over scarce resources virtually inevitable (Engelman and LeRoy , 1993) .
Whilst the magnitude and to a lesser extent nature of benefits (and occasional dis-
benefits) of water supply remain a subject of contention, their overall benefit and
importance for development are largely unquestioned. Thus for example it has been
suggested by the Director General of the World Health Organiz.ation that 'no single
type of intervention has greater overall impact upon national development and public
health than the provision of safe drinking water and the proper disposal of human
excreta' (Anon, 1995 p5) . At a practical level, the economic impact of water-related
disease is dramatically illustrated by the cholera outbreak in Latin America. In Peru,
the total economic cost was estimated to be greater than three times the total national
investment in water supply and sanitation improvement in the 1980s (IRC, 1992a).
As a result, water supply programmes form important components of national
development plans, of nationally and internationally-supported development
programmes and of community-based, charity and non-governmental organisation
(NGO) projects world-wide. In Pakistan's eight year plan for example, investment
was contemplated to raise coverage with improved water supply in rural areas to 70.5
per cent from 47 per cent and for 85 to 90 per cent in urban areas (Government of
Pakistan, 1993).

Whilst water supply per se is the focus of this work, it is difficult to disentangle
drinking water supply from water resource management more generally (Postel 1985;
World Resources Institute, 1993). In the rural sector, the linkages between
agricultural water use and water needs for water supply and sanitation are especially
clear (Okun and Lauria, 1992; Anon, 1992b; Engelman and LeRoy, 1993; Kandiah,
1995). Rapid development in the use of water in recent decades has lead to the
increasing recognition that quality and quantity aspects are effectively inseparable
(Bartram and Ballance, 1996) has led to the increasing spread of wastes of many types
and a general decrease in the quality of the aquatic environment affecting particularly
and most seriously the world's poor (Briscoe 1992; Engelman and LeRoy 1993;
Briscoe 1993). In the rural sector a vicious circle of water quality and quantity
deterioration - ill health - decreasing productivity - greater need to exploit resources
regardless of long-term cost entraps the rural poor (IRC, 1992a). Solutions to the

2
water supply problems of such populations will only be found within a framework of
poverty alleviation (Najlis, 1996). Against this backdrop the world faces a looming
water crisis with frightening social and financial implications (Postel, 1992;
Shiklomanov, 1993; World Resources Institute, 1993). Real price increases of around
300 per cent per decade have become the norm in many parts of the world, whilst it is
projected that by the year 2025 one of every three people will be living in countries
where there is water stress or chronic water scarcity (World Bank and UNDP , 1995;
see also Tyler-Miller, 1991 and Postel, 1992).

The importance of water supply to development is attested by the level of attention it

attracts from the international community. The commentary and declarations from the
periodic international meetings addressing it therefore chart the evolution of thinking
and approaches, including perceptions of priorities, successes and failures.

At the United Nations Water Conference, held at Mar del Plata, Argentina in 1977 and
which initiated the International Drinking Water Supply and Sanitation Decade
(IDWSSD or 'Water Decade') it was resolved that ·... member states should be
encouraged to prepare programmes to provide all people with water of safe quality
and in adequate quantity and basic sanitary facilities by 1990, according priority to
the poor and less privileged' (Anon, 1977). The IDWSSD, 1980 - 1990 was therefore
intended to represent a period of unprecedented advance in water supply provision
through concerted global effort. However the l 980's became a decade of global
recession, less multi- or bi- lateral funds were available than may have been otherwise
and national and international pressures on governments led to funds being diverted
from these activities. In addition, demographic growth necessitated considerable
investment in order to maintain percentage coverage figures; and the increasing
numbers of existing, and therefore deteriorating, water supply systems required an
ever-increasing investment in operation and maintenance - and in rehabilitation and
extension.

3
After ten years of unprecedented activity, the New Delhi 'Global Consultation on Safe
Drinking Water and Sanitation for the 1990s' (Anon, 1990a) provided governments,
external support agencies (ESAs) and the professional community an opportunity to
reflect on the IDWSSD. Whilst to some extent these reflections concerned the
successes and failures in achieving always-ambitious targets, it was also a perhaps
unprecedented opportunity to take stock and 'learn lessons' from the rapid
development of experience that had occurred in the Decade. It was concluded that the
IDWSSD had accelerated and advanced knowledge of the sector and that much could
be gained from the analysis, documentation and sharing of experience. Eight key
themes were identified which recurred in different parts of the world and which were
therefore seen as the major lessons learned from the Decade:
• focus on poverty (serving the un-served);
• building capacity (the promotional role of government);
• meeting demand (understanding what people want and are willing to pay for);
• sharing cost (appropriate pricing as a means to improve sector performance) ;
• technical innovation (a range of options to meet demand);
• women (sound reasons for emphasis);
• monitoring (extended coverage with achievable goals); and
• co-ordination (building national and international collaborative networks) (Anon ,
1990a).

Some of these have subsequently been well-addressed in national and ESA-driven

activities. This is especially the case with the cluster concerning meeting demand,
sharing cost and technical innovation which are reflected in the trend towards a
demand-driven approach, increasingly adopted in recent years (see for example
Gibbons et al 1996); and also that concerning the need to emphasise the role of
women (see for example Sims, 1994; IRC, 1995b). Others have found less fertile
ground and conspicuously those concerning the role of government, monitoring and
national co-ordination have attracted relatively little activity .

4
The International Conference on Water and the Environment, Dublin 1992, provided
the major input on freshwater problems to the UN Conference on Environment and
Development (UNCED), with the objectives of: freshwater resource status assessment
related to demand; developing co-ordinated sectoral approaches; formulating
environmentally sustainable strategies to present to UNCED; and to bring these to the
attention of governments. It worked through six working groups, one of which
considered 'water for sustainable food production and rural development and drinking
water supply and sanitation in the rural context'. The statement arising from the
conference noted four guiding principles:
• Freshwater is a finite and vulnerable resource, essential to sustain life,
development and the environment.
• Water development and management should be based upon a participatory
approach, involving users, planners and policy-makers at all levels.
• Women play a central part in the provision , management and safeguarding of
water.
• Water has an economic value in all its competing uses and should be recognised as
an economic good (Anon , 1992a).

With respect to rural water supply, the Dublin Statement also noted that the rural
population must have better access to a potable water supply and to sanitation services
and that whilst an immense task, it was not an impossible one, provided appropriate
policies and programmes are adopted at all levels - local national and international. It
is interesting to note - and to contrast with subsequent events as outlined later in this
thesis - that this statement essentially embodies two elements: that water supply for
the rural population is a high priority and that improving such services requires a
conducive policy environment. As discussed later in this introduction, whilst most of
the 'un-served' population of the globe is rural, most of the investment in extension of
water supply during the Water Decade was made in the urban sector . A call for better
data was one of further major products of the conference.

5
The United Nations Conference on Environment and Development (UNCED) marked
part of the trend towards viewing environmental issues as part of an integrated whole
rather than in compartments. It placed water supply as one part of competing human
uses making quality and quantity demands of water resources and of importance for
socio-economic development, which should be satisfied whilst preserving ecosystems;
and emphasised integrated planning for water resources planning and management.
The outcomes of UNCED included proposals for seven programme areas related to
freshwater, one of which was drinking water supply and sanitation and another water
for sustainable food production and rural development. Amongst activities
recommended in order to achieve drinking water supply and sanitation the report
included:
• participatory management involving users, planners and policy-makers;
• support and assistance to communities in managing their own systems on a
sustainable basis;
• the need for linkages between national plans and community management;
• the need to emphasise under-served rural populations (repeated for the programme
area concerning sustainable food production and rural development);
• rehabilitation of defective systems;
• strengthening of sector monitoring and information management at sub-national
and national levels; and
• improvement of sector co-ordination, planning and implementation with the
assistance of improved monitoring and information management (Anon, 1992b).

UN CED also recommended the establishment of national goals for water supply and
sanitation coverage, as had been recommended during the IDWSSD. Whilst
sometimes interpreted as a tacit admission that the goals of the Decade had not been
reached (IRC, 1995a), it may also be seen as a re-affirmation of the high importance
given to provision of drinking water.

In 1994, two years after the UNCED Conference, the Government of the Netherlands
hosted an international inter-ministerial conference at Noordwijk on drinking water

6
and environmental sanitation with the aim of ensuring that there would be genuine
follow-up to the recommendations concerning protection of the quality and supply of
freshwater resources coming from UN CED (IRC, 1995a; IRC, 1995b; IRC, 1995c). A
key theme underpinning the Conference was that access to water was a basic human
right but that shortage of clean water meant epidemics, hunger, despair and death for
many. As such it assisted in placing human health in the forefront. Five main points
were identified for governmental action :
• Freshwater is a finite, vulnerable and endangered resource.
• Access to water is an economic necessity as well as a human right.
• One of the serious threats to freshwater comes from inadequate human sanitation.
• The most important contribution a government can make is to create a positive
atmosphere to encourage co-operation among all concerned.
• Financial resources are limited, but can be made to go further than they presently
do (IRC , 1992a) .

Amongst the recommendations arising from Noordwijk, it was recommended that

governments produce an inventory of the current situation to identify problems and
constraints in providing water supply. The conference specifically reiterated the
importance of reliable national data on various aspects of water supply and sanitation
and recommended that governments establish nation-wide monitoring systems (IRC,
1995c).

1.1 Water and Health

'Water contributes much to health '

Hippocrates

There are numerous and now well-documented problems associated with assessing the
health impact of improvements in water supply provision and the disease burden
associated with inadequate supply (see for example World Bank 1976; Blum and
Feachem 1983; Esrey et al 1985; Briscoe et al 1986; Kirkwood and Morrow 1989;

7
Esrey et al 1991). The difference between the two is sometimes overlooked. It is a
common confounding factor in the interpretation of findings regarding the former and
is important in a sector where identifying the effectiveness of interventions is a greater
priority than proving cause-effect linkages (Renwick , 1973).

A review of the problem s of designing and undertaking health impact studies is

beyond the scope of this work. Nevertheless, some consideration of the health
dimension of water supply is necessary and this section therefore reviews evidence
concerning the scale of impact of water supply on health, the nature of the relationship
between water suppl y and health; the relative importance of different aspects of
drinking water supply services for health; and indicators of water supply quality .

1.1.1 Scale of impact of water supply on health

The overwhelming importance of infectious disease in relation to the adequacy of
drinking water supply is recognised and there is acceptance of this by the water supply
and scientific communities (Esrey et al, 1985; Hartemann et al, 1986; WHO , 1993). It
has been argued that chemical aspects of drinking water quality are almost irrelevant
where gross bacteriological contamination of water for consumption occurs (WHO,
1984; Regli et al 1993) and for this reason the emphasis of this thesis is on infectious
water-related disease .

The assessment of risks associated with variations in microbiological quality is

difficult because of the multi-factorial nature of disease, and lack of epidemiological
evidence (WHO, 1984). It is recognised that 'answers to basic questions such as
"what are the precise transmission routes of the various diarrhoeal agents within the
home?" ... remain largely unknown' (Anon, 1990a). Assessment of risks associated
with inaccessibility of water for personal and domestic hygiene is more problematic
and supported by a lesser bank of epidemiological evidence. The fact that the health
impact of inadequate water supply services, especially in the developing world has
never been established is recognised (Troare, 1992) and recent work highlights
unrecognised health burdens elsewhere (Payment et al 1991; Payment et al 1993).

8
Furthermore the benefits of improved water and sanitation are likely to have a
multiplier effect by acting on the morbidity and mortality rates of different diseases
and age groups. This is suggested by studies showing much greater impact of water
and sanitation improvements on life expectancy than would be expected on the basis
of reduction in one cause of death (Briscoe, 1987).

Many commentators appear to perceive it to be valid to highlight the importance of

water-related disease and there is therefore a tendency to present attention-grabbing
statistics and commentary. Thus for example in a quote from a UNDP official cited at
the beginning of the Water Decade it is suggested that: 'half of the infants that die in
the world each year die from water-borne diseases. Eighty per cent of all diseases in
the world are water-related Half of all hospital beds in the world are occupied by
people with water-borne disease' (Bourne, 1982). More recently the Director General
of the World Health Organization has stated that:
'Every eight seconds a child dies from a water-related disease. Every year more
than five million human beings die from illnesses linked to unsafe drinking water,
unclean domestic environments and improper excreta disposal. At any given time
perhaps one half of all peoples in the developing world are suffering from one or
more of the six main diseases associated with water supply and sanitation
(diarrhoea, ascariasis, dracunculiasis, hookworm, schistomosomiasis and
trachoma). In addition the health burden includes the annual expenditure of over
10 million person-years of time and effort ... in carrying water' (Anon, 1995)

Comments such as these which imply or claim dramatic impacts of inadequate water
supply on health - whilst widely cited and quoted and effective in drawing attention to
the theme - are difficult to substantiate. Furthermore, whatever the arguments
concerning the burden of disease associated with (generally inadequate) water supply,
this does not necessarily demonstrate that interventions in water supply (or sanitation,
or hygiene, or a combination of these) will relieve all of this. The importance of
assessing the impact of interventions rather than demonstrating cause-effect or
estimating of the burden of disease associated with water leads to a logical focus upon
testing abatements rather than proving cause-effect linkages which is in line with

9
thinking in water supply and sanitation (Esrey et al 1991), environmental health more
broadly (Renwick, 1973; Goldstein, 1995), and arguably research more generally
(Rantanen, 1992). It is also illustrated by the sanitary movement of the last century -
driven by an understanding of the effectiveness of interventions rather than of the
germ theory of disease (see for example Acheson, 1990) and recent work both outside
and within the established market economies.

The often-quoted reviews of health impact studies by Esrey et al ( 1985, 1991), like
that of Cairncross ( 1990b) suggest that water and sanitation improvements can reduce
the overall incidence of infant and child diarrhoea substantially (in the range 15 - 36
per cent for single or combined interventions) and total infant and child mortality
substantially. Whilst the figures are aggregates and based upon individually location-
specific studies, they do provide an indication of the abatement capacity of specific
interventions in developing countries . Nevertheless an important conclusion , noted in
the reviews cited above, was that health impact studies were not an operational tool
and could not be used for project orientation or evaluation. In this they supported
similar earlier conclusions such as that of the World Bank (1976).

Over recent years evidence has started to accumulate that water which fulfils
microbiological standards may have a health impact. Payment et al (1991, 1993)
reported a 35 per cent reduction in gastrointestinal illnesses in a population consuming
water treated by reverse osmosis when compared with a control group consuming the
same water without such treatment and which fulfilled water quality standards.
Limited evidence also relates to Hepatitis A (Lagarde et al, 1995). The general
observation is also supported by emerging evidence of very low infectious doses for
several important pathogens and particularly Giardia /amblia (Regli et al, 1991),
Cryptosporidium parvum (DuPont et al, 1995) and some viruses (Rose and Gerba,
1991; Haas et al, 1993). The primafacie implication is that microbiological and
disinfection water quality standards provide significant protection against outbreaks of
disease, but only partially control the background rate of disease arising from

10
consumption of drinking water; and contradicts much contemporary sector
commentary (see for example Hartemann et al, 1986).

1.1.2 Nature of the relationship between water and human health

One of the most fundamental developments in ' sector wisdom ' regarding the
interactions between water and health was the development of a categorisation of
disease based in terms of how an intervention would change the situation (Bradley,
1974; Bradley and Emurwon, 1968). Four fundamental categories of disease were
identified, as follows:

Water-borne disease transmission occurs when a pathogen or noxious chemical is

contained in water which is consumed. This includes all of the faecal-oral diseases
and therefore many causes of diarrhoea as well as cholera, typhoid and hepatitis A.

Water scarcity or water-washed diseases arise from transmission which can be

reduced by increased water use for personal and domestic hygiene. Since faecal-oral
disease transmission may be interrupted by personal and domestic hygiene this group
includes many of the infectious water borne diseases in addition to eye infections and
infections and infestations of the skin.

Water-based disease occurs through transmission of a pathogen with an obligatory

aquatic intermediate host or hosts. Examples include the schistosomes and Guinea
worm. The latter is also water borne but is not water-washed.

Water-related insect vector diseases involve transmission by insects which breed in

water or which live and bite near water. This group includes malaria since its insect
vector breeds in water and the arthropods which carry the viruses which cause dengue
and yellow fever.

11
These mechanisms are not necessarily mutually exclusive. Most infectious water-
borne disease for example is also water washed (being transmitted by the faecal-oral
route) (Bartram and Ballance , 1996).

There is also a series of secondary and indirect health benefits which may arise from
improved water supply services and dis-benefits associated with inadequate water
supply. They are of three inter-linked types :
• the effects of ill health (from both the water supply per se and the act of securing
water from alternative sources) ;
• time and energy saved or lost (arising from both ill health and from time spent in
water collection and household management) ; and
• financial (through cost of care for ill health and sometimes from purchase of
water).

Contact with water bodies (which may transmit water contact diseases such as
schistosomiasis or be associated with water habitat vector diseases such as
onchocerciasis (river blindness) may be reduced significantly. Schistosomiasis is
associated with water contact, principally through agriculture and domestic water
collection. Whilst prevalence is high in males, there is some evidence to suggest that
the severity of disease, which is related to the intensity of infection and therefore
frequency of exposure affects especially women. Regular and frequent exposure
during water collection may therefore be the cause of higher egg counts in women
than in men and decreasing egg count with age in adult males (Anyangwe et al 1992;
Nwaorgu, 1992).

In many rural areas in developing countries women are typically those responsible for
household water management and water collection in particular. It is not uncommon
for women to spend 15 per cent or even 25 per cent of their waking hours carrying
water (Anon, 1990a). It has been reported that on the eastern slopes of Mount Kenya
energy used to fetch water may represent 85 per cent of total daily energy intake
(Dufaut, 1990) and a typical woman who is breast feeding and responsible for water

12
collection has to use most of her available (daytime) energy for these tasks (lsely,
1980). The act of carrying water itself is also associated \\'ith health effects such as
cranial depression, increased rates of fractures, slipped discs and knee damage as well
as various forms of damage to the vertebral column, depending in part on the carrying
method employed (see for example Dufaut, 1990). In Bangladesh 50 per cent of the
people treated for broken necks fell while carrying a heavy load (such as water) on
their back. The impact of carrying water from source to the home is reduced through
the availability and use of more accessible water sources. Improved water supply may
also be associated with indirect health effects - for instance by freeing time which can
for example be dedicated to child care (Krishna, 1990).

Improved water supply may raise productivity through reducing time spent on
collection from distant sources, by reducing the costs of household treatment
(disinfectants, boiling) or costs associated with securing alternative household
provision (such as private wells). Economically, health effects may result in the
inability to work caused through an acute effect or acute exacerbation of a chronic
health effect (Brieger et al 1989; Watts et al 1989), or may lead to decreased
productivity especially as a result of chronic parasitic infections such as S. mansoni
(Parker, 1992). Reduced productivity may be manifest in economically-productive or
other activity. The latter includes activities related to water collection and
management and hygiene (Sims, 1994).

Both direct and indirect health effects are closely inter-related. Thus for example time
demands for water collection increase pressure to utilise more accessible (but
potentially more contaminated) nearby sources of water; and the time and energy costs
of fetching water govern women's perceptions of the importance of hygiene in disease
prevention and take priority over them in practice (Kendie, 1992).

Diverse social benefits may also accrue which are largely independent of the quality
of the water supply service per se. Thus for example Krishna (1990) reports
breakdown in patterns of class-based segregation and decreased importance being

13
given to the veiling of women in some areas in addition to time savings. Others have
indicated accelerated political maturity , gender equality, community cohesion and
national identity (IRC, 1992b ). Time, energy and other savings derived from
improved water supply accrue particularly to women and children and children may
be more likely to attend school (Falkenmark, 1982).

Investments in water supply

and sanitation

Safe water supply

and excreta
disposal
irect
Maintenance and Effects
expansion

Quality /
Economic quantity
development
Production
increase
Marketing
Work capacity/
knowledge

Food
Education
Hygiene facilities Health benefits from:
• improved nutrition
• community and personal
hygiene
• interruption of the
transmission of water-borne
disease

Figure I Direct and indirect effects of water supply and sanitation on health: a conceptual
framework (after Cvjetanovic, 1986)

14
A conceptual framework for the direct and indirect effects of water supply and
sanitation on health, which brings together the issues raised above has been proposed
by Cvjetanovic ( 1986) and is presented here as Figure 1.

1.1.3 Relative importance of different aspects of drinking water supply services

for health
Discussion of the relative importance of the different parameters of drinking water
supply has been polarised into the 'quality-quantity' debate for many years. It is
conspicuous that those who lead the reappraisal, such as Feachem in light of work in
Lesotho (Feachem et al, 1978), consistently emphasise the multi-factorial nature of the
transmission of diarrhoeal disease (Feachem, 1983; Feachem , 1984; Esrey et al,
1985).

One important aspect which is often overlooked in this debate is that all changes in a
parameter (quality or quantity for example) are not equal. Thus the diseases which
respond to changes in water supply service quality and the extent to which they
respond will depend on the nature and extent of the change and the range in which it
occurs (Esrey et al 1985).

The multi-factorial nature of faecal-oral infection has been emphasised above and it is
therefore encouraging that a more sophisticated theoretical model has emerged which
encompasses all aspects of hygiene. This model proposes a 'threshold-saturation' dose
response relationship for individuals exposed to pathogens transmitted by the faecal-
oral route (Shuval, 1981; Esrey, Feachem and Hughes 1985). This provides a model
for considering the impact of individual interventions on ingested dose and both
incidence and severity of resulting infections, summarised in Figure 2.

15
 High

Incidence
Severe
rate of
Diarr-
diarrhoea hoea
among
young
children
Mild
Diarr-
A B hoea
low

Dose of Enteric Pathogens Ingested

< low high >

Figure 2 Dose response relationship for young children at various levels of response to an array of
enteric pathogens. Adapted from Esrey et al, 1985.

Important theoretical implications of this model are:

• At high levels of pathogen dose (E-F) an intervention which results in only
moderate reduction in pathogen load may have little impact on the incidence of
either severe or mild diarrhoea.
• At moderate/high levels of pathogen dose (D-E) only the incidence of severe
diarrhoea may be reduced
• At moderate/ low levels of pathogen dose (B-D) both severe and mild diarrhoea
incidence may be reduced, but at different rates.

At a practical level the principal implication of this work is that greatest public health
gains are to be obtained by focusing activity in areas of greatest water related disease
prevalence and where environmental health conditions are worst (Bartram, 1996).

16
Whilst recognising the tentative and simplified nature of the model, its proposers were
able to point to various areas in which it appeared to be verified by published studies.

Several authors have attempted to suggest a relative weighting for the value of
different types of intervention on water-related disease incidence based on scientific
opinion or consensus. Thus for example Feachem (1982), by summing his estimated
relative scores on a scale of zero (no importance) to three (great importance) for
different interventions in controlling the principal 'Decade-related infections',
developed a rough guide to the overall relative importance of preventive measures,
which had evolved substantially by the following year (Feachem, 1983). The
weightings proposed were as follows:
Feachem, 1982 Feachem, 1983
water quality 14 11
water availability 22 18
excreta disposal 27 25
excreta treatment 23 15
personal and domestic cleanliness 22 18
drainage and sullage disposal 6 6
food hygiene 17 17

Whilst through an exhaustive critical appraisal of published health impact studies,

Esrey and co-workers (Esrey et al, 1985; updated Esrey et al 1991) found the results
summarised in Table 1.

Whilst it is germane to note the general accord between these two broad approaches,
the point raised earlier in this section - ie that all changes in a parameter (whether
water quality, water quantity or other) are not equal - should be recalled. Rigorous
scientific analysis is unlikely to provide a clear indication of the general health impact
of different water supply interventions, or predictively of a single or combination of
interventions in a specific circumstance (Cairncross, 1990a).

17
Table I Percentage reductions in diarrhoeal morbidity rates from improvements in one or more
components of water and sanitation (after Esrey, et al, 1991)

All Studies Rigorous Studies

Reduction Reduction
n* (o/o) n* (%)
Water and sanitation 7/11 20 2/3 30
Sanitation 11/30 22 5/ 18 36
Water quality and quantity 22/43 16 2/22 17
Water quality 7/16 17 4/7 15
Water quantity 7/15 27 5/10 20
Hygiene 6/6 33 6/6 33
• The first figure relates to the number of studies suitable for use in calculating the median, the second
the total number of studies considered

The emphasis upon generalised weightings of this type may also undervalue the
importance of the quality criterion, because of the ability of piped water supplies to
propagate outbreaks of disease (Bartram, 1996). Whilst it has been suggested that
most outbreaks of water-home disease are not identified unless at least one per cent of
the population in a community becomes ill within a few months (Regli et al 1991),
large-scale outbreaks such as those caused by Cryptosporidium in Milwaukee (Hayes
et al, 1989) and hepatitis, India (Ramalingaswamu and Purcell, 1988) and the
outbreaks of cholera in Latin America (Craun et al, 1991) clearly attest the importance
of this and are unaccounted for in studies such as those described above which
investigate the 'stable' situation. The effect of quality during extreme disruptions,
whether seasonal or related to natural disasters may also be underestimated
(Ramalingaswami and Purcell, 1988).

1.1.4 Indicators of water supply service quality

The fundamental parameters of water supply were defined at the UN Conference on
Water, Mar del Plata, Argentina (Anon, 1977) at which it was declared that 'all
peoples, whatever their stage of development and their social and economic

18
conditions have the right to have access to drinking water in quantities and of a
quality equal to their basic needs'. This declaration established the basic parameters
for judging the adequacy of water supply services and it is important to note that
emphasis was given to accessibility and equal importance placed upon quality and
quantity of water supplies. As early as 1986, upon recognition of substantial problems
with sector monitoring , WHO had repeatedly suggested that water supply could be
judged on the basis of quality, quantity, convenience and continuity of service (WHO,
1976; WHO, 1984). Finally, in recognition of economic barriers to access, the Dublin
Statement, resulting from the International Conference on Water and the Environment
declared in one of four guiding principles that: 'water ... should be recognised as an
economic good and that 'it is vital to recognise first the basic right of all human
beings to have access to clean water ... at an affordable price' (Anon, 1992a).

Substantial resources are devoted to improving water availability (including quantity)

and attempts are made to monitor trends in this regard (Espinosa, 1989; Watters,
1990). However comparatively little effort has been expended in assessing the actual
quality of water supply services in less-developed countries (Lloyd and Helmer,
1991). The greatest problem in judging the adequacy of services, particularly in rural
areas of less-developed countries has been the practical difficulty of assessing water
supply service quality (ibid).

A major development was therefore the development and field testing in 1986 and
publication in 1987, of a proposal to employ five quantifiable indicators in assessing
water supply service quality (Lloyd et al, 1987). The principal contribution of this
work was to propose quantifiable measures of 'accessibility'. The proposed indicators
were:
• Coverage: percentage of the total population served.
• Continuity: hours per day and days per year that water is available.
• Quantity: volume per capita per day available for domestic use.
• Quality : principally by faecal contamination and sanitary inspection.
• Cost: tariff paid per month for domestic use.

19
These service indicators were first employed in Peru, were rapidly adopted elsewhere
in Latin America (Power, 1986; Pickering, 1990; Bartram et al, 1991) and were tested
in a series of pilot projects in Indonesia, Africa and Latin America (Lloyd and
Helmer, 1991 ).

Limited evidence now suggests that multiple indicators are being increasingly used in
programme management decision-making. Gibbons et al (1996) for example cites
need-based eligibility criteria as including 'water scarcity, water quality and distance
to source ' and this broader approach is achieving wider acceptance (Bartram, 1996).

1.2 Problem Statement

The International Drinking Water Supply and Sanitation Decade provided

opportunities for sector professionals to develop, apply and assess diverse approaches
to sector development. In doing so, perhaps the most common single experience was
the problems faced by Government agencies in attempting to service often remote
rural village water supplies (Appleton, 1995b).

As a result of the IDWSSD and other initiatives, world-wide water supply physical
infrastructure has increased dramatically in recent decades. Coverage with water
supply globally was estimated to be 68 per cent in 1990 (Anon, 1990a). Coverage as
of 1995 has recently been estimated as 66 per cent - less than the figure five years
previously - despite 156 nations and every UN body adopting the year 2000 target of
universal coverage established at the World Summit for Children (Anon, 1995). To
what extent this represents real decrease in percentage coverage and to what extent it
is a reflection of the use of more stringent reporting criteria is unclear since re-
assessment of earlier figures has lead to gross change. The global population without
access to a safe water supply in 1990 has been re-estimated as 1.58 billion, rather than
1.2 billion (Najlis, 1996). Population growth creates obvious challenges upon

20
increased provision of safe drinking water (reviewed by Engelman and LeRoy, 1993),
whilst advancements during the Water Decade have enabled some reduction in unit
costs (see for example IRC, 1995b) and are important factors affecting the rate of
closure of the un-supplied population gap , as are the rate of system failure and the rate
of investment.

1.2.1 The rate of system failure

The deterioration of this accumulated water supply infrastructure - of increasing
importance as the total 'capital' increased (Bays, 1992) - became a widely-recognised
issue towards the end of the IDWSSD. Thus the need to increase attention to
sustainability of water supply service provision generally and to operation and
maintenance in particular is considered to be one of the principal lessons that may be
learned from the Decade (IRC, 1995b; Gibbons et al, 1996).

The extent of infrastructure failure in rural areas should not be underestimated.

Figures in the range 40 to 60 per cent of point source infrastructure being non-
functional are often reported (Troare, 1992) and reliable sources frequently quote
figures as high as 80 per cent. Thus for example in 1981, WHO and UNICEF were
citing that in the mid-l 970's there were handpump installation schemes where over 80
per cent of the handpumps were out of order after between three months and a year
(Beyer, 1990) and one UNICEF study estimated 80 per cent of rural water supply
infrastructure in India and Asia to be 'non-operational' (Watters, 1990). More
recently, an official of the Swedish Foreign Ministry is quoted as saying that in the
Swedish rural water programme in Tanzania and Kenya 'after 15 years of quite
considerable investment in piped water and mechanical pumping equipment, hardly
more than 10 per cent of our installations are still in use ' (cited in Pickford 1991,
p155). Work in the Region ofTolima, Colombia showed that although water quality
was extremely poor and considerable infrastructure for water treatment existed, no
water treatment plant in the study area (which included both urban and rural
communities) was operational (Bartram et al 1991).

21
Infrastructure failure relates not only to breakdown (ie interruptions to supply), but the
fact that small and private supplies, especially in rural areas, are more frequently
contaminated. Failure of supply and contamination are often connected (Bartram,
1996).

1.2.2 Rates of investment

In 1992 it was estimated that of expenditure on water supply and sanitation in the
period 1981 to 1990, 55 per cent was spent on water and 45 per cent on sanitation
(Anon, 1992a). Amongst the discussions concerning statistics arising from the Water
Decade some simple facts are often overlooked:
• a large majority (80 per cent) of the estimated 1.2 billion people lacking access to
a safe water supply at the end of the Decade lived in rural areas (Appleton,
1995b);
• the cost of water supply to rural areas is higher than in urban areas;
• notwithstanding the importance of burgeoning urbanisation world-wide, the
urban:rural ratio of investment during the Water Decade was 74:26 (WHO, 1992b)
and investment had been skewed to the urban sector since before the Decade
(Cajina, 1978).

Information regarding the present overall levels of investment in water supply and
sanitation is contradictory. Apparently sound sources claim either that since the end
of the Decade overall investment in water supply and sanitation has been declining,
due to donor fatigue, economic recession and competition with other development
sectors and other factors (Anon, 1995); or that over the past decade, the level of
investment has been growing (Gibbons et al 1996). Certainly country examples of
both increase and decrease exist and in Peru (one of the case studies addressed in this
thesis), for example, overall social expenditure (including investments in water supply
and sanitation) decreased from 49 to 12.5 US$ per capita between 1980 and 1993
(Zucchetti, 1994).

22
Finally, it should be recalled that external financial assistance, whilst small in
comparison to national contributions (Le Moigne, 1996), has a large influence on how
national finances are directed (Okun and Lauria, 1992). Most external finance is
provided for the development of new facilities (Robinson, 1991). In Africa for
example around 25 per cent of funding derives from national sources and the
remainder from external funding agencies. This places the system intended to ensure
continued functioning of existing infrastructure under greater stress (Taylor, 1993). In
this context it is relevant to recall that the primary limiting factors on development of
water supplies in Africa (Hartvelt and Okun, 1991), and elsewhere (Okun and Lauria,
1992), have been a lack of capacity in the least developed countries and in the
external support agencies to develop and utilise the available resources effectively.

1.2.3 Changing roles in water supply

Recent years have seen a fundamental change in the recommendations provided by the
international community to national governments regarding optimal means for
provision of drinking water supply services, paralleling changes in the political world
order. There has been a paradigm shift since the Water Decade with respect to the
role of government in water supply provision. The new paradigm emphasises
reduction of direct government action; the importance of private sector participation
and funds; community involvement; and the role of government as a regulator and
facilitator. The 'new' way of thinking is exemplified by the following quotation:
'Past experience in water and sanitation illustrates the limitations of direct
government provision of household services. Despite technical progress in
developing affordable engineering solutions to the problems of water, sanitation,
drainage and housing, the delivery and maintenance of these services, especially
by governments, have been disappointing. At the end of the International Water
Supply and Sanitation Decade (the 1980's), most people in the poorer regions of
the world still lacked sanitation, and the number of urban residents without water
had not been reduced

Supply-side failures are largely caused by inefficient and unresponsive public

sector monopolies which, in the water sector, typically provide subsidised services

23
 at between one third and two thirds of the full economic cost. Massive public
investments, often supported by the donor community and the World Bank, have
been made in public or quasi-public agencies responsible for the delivery and
maintenance of household services. The net result has often been bloated public
agencies with low accountability to their customers and few incentives for
improving efficiency; a middle class that is increasingly well-served with
subsidised services; a poorer class that receives little or no service; and a ripe
environmentfor political patronage ' (World Bank, I 993 ).

No attempt is made here to analyse the veracity of claims such as these or of the
evidence to support recommended adjustments. Whilst the Bank continues to note the
importance of public sector involvement it makes no concrete proposals for the
generation of such a system, especially with regards to the role of public institutions.
Major initiatives in which it and other agencies are involved, such as the UNDP-
World Bank Water and Sanitation Programme promote private sector and NGO
activity to the almost entire exclusion of Government (the most recent annual report of
the Programme (Gibbons et al 1996) illustrates this clearly). Nevertheless, at the
behest of various international meetings (Anon, 1990a, Anon, 1992a; Anon, 1992b ),
the role of Government and of Ministries of Health or their equivalent in water supply
is being radically re-assessed and changed and little evidence is available for external
support for governments in adapting to their to their new roles.

Much of the new thinking may be traced back to 'lessons learned' during the
IDWSSD. It is therefore interesting to note that the New Delhi Conference, which
concluded that Decade, made clear recommendations for a positive role for
government in creating the 'enabling environment', in setting standards and in
monitoring performance targets, especially to promote service provision to peri-urban
areas and rural communities (Anon 1990). Other agencies have also been positive
regarding the need for governments to adopt a new role and to accommodate changes
resulting from initiatives driven by this new thinking. The Director General of the
World Health Organization for example highlights facilitation, including establishing

24
regulatory, training and financial environments' (Anon, 1995), as did the Noordwijk
Conference (IRC, 1995c).

1.2.4 Community management

The trend established prior to the IDWSSD of advocating direct community
management of small and especially rural water supplies has continued (Anon, 1990a;
Anon, 1992a; Anon, 1992b), not least because of the widely held view that attempts to
manage operation and maintenance through centralised governmentally-controlled
organisations have proven unsustainable (Appleton, 1995b ). Furthermore community
management of water supplies remains the most common form of water supply
management in rural areas outside the established market economies (IRC, 1995b).
Thus the New Delhi report notes that community management has become the
cornerstone of attempts to sustain services in rural areas (Anon, 1990a).

Whilst the thrust toward community management has now been increasingly in
fashion for more than 20 years and is rarely questioned, the observation levelled by
Feachem at the beginning of the Water Decade remains valid: most positive
experience with community management of water supplies in rural areas remains at
the level of pilot or demonstration projects (Feachem 1980). The costs of
extrapolating to comprehensive national coverage may well be prohibitive and whilst
this is the case the international community is failing to provide a direction for
effective provision of water supply services to rural areas.

There is a danger that - caught between the evolution of thought regarding the role of
government described in Section 1.2.3 and the failure to identify and support realistic
strategies for comprehensive support to community management - rural communities
and especially those with piped water supplies will benefit from neither governmental
regulatory nor facilitatory functions.

In many developing countries prior to the IDWSSD, the Ministry of Health was
responsible for both water supply surveillance and for construction of (principally

25
rural) water supplies. It therefore suffered a conflict of interests in having
responsibility for monitoring its own undertaking. Resources for implementation
(such as field staff and laboratory facilities) would often be deployed indiscriminately
between the two functions. Proposed changes which reduce government action in
water supply per se go some way to alleviate the intrinsic conflicts this situation
posed.

1.2.S Information for sector management

The need for reliable information for establishing national policy, legislative
frameworks, institutional structures and economic instruments has been
emphasised at the Dublin and Noordwijk Conferences (Anon, 1992a; Anon,
1995c); and others (Troare, 1992; Anon, 1995). Yet even within a single State,
monitoring conducted under one law may duplicate that conducted under another
(Troare, 1992; WHO, 1994a; Ward 1995) and harmonisation of methods and
results is rare (WHO, 1994b; WHO, 1995).

During the period 1992 to 1994 the European Regional Office of the World Health
Organization made an unprecedented attempt to collect information with which to
generate a balanced and objective overview of the principal environmental issues of
present or potential concern for health. In doing so it concluded that, for one of the
more information-rich regions of the world, 'the exercise has shown the many
shortcomings of existing databases and systems for collection, collation, analysis and
dissemination ... Much data is fragmented, incomplete and of doubtful relevance ...
Much is collected and remains within separate administrations at central, regional
and local levels. Much monitoring seems to lack clear objectives and does not appear
to be used in decision-making/or environmental health management' (WHO, 1994a
p7). The key point is that not only are there problems with collection and analysis of
information, but monitoring is poorly orientated to support management decision-
making and this is endorsed by other commentators (Najlis, 1996). Monitoring of
water supplies cannot be justified by simply describing the situation and its

26
improvement or deterioration, but is justified by contributing to its improvement
(Bartram and Wheeler, 1990b ).

Even where data is available there is a tendency to a 'data rich/information poor'

syndrome in which, despite availability of data, we are unable to answer even basic
questions (Ward et al, 1986; Anon, 1990a). In an information-poor environment,
policy and strategy development occur in a partial vacuum and cannot be based upon
objective assessments. This is the case with orientation of external support for the
water supply sector (see Acheson, 1990 for example). At local level, management
decision-making suffers similar restrictions. Thus, the New Delhi consultation noted
that 'the absence of adequate information on water supply and sanitation at the
national level is still often a serious constraint to sector planning and management·
(Anon, 1990a).

The resulting problem has been succinctly described by the FAO/WHO Working
Group on Legal Aspects of Water Supply and Wastewater Management (Anon 1990b)
as follows:
'With regard to planning, the drinking water supply and sanitation sector suffers
from a general inability to translate policy priorities into operative actions and
plans; to ensure and safeguard the viability and sustainability of programmes
and projects; to assess the different altematives for the satisfaction of drinking
water supply and sanitation needs ... ; and to critically assess water supply and
sanitation standards commensurate to the problems, needs and resources of the
systems and resources which they serve. '

The immediate practical application of policy, for instance in targeting undeserved

populations has been highlighted (Mather, 1995; Bartram, 1996) which would be
identified by monitoring and assessment and the need for increased generation of
useful information products derived from monitoring and assessments is transparent
(Troare, 1992).

27
1.2.6 Monitoring and assessment
Monitoring in general originates from a broad scientific paradigm underpinning a
general quest for knowledge (Ongley, 1995; Ward, 1995) and has been described as a
cult of measurement (daSilva and O'Kane, 1989). The underlying motivation is
frequently (if not explicitly) scientific, although in the water supply sector this
generalisation is sometimes not maintained because water supply monitoring may be
dominated by legislative requirements, frequently orientated to the assessment of
compliance (daSilva and O'Kane, 1989) and primarily designed for an urban context.
Monitoring programmes world-wide are poorly focused upon sector information
needs or programme objectives (Platts, 1982; Ward et al, 1986; Adriaanse and
Lindgaard-Jorgensen, 1995).

The monitoring and assessment functions are poorly perceived amongst potential
users of their information product, notably engineers, planners and policy makers.
Without the support of these persons (ie without demand for the information product),
monitoring becomes expendable , fails to generate demand for its own information
product and spirals into a self..justifying decline in intensity, usefulness and output
(Ongley 1995; Ward 1995; Ward eta/, 1986). Symptomsofthisincludethe
expression of doubts regarding the value of investments in monitoring (Ward, 1995;
Council on Environmental Quality, 1980) as well as overt criticism of monitoring that
is not useful for decision-making (National Research Council, 1987; Hofstra, 1995).
The need for multi-sectoral participation in information contribution and exchange in
such systems is clear (Kandiah, 1995) and may contribute to the development of
inter-sectoral co-ordination.

As both cause and effect of the above, few if any countries outside the established
market economies have a clear and up-to-date assessment of their overall water supply
physical infrastructure and of population coverage (see for example Government of
Pakistan 1993). This is especially the case with regard to small towns/municipalities
and rural populations. The availability of information regarding the quality of
services provided through this infrastructure (such as accessibility or water quality) is

28
poorer than the availability of information concerning the infrastructure itself. The
limited available information suggests that regular surveillance of drinking water in
rural areas is rare in any developing country (Ward, 1990; Lloyd and Helmer, 1991)
and it has been claimed that not one third world country has yet established routine
water supply quality control of its rural supplies (Young, 1989).

Data sharing between, for example, water supply and health authorities is clearly
desirable (Troare, 1992) but rarely practised. The principal agencies producing
information concerning water supply service quality - or potentially doing so - are
those comprising the water supply sector and the health agency or whichever other
agency - such as local government - takes responsibility for independent surveillance.

The water supply sector is generally accepted to have a responsibility to monitor the
quality of the services it provides (WHO, 1984). The information it generates has two
principal limitations: firstly water supply sector monitoring activities are limited, by
their nature, to established, normally piped, water supplies and their served
population . Given that policy development may wish to emphasise un-served
populations, and that such populations represent approximately 46 per cent of the
global total (Anon, 1990a) this is a fundamental limitation. Secondly the sector is not
impartial - data is generated for limited management purposes and there may be an
unwillingness to share information, especially if there is an inadequacy in service
quality. Furthermore in many countries there is not a single entity that may be
described as 'the water supply sector' and which can provide consolidated
information. The sector typically comprises many, often small, water supply
organisations which may be poorly- or un- co-ordinated and networked (Okun and
Lauria, 1991). Finally, sector self-monitoring in the rural sector is often weak or
inexistent; especially where, as is commonplace, the 'supply agency' is a village
committee or equivalent.

Water supply surveillance, that is 'a policingfunction on behalf of the public, to

overseeoperations and ensure the reliabilityand safety of drinking water' (WHO,

29
1976), has traditionally been practised by Ministries of Health , although other
agencies, notably those concerned with environmental protection may adopt this role
in some States (ibid). It is noteworthy that this definition of water supply surveillance
specifically encompasses both safety (ie quality) and reliability. Whichever agency is
responsible for surveillance there is good reason for the authority to assume
responsibility for assessing the provision of drinking water to the population as a
whole (although this may not be common in practice), since 'un-served' populations
often represent those at particular risk (Bartram, 1996). The risk exists that ongoing
changes arising from changed governmental roles in water supply will reduce the
surveillance function to a level of ineffectiveness. In Romania, where these changes
are occurring at present, the diminished perceived importance of surveillance
coincides with a clear need for a strong surveillance function to oversee the activities
of many newly-created private water supply companies (Jacab, pers comm).

With regard to monitoring of rural water supplie s, at the beginning of the IDWSSD ,
WHO, recognising the special situation of rural communities and especially those in
developing countries, developed a specific approach to them. According to Helmer
(1990) :
'... in rural areas and small communities where standards have little meaning,
action plans need to be developed and implemented to improve the protection of
water supplies from bacteriological contamination. This requires regionally- or
locally-based systems linked to primary health care for raising public awareness
of the problem and possible solution, including the implementation of minimal
water quality surveillance and remedial measures relying on appropriate
technology and community participation. '

1.3 The Study

1.3.1 Purpose of the study

There is some evidence that budgets for support of monitoring have been decreasing
in recent years (Adriaanse, 1995; Ward 1990). In parallel there has been an increasing

30
recognition of the importance of generating information useful for decision-making
from monitoring (Adriaanse et al 1995; Ward 1995; Bartram and Ballance 1996).
Information needs of management need to be defined clearly and monitoring
programmes designed and implemented to collect the necessary information.

Similarly, whilst water supply and sanitation has remained high on the political
agenda, evidence suggests that coverage with improved water supply globally is in
fact decreasing (IRC, 1995a). Furthermore although the health benefits of
improvements in water supply and sanitation can be readily demonstrated,
investments in this sector do not give sufficient importance to health objectives
(Troare 1992; Anon, 1995). This situation is further aggravated by the aggressive
adoption of demand-driven approaches to the provision of rural water supply services.
Whilst clearly-defined health objectives and the adoption of a demand-driven
approach to service provision are not necessarily mutually exclusive, major initiatives
such as the UNDP-World Bank Water and Sanitation Programme have adopted
demand driven principles to the extent that health-based criteria are almost excluded
from operational decision-making (see for example Gibbons et al 1996).

The combined effect of the above require a radical re-appraisal of approaches to

monitoring, addressing information needs, data collection and use. The purpose of
this study was therefore to critically appraise and make proposals regarding
orientation of water supply monitoring activities. The work focused upon piped rural
water supplies outside the established market economies. This was achieved through:
1. Development of a conceptual framework for the linkages between the information
generated by monitoring of water supply services and improvement of those
services (and thereby health); including identification of the information product
users for each information-action linkage (Section 2).
2. Assessment of the use and effectiveness of each information-action linkage in
improving water supplies, through case studies and literature review (Section 3).
3. Assessing the implications of the work for approaches to, indicators for, and
methods used in, data acquisition (Section 4).

31
4. Assessing the findings of the work regarding generation and management of
infonnation (Section 5).
5. Considering the implications of the work for policy, legislation and regulations and
institutional frameworks in light of the experience gained with these aspects in the
case studies (Section 6).

Whilst many sections include discussion and conclusions, it should be noted that due
to the structured nature of the work , sections build on the conclusions of those
preceding them and experience from the case studies is introduced wherever
appropriate in the development of ideas and arguments. This document therefore
concludes with a summary of conclusions in Section 7.

1.3.2 Nature of work undertaken and structure of the thesis

The field work/data collection for this document has been undertaken over a period of
ten years and concerns ten case studies from eight countries. Several case studies
contributed relevant experience to each of the areas under investigation and most
studies contributed to more than one area. Whilst diverse in nature and not fully
geographically balanced, they are generally representative and provide a suitable basis
for the purpose of the work as described in Section l .3 .1. The basic characteristics of
the case studies, which are described in detail in Volume II: Annexes are as follows:
• Three (from Egypt, Pakistan and Yemen) are national status assessment reports
based upon intensive programmes of visits to the countries concerned for which
data was collected by interview, visits to offices and laboratories and field
observation.
• Three (from Pakistan, Nepal and Nicaragua) concern the role of monitoring and
assessment in support of major water supply initiatives by large international non-
governmental organisations (NGOs).
• Two (from Peru and Romania) concern external initiatives to support development
of monitoring and assessment by governmental agencies.

32
• One (from Colombia) concerns support for re-establishment and development
following a natural disaster and involved activity by both regional government and
a regional University.
• One (from Peru) concerns the role of monitoring and assessment in development of
water supply activities by a large and well-established self-help organisation.

33
 Section 2:

A Conceptual Framework for the

Linkages Between Monitoring
and Assessment Information
and Improved Water
Supply

It has been argued that there are four fundamental information-action linkages by
which the information generated by a monitoring function (ie the collection, analysis
and dissemination of information concerning water supply quality) may lead to
improved water supply and thereby improvedhealth(Bartram, 1990).

The work reported here focuses on these linkages between the information products of
monitoring and assessment and improved water supply. Other benefits of monitoring
and assessment may be hypothesised, for instance those concerned with its
educational value and its use to 'piggy back' other activities such as hygiene
education, cost recovery or operation and maintenance. Such additional roles are
beyond its scope of this work and are not considered here.

34
The four information action linkages may be summarised as follows:

Overview assessment
When the most common problems and recurrent shortcomings in water supply
and water supply systems are identified, national or regional policies and
strategies can be formulated for improvement. These might include, for
example, changes in training, rolling programmes for rehabilitation or changes
in policy or funding orientation.

Regional and local management and operations

With an adequate information base regional offices of water supply and
construction agencies can decide which communities to work in and which
remedial actions are priorities based upon public health criteria. For the
purpose of this thesis, this information-action link is sub-divided into aspects
supportive of prioritisation/selection of major interventions (generally
rehabilitation and extension, occasionally also service level upgrading), and
aspects supportive of operation and maintenance by formal supply and
construction authorities.

Enforcement of standards
The information generated by monitoring enables assessment of the fulfilment
of standards by supply and construction agencies. Legal action may be taken
or threatened where necessary although the feasibility of corrective action
should be taken into account and enforcement of standards should be linked to
strategies for progressive improvement.

Community management
Monitoring should also address information to the local authority responsible
for management of private and rural small community supplies. Such

35
 information provision may take diverse forms, but of particular relevance to
the theme of this thesis is information supportive of operation and maintenance
of community-managed water supply systems.

This categorisation is based principally on the consumers of the information product

ie those who will make use of the information. The importance of defining the users
of the information products of monitoring has been emphasised previously and the
need to assess the data and information needs of potential users and to match these
with the services provided by the information centres' noted (Anon, 1992a; Ward,
1995; Adriaanse, 1995).

In the following sections each linkage is described, the principal information users
noted and a series of hypotheses established for testing each linkage.

2.1 Overview Assessment

Those linkages which employ an overview assessment of the sector as a whole or of a

part of the sector may be used to orient activity at a relatively central level, typically
central government, but also project steering groups and regional authorities .
Information analysis at this level leads to an understanding of common factors and
trends which are often beyond the capacity of local or sometimes regional institutions
either to assess or to address and may involve other sectors in their solution (Anon,
1992b).

Examples of uses of information in this way include:

• orientation of investment strategy (for example to specific geographic areas or
certain population segments or to operation and maintenance) (Bartram, 1996);
• establishment of or changing elements of legal and regulatory frameworks
(Caponera, 1992); and

36
• recurrent errors or shortfalls such as those in construction practice which may
require changes in curriculum or professional development schemes to amend
(Alaerts , 1991) .

Such problems are best addressed, not on a case-by case basis but en bloc, through for
example policy, investment or curriculum changes.

The importance of such mechanisms was emphasised at the Dublin Conference

(Anon, 1992a) and it has been suggested that in some countries there is increasing
interest in formulating policies that will prioritise areas and regions for water supply
extension, based upon specific health parameters for example (Troare, 1992). Within
Europe, this approach has been integrated into the concept ofNEHAPs (National
Environment and Health Action Plans). Development of NEHAPs by 1997 was a
joint commitment entered into by Ministers of Health and of Environment at the
Helsinki Conference (Anon, 1994b) and experience in the NEHAP pilot countries has
illustrated precisely this approach (Wyes, 1996).

Key information product users are policy makers and planners at regional and national
levels and also project co-ordination and steering groups for large water supply
programmes and projects. A significant proportion of such persons do not have a
technical background in water supply (Alaerts et al, 1991; Wheeler and Bartram,
1990b).

One limiting factor for this approach may be that problems are perceived to be
transparent and obvious especially by national sector experts. Where this is the case
this may impede willingness both to carry out monitoring and assessment with this
objective and to accept or act upon the findings (Ward, 1990).

It is becoming increasingly perceived that decision-making should occur at the lowest

effective level, as reflected in the statements of recent international conferences

37
(Anon, 1992a; Anon, 1992b; IRC, 1995c). Whilst the importance of de-centralisation
and de-concentration is part of a political polemic being played out at diverse levels
world-wide, practical experience is supportive of this conclusion in the context of
water supply (Alaerts et al, 1991; LeMoigne, 1991). In the case of water management
this approach was supported by Dublin Conference (Anon, 1992a). The principal
challenges of de-centralisation/de-concentration to water supply and sanitation relate
to harmonisation of data and information (and therefore the ability to combine
information for, for example, preparation of national assessments), sectoral co-
ordination and the support structures for (local) monitoring and (local) water supply
which should both provide means to support wide-scale activity and change.

An approach of this type would fail were supportive institutional arrangements not to
be in place. Such arrangements include definition of institutional roles and
responsibilities , arrangements for sectoral and inter-sectoral co-ordination, policy and
priorities, targets and standards (see for example Caponera, 1992; Alaerts et al, 1991;
Okun and Lauria, 1991). Problems and limitations to the decentralisation of the water
supply sector have been highlighted (Troare, 1992) whilst recognising that public
health agencies as 'software providers' have greater capacity in this regard.

Hypotheses
1. Through monitoring it is possible to quantify the prevalence or trends in the
prevalence of problems at a large scale (regional or national).
2. The relative prevalence of problems varies sufficiently to merit analysis.
3. The information produced by monitoring can influence national, regional or
project policy and investments to address common problems.
4. The information produced by monitoring can lead to resource allocation to rural
water supply as a priority sector.

38
2.2 Prioritisation of Major Interventions in Existing Water Supplies

The fact that a very large proportion of constructed rural water supply infrastructure is
non-operational has been discussed in Section 1.2.1. The causes of failure are diverse.
Some for example relate to inappropriate technology selection or training of, for
example, engineers and would be identified through overview assessment and acted
upon through that linkage (Section 2.1 ). Many others however relate to the inevitable
process of wear and tear and accident which afflicts any infrastructure (Weibkircher,
1992). Such problems should be identified and acted upon, but the abundant evidence
for the failure of this in practice (ie the very high percentage of non-functional
infrastructure) indicates a fundamental problem in this.

As noted in Section 1.1.3 no predictive estimate of the health impact of individual

interventions is available or likely to be forthcoming with which to prioritise amongst
available interventions . It has therefore been argued that activities should be
concentrated on those communities where environmental conditions are worst, and not
to bother with health impact aspects (Cairncross, 1990a; Bartram, 1996) and this is
coherent with an emphasis upon abatement rather than cause and effect (Renwick,
1973). The impact of water, sanitation and behavioural interventions to reduce
diarrhoeal and other infectious diseases has been demonstrated to be greatest amongst
those living in worse sanitary conditions (Esrey et al, 1985; Esrey et al, 1991).
Targeting this group for water and sanitation interventions is therefore ethically
desirable, politically acceptable and administratively possible (Bartram, 1996).
Furthermore, limited published evidence exists that government programmes of water
supply provision may not be managed equitably and may be subject to inappropriate
influences (Rao, 1991).

Nevertheless problems are diverse and in practice decisions regarding priority

amongst diverse and often compounded problems of different severities must be made
(Bartram and Wheeler, 1990b). Regional engineers and their equivalents world-wide

39
are regularly confronted with choices between, for example, rehabilitation of the water
treatment plant of water supply system A (to improve water quality to already-served
population X), and extension of an existing water supply to bring water to un-served
population Y. In practice such choices are often compounded and a choice amongst
systems A to Z, most of which will be deficient in at least one respect and many
(possibly the majority) deficient in several ways. Such engineers may become
exasperated by products of monitoring which provide no assistance in prioritising
amongst them . Confronted by an impossible excess of potential work and no useful
tools for prioritisation , it is often easier to focus on the readily-recognisable priority of
constructing new systems to provide drinking water to ·un-served' communities.
Whilst apparently logical , given the high rate of system failure world-wide (Section
1.2.1), such a strategy might be argued to contribute primarily to the stock of
inoperative infrastructure .

The simple economic logic (ie high return) underlying rehabilitation - that is
maintaining existing infrastructure in operation - is compelling and its particular value
in developing countries has been commented on (Weibkircher , 1992); as is also the
case for operation and maintenance (Robinson, 1991).

This linkage therefore concerns the means by which monitoring and assessment may
identify failed or deficient systems and characterise them sufficiently for priority
setting and planning purposes; and thereby support the rehabilitation and extension of
water supply systems by formal sector agencies. It places this alongside extension of
supply to un-served populations.

Key information product users are water supply managers and supply and construction
agency engineers. Many have a technical background in water supply and are located
at regional level. This group includes those representing NGO and ESA initiatives as
well as the government and private sector.

40
An important potential limiting factor to the effectiveness of this linkage may be the
willingness of persons such as the above to receive and act upon information products
of monitoring (Ward, 1995), especially since they may be seen to be judgmental of
that person s work performance.

Hypotheses
1. Water supply and construction authorities undertake major interventions in
already-constructed rural water supplies.
2. In most projects and at operational level in most water supply progranunes there is
an excess of potential major interventions relative to the scale of rehabilitation
activity .
3. Selection or short-listing of interventions fails to take account of public health
priority .
4. It is possible to prioritise amongst potential interventions and to target priorities
such as areas of worst environmental health status where health gain is likely to be
greatest .
5. The outputs of monitoring may be used to integrate prioritisation into operational
planning.

2.3 Support for Operation and Maintenance by Formal Water

Supply and Construction Authorities

The introduction to Section 2.2 which highlights the high rate of infrastructure failure
is also relevant here. This linkage however relates to the intervention of formal water
supply and construction authorities in routine operation and maintenance of rural
water supplie s.

The popularity of community management as the preferred and de facto means of

ensuring administration, operation and maintenance of rural water supplies has been

41
discussed in Section 1.2.4 and the assertion that attempts to manage operation and
maintenance through centralised, governmentally-controlled organisations have
proven unsustainable (Appleton, 1995a) noted. Nevertheless it has been argued
variously that there is little (Feachem , 1978) or extensive (Okun and Lauria, 1991)
supportive experience of community management from the 'first' or 'developed'
world and the fact that successful experience related to community management
outside the established market economies has been derived from small scale and pilot
studies was highlighted as early as 1978 (Feachem, 1978). Little new experience has
been forthcoming in the intervening years to substantially mitigate concerns regarding
the cost and difficulty of extrapolating to large-scale or national operations.

Whilst the role of information supportive of community management is explored in

Section 2.5, this linkage concerns support for the role of formal agencies, external to
the community per se in operation and maintenance.

Operational or managerial decisions at regional or local level should be supported by

clear objective information and the importance of the linkages between operation and
maintenance and drinking water supply surveillance have been noted (Troare, 1992).
Since any monitoring and assessment programme is likely to involve a programme of
visits it would appear logical that it could support the operation and maintenance
function, whether carried out by community authorities or by a formal agency.
Actions tending to increase the scale and effectiveness of operation and maintenance
could appear to be a cost-effective means of increasing real rates of access to safe
water supply, although they would be unlikely to impact significantly on national
statistics as presently compiled (Appleton, 1995b).

Key information product users are managers and supervisors and occasionally
engineers in local or regional offices of formal water supply and construction agencies
who are directly responsible for organising operation and maintenance of rural water
supplies in their jurisdiction; as well as local staff responsible for taking required

42
actions. Actions in this category are within the scope of authority of the drinking
water supplier at regional or local level to act.

In exploring the constraints to this linkage it should be recalled that operation and
maintenance is generally given a low priority by regional and district agencies
(Appleton, 1995b). The high failure rate in infrastructure is recognised (Section 1.2.1)
and clearly all systems, VLOM (Very Low Operation and Maintenance) or otherwise
will deteriorate through normal wear and tear and occasional accidents. A significant
proportion of this deterioration will be beyond the capacity of even well-prepared
communities to address and will often occur considerably before the design life of the
system is reached. This situation is uncomfortable to many construction agencies,
both national and otherwise, for whom it potentially implies a need for a continuing
commitment to systems either through routine maintenance or through strategies for
periodic rehabilitation and extension, or both.

Hypotheses
1. Formal authorities responsible for operation and maintenance are a significant
feature of rural water supply and/or construction authorities maintain a role in
operation and maintenance.
2. Routine monitoring can detect operation and maintenance requirements.
3. Information links can be established between those responsible for monitoring and
for operation and maintenance and can contribute to operational planning for
operation and maintenance activities; or
4. The operation and maintenance and monitoring functions can be effectively
integrated.
5. The influence of monitoring on externally-managed operation and maintenance
can lead to improved water supply.

43
2.4 Enforcement of Standards

The most frequently articulated reason for routine monitoring of water supplies is to
detect failures to comply with water supply standards and regulations and for these to
be employed to enforce improvement (daSilva and O'Kane , 1989; Ward, 1995). Thus
Le Moigne (1996 p20) suggests that 'the best water management strategy would mean
little without laws and regulations that can be enforced '; whilst Lloyd and Helmer
(1991, p58) have gone as far as to claim that in rural areas 'it is only worth
considering planning the development of surveillance programmes if the political will
to implement water legislation exists'.

It should be recalled that standards are intended to ensure that the consumer enjoys a
reliable supply of safe, potable water; not to shut down deficient systems (WHO,
1984; Wheeler 1990; Bartram 1996) and the ambiguous position of enforcement of
water supply standards in rural areas and small communities is recognised (Troare,
1992). Nevertheless, developing countries have tended to adopt imported standards
and approaches with reliance on central, public systems (Troare , 1992; Caponera
1992) although broader approaches have been promoted (see for example de Koning,
1987). Many water supply monitoring programmes are therefore designed to assess
measures of water supply service quality (and especially water quality) , to compare
results with a standard and to take some form of action upon detection of failure .

Whilst monitoring often focuses upon water quality standards, in this context the
scope for enforcement also includes:
• construction standards;
• plumbing standards;
• service quality standards (cost, continuity);
• water quality standards; and
• coverage (eg when an authority has responsibility for a defined geographical area
or population).

44
Key information product users are the staff of the independent surveillance agency
and the water supply agency .

Conflicts may exist between standards and ensuring optimal health impact (Holland,
1991). Resources are finite and in practice a supply agency may have to choose
between, for example, investing in fulfilling water quality standards despite relatively
good quality, and extension of coverage. The choice between these two may have a
profound influence on the resulting impact on the health of the population (Esrey et al,
1985; Esrey et al, 1991). There has been a change in approach in recent decades
amongst public health professionals to water supply provision from 'all or nothing' to
'something for all' (IRC, 1995b). Whilst the recognition of this conundrum is
relatively new to the drinking water supply sector, it has a longer background and the
philosopher Sir Karl Popper is cited as having 'pleaded for piecemeal engineering,
because utopian engineering by demanding everything achieves nothing' (cited in
Steensberg, 1989). Where water supply legislation is 'utopian' it will tend to promote
the perfection of existing water supplies at perhaps great cost despite minimal health
risk at the expense of providing an improved, but perhaps imperfect supply to
(perhaps many) more individuals. In this area legislation and regulatory thinking have
not yet heeded Sir Popper's plea, nor kept pace with the pragmatism of project and
programme co-ordinators and as a result there are two schools of thought in conflict.

A further problem with approaches to water quality improvement through compliance

monitoring and legal enforcement is that laws may have lost all credibility in practice
(Jensen, 1967; Okun and Lauria, 1992).

Hypotheses
1. Failure to comply with water supply standards selects those supplies presenting
greatest public health risk, either because the rate of failure is low, or because
measures for progressive implementation exist and are used.

45
2. Rural water supply monitoring can generate legally-valid results .
3. A legally-definable person or agency exists who may be held responsible for a
water supply and against whom legal proceedings may be instigated .
4. Legal action or the threat of legal action will lead to improved water supply in
those supplies targeted by it.

2.5 Support to Community-based Management

It has been claimed that there has been a development in thinking over recent decades
from 'community development' (generating contributions), 'community participation'
(local involvement) and most recently to 'community management' (local acceptance
of responsibility) (see for example Troare, 1992; Visscher et al, 1996; IRC, 1995b ).

Information linkages between monitoring and communities may be broadly classified

into three types:
• Community members and authorities may act as generators of data and
information; the concept of the public as the eyes and ears of government is being
increasingly recognised (Nagy et al 1994, Ward 1995).
• Community members at large may act as consumers of information. This may be
important in terms of developing public capacity to participate in decision-making
(Nagy et al, 1994; Anon, 1992a) and in increasing the awareness of improved
water supplies which is an often-cited root cause of system deterioration and
failure (Troare 1992, Anon, 1992a).
• Community authorities act as consumers of information to support operation and
maintenance of their own water supply.

For the purposes of this thesis only the third of these types of linkage is considered. It
is the only information-action linkage amongst the three and therefore represents the
thrust of the work. This does not detract from the importance or validity of the other
types.

46
This hypothesis concerns the feasibility of providing support to community
management through routine monitoring visits. The principal consumers of the
information product are community members themselves.

Whilst poor technology choice, shortage of skilled staff and unavailability of fuel or
spare parts are often the most visible (and reported) reasons for failures in operation
and maintenance, financial and institutional failings are usually the underlying causes
(Appleton, 1995b ). Whilst the pivotal role of operation and maintenance in ensuring
the maximum benefit of the water supply infrastructure 'capital' is now well
recognised and the key role of the community in this widely accepted (Bays, 1992;
Mather, 1995), there are very few practical proposals regarding how this may be
promoted ensured and the commentary ofFeachem (1980) to the effect that all
experience with community management of rural water supplies remain s at pilot level
or demonstration projects has already been referred to and discussed in Section 1.2.5.

Since any monitoring and assessment programme is likely to involve a programme of

visits it would appear logical that it could provide a support to the operation and
maintenance function, whether carried out by community authorities or by a formal
agency. Actions tending to increase the scale and effectiveness of operation and
maintenance would appear to be a cost-effective means of increasing real rates of
access to safe water supply, although they would be unlikely to impact significantly
on national statistics as presently compiled (Appleton, 1995b).

Potential limiting factors to this linkage include the existence of community

authorities and their willingness to assume responsibility for their water supply
(Appleton , 1995b ).

47
Hypotheses
I. Community management of rural water supplies is significant and community
authorities exist with whom information linkages can be established.
2. Operation and maintenance is inadequate at a significant frequency.
3. Routine monitoring can detect operation and maintenance requirements.
4. Communication linkages established with community authorities can lead to
effective community action in operation and maintenance .

48
 Section 3:
Testing the Information-
Action Linkages

This Section is structured according to the hypotheses proposed in Chapter 2, using

the hypotheses as sub-titles for each section. For each hypothesis evidence from all
relevant case studies is reviewed. For each of the information-action linkages the total
evidence is then analysed and discussed in the context of the published literature.
Section 4 considers methods for data acquisition and data quality which are common
issues to many hypotheses and are therefore treated separately.

There is a tendency for water supply and monitoring programmes, whether undertaken
by the supply agency or in the form of independent surveillance to emphasise water
quality. Much of the experience available therefore relates to this at the relative
expense of other indicators. In presenting evidence for and against each hypothesis all

49
relevant information from the case studies is included and qualified where necessary
regarding its limitations.

3.1: Overview Assessment

3.1.1 Through monitoring it is possible to quantify the prevalence or trends in the

prevalence of problems at a large scale (regional or national).
Whilst this hypothesis might appear likely to be substantiated, it was found to be
rarely fulfilled in practise.

All three countries visited for preparation of status assessment reports (Egypt,
Pakistan and Yemen) had monitoring schemes which were exclusively water quality-
oriented and relied upon water quality analysis to determine that a problem existed.
Investigation of the cause of the problem was reactive to the detection of the problem.

Using microbiological analyses

Disaggregated analysis (for instance by supply type) of the results of microbiological
analysis enabled identification of problem areas in some case studies, although not the
nature of the problems causing contamination. Thus utilising water quality data alone
it was clear that problems existed with rural water treatment systems in Peru I (Table
2) and that there were extreme differences in source water quality by type in Peru II
(Table 3) that merited further investigation.

The 'quebradas' - a term used in the region addressed in the case study Peru II to
mean any surface water course other than the principal rivers themselves - are of better
quality than groundwater from wells. Community survey results showed that the
wells were frequently located within communities, which had very poor standards of
general sanitation. Furthermore, the wells themselves were typically shallow
depressions in an impermeable layer immediately beneath a shallow surface topsoil.

50
Water filtering through the topsoil accumulates in these depressions and is collected
from them manually with multiple opportunities for initial and re-contamination. In
contrast, it is rare to find a community downstream of another on the same quebrada;
and domestic animals are kept within the community itself. Previous educational
initiatives related to water supply in the region had emphasised the better quality of
well-water compared to surface water.

Table 2 Water quality by supply type in the central region of Peru, 1986- 7

System Type Number Existing Water Quality (tbermotolerant coliforms

per IOOml)*
(percentage of systems in category)

A B C D
Simple gravity 273 23 43 17 18
Gravity with treannent 25 4 8 12 76
Pumped 9 11 22 22 44

• thennotolerant colifonns per 100ml. A: less than l; B: 1-10; c: 11-50; D: greater than 50.

Table 3: Water quality by source type in communities affiliated to the Consejo Aguaruna and
Huambisa, 1989.

Source type Number Water quality (thermotolerant coliforms per 100ml)

sampled (percentage of systems in category)
A B C D
Well 30 11 (36%) 5 (17%) 8 (27%) 6 (20%)
' Quebrada' 14 8 (57%) 4 (28%) 0 2 (14%)
River 1
• thennotolerant coliforms per 100ml. A: less than 1; B: 1-10; c: 11-50; D: >50 .

51
Microbiological analysis was used as the primary monitoring tool in Egypt , Pakistan
and Yemen. In Egypt, sanitary inspection was also used reactively following problem
identification through water quality analysis. Although data was amenable to analysis
for detection of trends and patterns through overview assessment , this was not
attempted by the authorities in these three countries.

Microbiological contamination may vary widely and rapidly (Pipes, 1987) and is
subject to seasonal variation as discussed in Section 4.2.4. Certain sanitary
deficiencies are likely to result in contamination associated with rainfall, but sampling
may not be undertaken at that time because of problems in visiting rural communities
under such conditions (encountered in the case studies from Peru I and Nepal for
example). Infrequent (such as annual) sampling of water supplies is therefore likely to
significantl y under-estimate contamination and would limit its value when used alone
in identifying the relative prevalence of problems .

Sanitary inspection of water supply systems

In Colombia, Nepal, Nicaragua, Pakistan I, Peru I and Romania the means of problem
identification included sanitary inspection with or without household interviews and
with or without water quality analysis.

Tables 4 to 8 provide examples of findings from three of the case studies which
employed sanitary inspection systematically as a monitoring tool. Similar tables have
been reported by other workers using sanitary inspection as an investigative tool
(Jensen, 1967). In all the range of prevalence of sanitary haz.ards
was large (32 - 86
per cent) and in all cases important risk factors were found to occur at very high
frequencies.

52
Table 4 Prevalence of 12 common sanitary hazards in gravity-fed water supply systems from
protected spring sources in Peru 1986 - 87

Sanitary Hazard Prevalence

(per cent)
No lock on reservoir 98
Chlorination not practised 91
Leaks in adduction line 88
Spring source unfenced 87
Leaks in conduction line 87
No disinfection equipment 85
No surface water diversion ditch around source 83
No lock on spring catchment 83
Faecal contamination near catchment 75
No sanitary lid on spring catchment box 55
No concrete cover behind spring box 47
No sanitary lid on reservoir 42

Table S Prevalence of sanitary hazards at source in a sample of 17 Nepalese rural water supplies
from protected spring sources 1990-1

Sanitary H87.8rd Prevalence (per cent)

Lack of sanitary lid 69

Open to surface contamination 54
Animals within 20m 54
No surface water diversion ditch 50
Overflow not sanitary 46
Silt or animals present 42
Unfenced 38
Air vents not necessary 33
Faults in masonry 16
Latrine(s) within 30m 8

53
Table 6 Prevalence of sanitary hazards at source in a sample of nine Nepalese rural water
supplies from unprotected surface water sources 1990-1

Sanitary Hazard Prevalence (per cent)

No treatment 100

No flow control 90

No minimum head device 50

Intake not submerged 50
Risk oflandslide/mudflow in catchment 50
Unfenced 40
Intake unscreened 40
Human habitation upstream 30
Fann animals upstream 30
Crops upstream 30

Table 7 Prevalence of sanitary hazards in conduction and distribution in a sample of 25 Nepalese

rural water supplies 1990-1

Sanitary Hazard Prevalence (per cent)

Tapstands
Unfenced 63
Ponding around tapstand 31

Leaking tap 23
Human excreta within I Om 15
Plinth cracked or eroded 7
Conduction and Distribution
Lid to pressure break tank(s) not sanitary 82
Threat to conduction line from landslip 61
Lid to storage tank not sanitary 50
Leaks in pipe from source to storage tank 32
Leaks in distribution 18
Reservoir defects 8

54
Despite the value of sanitary inspection as a primary diagnostic tool as attested by
both the literature (Jensen, 1967; WHO, 1976; Bartram and Wheeler, 1990b, Lloyd
and Bartram, 1991) and experience from the case studies, it was not used for this
purpose in many of the case studies. Thus for example in Egypt, whilst sanitary
inspection was the general response to detection of a water quality problem, it was
unused as a primary monitoring tool. In Pakistan sanitary inspection was almost
completely unused as a component of water supply surveillance or quality control.

Table 8 Prevalence of 12 common sanitary hazards in wells used for rural drinking water supply
in Romania, 1995

Risk Factor Percentage Percentage of

Response Wells with Risk
Factor
Un-roofed 32 35
Un-covered 76 lI
No impenneable plinth (surround) 48 42
No periodic disinfection 64 43
Latrine less than l Om from well 97 84
Distance to 'garden' less then I Om 88 33
House within tom from well 100 97
Water stored in open top containers in household 100 91

Given the low frequency of monitoring of smaller supply systems as seen in all case
studies (less than yearly in all cases in practice) and the high variability in water
quality discussed above, sanitary inspection could readily and usefully have played a
greater role in routine monitoring, both in complementing water quality analysis and
in assisting in the identification of causes of problems identified by water quality
analysis (Lloyd et al, 1987; Lloyd and Bartram, 1991).

55
Community surveys
In several case studies, wider community surveys were performed, using interview
techniques and investigating factors beyond the risk of contamination of the water
suppl y system p er se. In Nicaragua and Nepal. water quality analysis, sanitary
inspection and household-level interviews all identified and quantified the prevalence
of problems. Results of the preliminary diagnostic surveys from the case studies in
these two countries are presented in Tables 9 and 10 respectively.

Table 9 Results of the Nicaraguan preliminary diagnostic study

Supply Type Number Visited Continuity Sanitary Water Quality

Inspection Analysis
Hand dug well 46 16/46 dry 9/46 handpumps 7/46 acceptable
(with handpump) 7/46 dry in removed for 4/46 non-
summer repair and never operational
returned
13/37 handpumps
non-operational
Borehole with 9 (100%) 1/9 pumps broken 8/9 acceptable
handpump
Spring to gravity 7 (100%) 3/7 multiple 4/7 very
fed piped supply deficiencies contaminated
Surface water (100%) 1/1 very
source to gravity contaminated
fed piped supply

• All systems were less than IO years old

Household-level studies
In several case studies, both water quality analysis and direct observation sanitary
inspection were used to collect data at household level. Data from Romania obtained
by direct observation are included in Table 8.

56
The use of sanitary inspection within households in the case study Peru II provided a
clear indication of region-wide hygiene problems. Results of direct observation of
indicators of household hygiene detected through this work are presented in Table 11.

Table 10 Results of the Nepal initial monitoring activities

East Region (19) West Region (5)

From Spring Sources From Surface Water From Spring Sources
Sources
Coverage (dwellings per tapstand)
minimum 1.0 15 1.4
maximum 19 33 39
mean 13 24 12
Continuity
minimum 33 100
maximum JOO 100
mean 78 100
Quantity (/pd entering distribution)
minimum 14 8.6
maximum 397 96
mean 206 53

Table 11 Indicators of household hygiene assessed through direct observation sanitary inspection
in households in communities affiliated to the Consejo Aguaruna and Huambisa*.

Indicator Frequency (percent)

Dwellings with domestic animals inside 83
Cooked food stored raised off ground 62
Cooked food stored with cover/lid 62
Water storage container raised above ground 32
Water storage container stored with lid/cover 43
* Previously published in Bartram and Johns , 1989

57
In Nepal, the results of water quality analysis obtained from a water supply system
and household containers ('gagris') during pilot testing indicated that household
contamination might be significant (Table 12) but were unsubstantiated by further
survey work (Table 13).

Table 12 Water quality results from the community ofSiling Karantar, Nepal, December 1990

Sampling Site Thermotolerant Coliforms per 100ml

Surface water source 0
Pressure break tank 0

Reservoir 0
Tap I
Tap2 0

Tap 3
Gagri I 150
Gagri 2 43
Gagri 3
Gagri 4 2

Table 13 Faecal contamination by supply type and stage of distribution in a sample of 23 Nepalese
water supplies 1990-1

Stage of distribution Number of Mean faecal coliforms

Observations per 100ml
Systems from unprotected spring sources
Source 12 12.5
Tap stands 30 4.1
Gagri• 3 52
Systems from unprotected surface water sources
Source 4 80
Tap stands 9 51
Gagri* (no data)

•a gagri is a narrow-necked water vessel which is used for both collection and household storage of
water. They are typically made from aluminium, brass or copper and vary widely in size

58
The importance of assessing water quality up to the point of consumption has been
emphasised (see for example Feachem et al, 1978; Shiffinan et al, 1978; Rojas et al,
1994) and this approach was adopted in some studies. It is important to try to
distinguish the contribution of various potential points of contamination. By
separating and assessing different sources of contamination their relative importance
can be assessed and resources allocated to preventive and remedial measures
accordingly (Bartram and Wheeler, 1990b ).

The limited findings regarding household-level studies indicate that conclusions may
be drawn regarding household-level water management in the same way as for water
quality analysis and sanitary inspection.

3.1.2 The relative prevalence of problems varies sufficiently to merit analysis

Wide variation in the prevalence of problems was demonstrated in all case studies
where data were analysed in this way. Summary data from more than 300 Peruvian
water supplies have been presented in Table 4, from Nepal in Tables 5 to 7 and from
pilot scale work in Romania in Table 8. The data presented concerning water quality
in Tables 2 and 3 also support this conclusion without being problem specific. The
Peru data show a high prevalence of a range of risk factors and substantial variation in
frequency amongst them in the range 42 to 98 per cent. In Romanian wells the range
extended from 33 to 97 per cent. Work undertaken in Colombia (Table 14) and Peru
(illustrative sample of results in Table 15) also illustrate this for a range of
accessibility-related parameters.

Whilst these studies graphically illustrate wide variation in the prevalence of

problems, they do not represent a rigorous scientific basis for determining whether
this is 'significant'. Statistically this can be achieved by assuming a binomial
distribution for these principally binary variables and demonstrating that differences
are significant. However ultimately the only measure of whether a difference in

59
prevalence is significant is whether it is sufficient to 'bother about' - that is it is of
interest to decision-makers (Adriaanse 1995).

Table 14 Quality of water supply services in a sample of communities, Tolima, Colombia, 1989.

Population Water Supply Number of Coverage of Quality Continuity of

Type System Type Systems Households (thermotoleran Service, hours
Surveyed with Water t coliforms per per day
Supply 100ml)

Urban Surface water 4 83-96 3 with greater 1 with 1-10

source with than 50; 2 with 11-23
treatment 1 with 11-50 1 with 24
Rural Surface water 96 greater than 50 24
source with
treatment
Rural Surface water 7 65-96 3 with greater I with I - 10;
source, no than 50; 6 with 11 - 24
treatment 3 with 11 - 50;
I with I - 10

Previously published in Bartram et al 1991.

Table 15 Example summary report of water supply service quality indicators from Peruvian pilot
region surveillance activities, Department of Junin, Province of Huancayo.

Community System Source Total Cover- Contin- Quality Quantity Tariff

Type Popul- age(%) uity (•/. (1) (lpd) (lntis/
(1) ation of Time) Month)

9 de Julio GNT Spring 1590 54 100 B 245 30.2

Achin GNT Spring 480 75 100 B 54 5.0
Alayo GNT Spring 925 51 100 B 420 30.2
Andamarca GNT Spring 690 61 100 B 75 20.0
Andamayo GNT Spring 402 21 100 A 580 40.0
Anexo GNT Spring 705 83 100 D 184 5.0
Huandar

(1) Gravity, no treatment / gravity with treatment / pump no treatment / pumped with treatment.
(2) Thennotolerant colifonns per 100ml: A: < l; B: 1-10; C: 11-50; D: >50.

60
Definition of the level of information that will influence policy makers is subject to a
range of influences of which objective assessment is only one. No clear-cut value or
percentage prevalence acts as a trigger for action and the immediate context is a major
influence on decision-making (this is discussed further in Section 6.2.2). This
evidence is therefore best interpreted in light of the following section (Section 3.1.3).

Nevertheless, a number of useful indications are available. Steensberg (1989) based

on work by Greenberg (un-cited) suggests that when weighing up the consequences of
action choices, the degree of proof needed to recommend an action increases with the
consequences following a wrong decision. Importantly, understanding the mode of
causation of an ailment is not an essential step in considering abatement strategies
(Renwick, 1973). Nevertheless, scientific thinking indicates, quite reasonably, that we
believe that we have not understood anything fundamental unless we have understood
the mechanism of causation; and we often conclude, unreasonably, that such
understanding is a prerequisite for wise action. Renwick (op cit) quotes Kant as
saying that: 'it is often necessary to make a decision on the basis of knowledge
sufficient for action, but insufficient to satisfy the intellect'. The degree of proof
demanded before taking action may therefore be considerably less for a politician or
other senior decision-maker than for an academic or scientist, especially where the
consequences of error are low. This is conspicuously the case where moderate re-
alignment of water supply strategy is concerned, especially where initiated though
pilot-scale activity.

3.1.3 The information produced by monitoring can influence national, regional or

project policy and investments to address common problems.
The evidence in support of this comes from five of the case studies within the
experimental areas: from Colombia, Pakistan, Peru (two) and Nepal and may be
summarisedas follows:

61
• From Colombia, where a survey identified extreme water quality problems despite
substantial water treatment infrastructure. The results of the survey lead to an
educational initiative, pilot rehabilitation and further monitoring and follow-up. As
a direct result the regional health authority changed policy in favouring
rehabilitation rather than abandoning water treatment as ineffective and in changing
policy towards technology of choice for rural drinking water treatment.
• From Pakistan I where a new rural water treatment initiative was found to be
ineffective through an assessment. Monitoring and assessment established a
tension between programmes, leading to changes in monitoring practice and
substantial policy changes including resourcing for rural water treatment research
and withholding further rural water treatment plant construction pending its results.
• From Peru I where severe problems with rural water treatment were identified
through pilot scale monitoring and assessment. Pilot constructions and
rehabilitations were initiated and significant tension generated between monitoring
and construction agencies. The results of monitoring and assessment and pilot
work lead a major NGO operating in the country to both adopt survey approaches
to monitoring and to construct appropriate drinking water treatment plants. The
governmental construction agency also paralysed construction of all rural drinking
water treatment plants; provided training to its regional engineers in more
appropriate technology and subsequently reinitiated rural water treatment plant
construction. Some regional engineers also initiated programmes of rehabilitation
of existing drinking water treatment plants.
• From Peru II where a systematic assessment of water supply provision led the
highest authority of a health programme to seek increased resourcing for rural
water supply; which included a training initiative known to have lead to replication
within the region. Additional resources were obtained for rural water supply as a
result of the work .
• From Nepal where the results of a survey led to the identification of both problems
of source contamination and spring protection which had been unrecognised for
many years. As a direct result the NGO concerned altered standard designs for

62
 spring protection and provided training for its construction supervisors in improved
source protection .

These case studies indicate successful influence of the outputs of monitoring upon
policy at diverse levels including national and regional policy \\'ithin governmental
agencies and upon large-scale NGO activity. In some cases the link between
monitoring and policy change is direct, as is the case in Colombia. In others, such as
Pakistan, the link is difficult to explore, although all indications are that the results of
monitoring were taken seriously by the NGO's international headquarters and
construction sub-programme and were the impetus behind substantial decision-
making.

It is noteworthy that in the case of Peru I, results of monitoring led to policy changes
in an agency other than that directly involved in the work. The Ministry of Health
monitoring activities therefore impacted not only upon the Ministry of Health
construction programme, but also on a major NGO. However in contrast the study
planned by the health sub-programme in Pakistan I and which in many ways might
appear a model for the development of an overview assessment provides little
evidence. A number of danger signals may be noted. The overall project was large,
ambitious and complex; few or no intermediate products of immediate use were
identified and so expectations focused upon a far-off final report. Because of its
complexity, the programme suffered managerial problems and after around one year
several key positions remained vacant.

Notwithstanding the above, organisational linkages are rarely structured such as to

facilitate use of information collected to influence national and/or regional policy.
Thus for example in the case of Egypt, whilst NOPW ASD was well-positioned
organisationally to influence the activities of Govemorate Housing and Utility
Sections, it had no information-capture capacity of its own, and since health sector
information-capture locally was not fed into a central system, information from this

63
source was unavailable. In the same country, ORDEV, whilst responsible to co-
ordinate implementation of water supply at village level between central government
and the Govemorates was similarly constrained. In Peru, where a specific agency
(CONCOSAB) had this mandate, no evidence was found that its existence effectively
influenced policy .

3.1.4 The information produced by monitoring can lead to increased resource

allocation to rural water supply as a priority sector
In only one case study was significant evidence generated concerning this. Whilst the
experience was positive (ie additional resourcing was secured by the programme
concerned), this relates to a single NGO initiative and funding secured from a major
charity.

In few case studies was there any indication of attempts to use the information
generated by monitoring in this way. In light of the paucity of evidence and the
timing of most of the observations reported in the case studies (ie near the end of the
IDWSSD and during a period of economic recession) the implications for the
hypothesis more generally are difficult to infer. The contradictory indications
regarding world-wide trends in funding for water supply and sanitation have been
noted in Section 1.2.2. nevertheless it is likely that the limited scope for rational
analysis (as discussed in Section 6.2.2) is of importance.

3.1.5 Discussion and conclusions

The first three hypotheses may reasonably be accepted and the overall mechanism ie
influence of overview assessment on national or regional policy is clearly effective.
The overall linkage may also be seen to be robust: a range of data acquisition methods
may be employed, diverse influences (on construction practice, investment policy and
on policy with respect to hygiene education), on diverse types of agency
(governmental, non-governmental) and in diverse geographic settings has been shown .

64
In only one of the case studies (Peru II) was information generated which would
indicate success in securing additional resourcing for rural water supply. Clearly
approaches and constraints to securing increased funding for the sector will vary
substantially between governmental and non-governmental programmes.

Significantly in all governmental programmes investigated, either inter-sectoral co-

ordination mechanisms were missing or were ineffective. The importance of such
mechanisms both for influencing policy and attracting additional resourcing is
discussed in Section 6.3.1 .

In several case studies no attempt was made to analyse data to develop an overview
assessment. This was the case in Egypt, Yemen and Pakistan for example where most
water-quality related data were found to be managed at a local level. Reports were
produced on paper and not fed into a computerised system or otherwise analysed at a
macro level. Furthermore in practice, the available computerised database systems
appear to have served only for demonstration purposes and were not in use. This is
likely to be, at least in part, a reflection of the low perceived need for analysis of data
at macro levels and has inevitably inhibited the development of national overview
assessments and therefore of policies and strategies for improvement of drinking water
quality.

In seeking to further explore the implications of the findings of this section, it is

conspicuous that many of the positive examples of remedial action were driven not by
comprehensive monitoring, but by relatively small-scale surveys. Successful problem
identification and promotion of abatement can be achieved through investigation of a
representative sample of systems and an assessment rather than comprehensive
monitoring approach is adequate to 'drive' this information-action linkage. This is an
important observation in light of the trend toward assessment rather than
comprehensive monitoring in other water-related sectors but which is little practised
in the water supply sector (Ongley 1994).

65
It is significant to note influence beyond the immediate environment of the work in
the case study from Peru where the influence of activity carried out by a government
agency and oriented specifically toward another government agency was felt upon an
independent NGO.

3.2 Prioritisation of Major Interventions in Existing Supplies

3.2.1 Water supply and construction authorities undertake major interventions in

already-constructed rural water supplies
In the case of Peru I, community management was common and direct management
by formal supply authorities was limited to the larger (still rural) supplies. The
Directorate of basic Rural sanitation ('DISABAR') , which had constructed 70 per cent
of the systems in the area described in the case study, retained a role in rehabilitation
of systems which it had constructed, and to lesser extent other systems also (Table
21).

Similar findings were found in other case studies, that is that the national
governmental water supply construction agency (normally part of the Ministry of
Health) was the dominant player in rural water supply construction and although it
nominally handed over responsibility for supplies to community-level authorities it
retained some interest in the supplies which it constructed (eg Colombia). Where
NGOs were directly involved in construction, their project offices performed
similarly, handing over systems to community management but retaining informal
interest in systems they had constructed.

In Pakistan I the NGO in question assumed that ensuring the long-term effectiveness
of its interventions was a part of its responsibility. Whilst this did not translate into a
rehabilitation programme per se, villages benefiting from the systems it constructed
were able to approach it for assistance in resolving problems which they encountered

66
and such requests were, generally, responded to favourably. This experience contrasts
with the situation encountered in Nepal where a long-term NGO construction
programme had provided no back-up to constructed systems and had focused its work
exclusively on construction and hand-over . As in Pakistan I this experience relates to
a large NGO, well-established in the country and with a long-tenn commitment to the
area and to water supply activities in the area.

In Pakistan II it is noted that across that country practice with regard to rural water
supply management varied widely and that in some areas Public Health Engineering
Departments (PHEDs), effectively rural water supply construction agencies ,
undertook substantial activities in rehabilitation and/or operation and maintenance.

In practice therefore, construction authorities often retain, albeit often informally, a

significant role in rural water supply. This is poorly systematised and often
' parochial' in the sense that a moral imperative exists for a construction agency to
look favourably upon requests for rehabilitation of systems it has constructed.
Nevertheless this activity depends upon lobbying by community members and were it
to be systematised additional need demand would be likely to be recognised. The
construction agencies themselves therefore confront the risk of recognising the rate of
failure of infrastructure they have constructed and potentially attracting considerable
additional rehabilitation work if limited perceived importance. It is unclear whether
these two considerations were a significant influence on development of this area .

3.2.2 In most projects and at an operational level in most water supply

programmes there is an excess of potential major interventions relative to the
scale of rehabilitation activity.
The scale of need for rehabilitation activity is large as indicated from the data
presented in Section 3.1 (Tables 4 to 9). This is in full accord with the published
literature as discussed in Section 1.2.1.

67
Numerical evidence regarding scale of rehabilitation activity in relation to need for
rehabilitation is available for some study areas and is summarised in Table 16 in
relation to potential need. The lack of data concerning scale of rehabilitation from
some other study areas is often a reflection of a lack of major rehabilitation activity.

Table 16 Rehabilitation activity versus indicators of the scale of gross failure of service quality* in
the case studies

Case Study Proportion of Systems Scale of Rehabilitation

Presenting Gross Failure of Activity
Service Quality Standards*

Colombia 50% in worst category for none

quality;
12% less than l O hours per day
continuity
Nicaragua 16/46 wells dry negligible prior to initiative
4/46 wells in worst quality described in the case study;
category 20/63 major rehabilitations
during the case study
Pakistan I All surface water sources Ad hoc only
contaminated
Peru I 7% in worst quality category; approximately 5 systems per
12% continuity less than 18 year (from a total of ore than
hours per day 300 systems)
low percentage coverages within
communities common
Romania 100% of wells failed national no external support for
construction standards rehabilitation or upgrading

• For the purposes of this table 'gross failure' is understood to be either total system breakdown or
falling into the worst category where grades of performance were employed.
Note: the Nepal case study is unsuitable for inclusion here as its focus was upon newly-constructed
systems

68
3.2.3 Selection of interventions fails to take account of public health priority
Responsible staff in the areas of the case studies were interviewed regarding
prioritisation in their ongoing activity. Whilst the low scale of remedial action in
general has been referred to above, Table 17 summarises responses of those
interviewed alongside a summary of the principal health-related water supply
problems for the areas under their responsibility. In no case were public health
priorities comprehensively addressed with the possible exception of Nicaragua.

Table 17 Use of public health criteria in prioritising major remedial actions

Case Responsible Person Public Which Criteria ? Principal Existing

Study Health Water Supply
Criteria Problems
Used?

Colombia Regional Chief of No(no Water quality

Environmental Health rehabilitat
ion)
Nepal Programme co- (variable) Depending on System breakdown
ordinator ( changed incumbent (short working life)
every few years);
engineers changed
more frequently
Pakistan Project team Yes Microbiological quality Distance to stand- post,
for rehabilitation quality of surface water
sources
Peru I Regional engineer No Failure of all treatment
(Hyo) systems
Peru I Regional engineer Yes Continuity of supply Failure of all treatment
(Tanna) for rehabilitations systems
Peru CAH Project sanitarian No Focused on community Negligible coverage
demand
Nicaragua Project officer n/a Full rehabilitation of all Varied by supply type,
systems projected generally quality and
gross infrastructure
failure

69
One of the reasons for minimal use of public health criteria which emerged from these
discussions relates to the emphasis on extension of coverage to un-served
communities rather than maintenance and rehabilitation of existing supplies. The
consequences of this focus are discussed in Section 4 .1.1. In programmes focusing
upon extension of coverage through new construction it was found that all 'needy'
communities (ie those who had not benefited from an intervention of some type) were
considered an equal priority and that maintenance of supply in communities with
water supply was considered a lower priority. While rehabilitation is considered a
minor programme element it is unlikely that there will be significant success in
introducing public health priority ranking systems. Other areas in which this has been
successfully achieved have been where a commitment to such rehabilitation has been
made by national authorities (Lloyd and Helmer 1991).

3.2.4 It is possible to prioritise amongst potential interventions and to target

priorities such as areas of worst environmental health status where health gain is
likely to be greatest
Two principal lines of conclusion are available to support this hypothesis, the first
relating to water quality alone and the second integrating water quality and
accessibility-related aspects.

Water quality
The first line of conclusion illustrates the feasibility of ranking systems according to
hygienic risk and also the feasibility of using such ranking in operational planning
(see next hypothesis). This work described in the case study from Peru, has
subsequently been employed elsewhere (Lloyd and Helmer, 1991).

Because of the potentially rapid and extreme variation in microbiological water

quality (Pipes et al, 1987, discussed further in Section 4.2.4) a combined index

70
incorporating both the findings of water quality analysis for faecal indicator bacteria
(ie actual contamination) with that of sanitary inspection (ie the susceptibility of the
supply to contamination) was developed . This represented a pragmatic acceptance of
the distinct strengths and weaknesses of these two tools for investigating water
quality. The relationship between the results of sanitary inspection and of water
quality analysis are discussed in Section 4.3 and their implications for risk
management in Section 5.2.1.

Whilst various classification schemes for the degree of faecal contamination were
tested , the principal considerations in development of such schemes were found to be:
• that they classify supplies according to relative hygienic risk; and
• that they discriminate amongst levels of contamination in practice.

In all case studies classification according to relative hygienic risk was achieved by
analysis of thermotolerant (faecal) coliforms as the indicator of faecal pollution and
classified according to increasing levels of contamination.

Because most systems were relatively small, supply systems were considered as single
units and each system as a whole classified. This is equivalent to treating each
system as corresponding to an 'isolated area' (Pipes and Christian, 1982; Pipes, 1990)
which would appear likely to be valid for small systems with fairly rapid rates of
throughput. In the case studies concerned, water quality was graded according to the
worst single result and since systems were generally visited only once per year, the
classification was based upon findings from a single monitoring visit. This represent
a very low frequency of collection. The schemes used in Peru is outlined in Table 18.

Similar grading schemes have been adopted for use with point sources. In Nicaragua
the scheme presented in Table 19 was used for both piped supplies and point sources;
whilst one based upon increasing orders of magnitude of contamination was adopted
for application to point source water supplies in Indonesia (Lloyd and Suyati, 1989;

71
Lloyd and Bartram, 1991). In Denmark, a similar classification was used employing
more stringent standards, but retaining the criterion of needing to differentiate levels
of contamination in practice (Jensen, 1967). Similar criteria were used in their
development ie the need to discriminate between levels of contamination in practice.
Conspicuously all case studies and papers cited here also adopted a simple risk
description which was used to facilitate reporting to communities and decision-makers
(see for example Tables 18 and 19).

Table 18 Peruvian thermotolerant (faecal) coliform classification scheme for water supplies

Grade Count per 100ml Risk description

A 0 WHO Guideline value, no risk

B I - 10 Low risk
C 11 - 50 lntennediate to high risk
D > 50 Gross pollution, high risk

Table 19 Nicaraguan thermotolerant (faecal) coliform classification scheme for point sources of
drinking water

Count per 100ml Risk Description

0 - JO acceptable
11 - 50 unacceptable
51 - 500 highly contaminated
greater than 500 highly dangerous

The use of sanitary inspection as a co-indicator of health risk was achieved through:
• standardisation of response amongst sanitary inspectors;
• expressing each risk factor in the form of presence/absence ; and
• expressing the susceptibility of a system to contamination as the proportion of all
sanitary haz.ards present.

72
By examining the resulting grading for faecal contamination alongside the sanitary
inspection sanitary hazard score for a number of systems it was possible to categorise
systems into groups according to degree of priority for remedial action. Whilst
variations on the methods for prioritisation were identified, all followed the pattern of
simple zoning shown in figure 3.

Thermotolerant
coliforms/
JOOml
>50

10-
50
1-9

<I

No Low Risk : Intermediate - High Risk: Very High Risk :

Risk Low Action Priority Higher Action priority Urgent Action
0 1-35 3S-6S 65- 100
Sanitary inspection score (percentage of sanitary hazards present)

Figure 3 Combined risk analysis of sanitary inspection and thermotolerant (faecal) coliform
contamination showing zoning for remedial action (after Lloyd and Bartram 1991)

Other attempts to investigate this means of prioritisation include Jensen ( 1966) who,
for point sources, found a correlation between the results of technical-sanitary
estimation and microbiological water quality and proposed that it would be possible to
evaluate the water quality using only technical-sanitary estimation of the conditions
of the water supply system. Similar findings have also been reported by Lloyd and
Bartram ( 1991) and the implications of this are discussed further in Section 5 .2.1.

73
Integration of water quality and accessibility-related parameters
A limitation of the above work is that it addresses only one indicator of water supply
service quality: water quality. A water supply system with good quality but poor
continuity of supply for example would therefore be ranked as good. Much work with
ranking systems of this type has been carried out in communities in which water is
collected from wells which may then be individually ranked (Jensen, 1966; Jensen,
1967; Lloyd and Suyati, 1989; Lloyd and Bartram 1991; Lloyd and Helmer, 1991).
Nevertheless the ideal ranking system would take into account health risk due to
several indicators of water supply service quality and prioritise systems on the basis of
these in combination or through co-presentation. This approach was employed in both
Peru and Nepal.

In Peru, each of the five adopted indicators of water supply service quality (coverage ,
quantity , continuity , quality and cost) were weighted equally. Limited experience
indicated that whilst the overall index was of some interest to the engineers who made
use of the information produced for prioritisation, all wished to review the results for
the individual indicators before decision-making and printouts such as that illustrated
in Table 15 adopted . A similar approach was adopted in Nepal, except that the
indicator 'cost' was omitted (Table 20).

Given the limited numbers of case studies in which prioritisation was attempted the
hypothesis may be accepted.

74
Table 20 Nepal: Format for calculation of summary of water supply service quality indicators

Data collected Indicator values

Population [a]
Number of households [b]
Number of standpipes [c] Conrage(¾)
Number of houses with household = {[b] + [d]} X 100 / [a]
connections [d]
School? yes / no
School tap? yes / no

Flow data
Flow entering at source [e] Vsec
overflows [t] Vsec Quantity supplied (I/person/day)
Flow delivered to taps and tapstands [g] = [e] - [t] = {g] X 86400} / [a]

Functioning
Water entering system on day of yes / no
inspection
Standposts /taps operating :
Tap I Tap2 Tap 3
Operating? y n Y n y n
Supply all day ? y n y n y n Continuity
Supply all year y n y n y n = (No of ' yes ' ) x 100 I 6

Sanitary inspection
Spring source :
hazard score / 10
hazard grade
Distribution system: Sanitary inspection
hazard score / 21 total score / 3 1
hazard grade
Faecal coliform count per 100ml
source / 100ml
highest count in distribution / 100ml Bacteriological grade
A / 8 / C/ D

3.2.6 Discussion and conclusions

The experience obtained from the case studies indicated that rankings based upon
sanitary conditions could be developed and used to support operational planning.
Nevertheless relatively little experience exists with respect to integration of different
parameters of water supply service quality and none with respect to integration of
supplied and un-supplied populations. Considerable potential exists to refine this and
is discussed further in Section 4.4.

75
Despite potential rejection, evidence suggests that key staff are receptive to
information products of monitoring which assist in decision-making within real-scale
constraints. Whilst some success in information presentation was detected,
considerable scope for further development of this exists (Snell , 1994) and is
discussed further in Section 5.2.

Adequate evidence exists to accept this series of hypotheses and the effectiveness of
this linkage in ensuring improved drinking water supply. Nevertheless it is apparent
that there is considerable scope for optimisation and an important limiting factor in all
study areas was the low level of attention given to rehabilitation especially in
comparison to construction of new systems in an attempt to extend coverage. The
poor credibility of coverage targets as a means to encourage water supply
improvement has been noted previously (Anon, 1995) and evidence suggests that
emphasis of such targets may detract from ensuring functioning of established water
supplies.

3.3 Support for Operation and Maintenance by Formal Water

Supply and Construction Authorities

3.3.1 Formal authorities responsible for operation and maintenance are a

significant feature of rural water supplies and/or construction authorities
maintain a role in operation and maintenance
In Egypt, Govemorates through their Housing and Utilities sections retained direct
responsibility for water supply, even in rural areas and in some areas of Pakistan
Public Health Engineering Departments (PHEDs) had progressively assumed an
increasing responsibility for rehabilitation, operation and maintenance such that in one
area (Peshawar) it commanded 60 per cent of the budget. The PHEDs and national
authorities considered this inappropriate and measures were in hand to reduce this

76
activity. However overall in the case studies it was much more common to find
construction authorities handing over water supply operation and maintenance to
community authorities as was the case for example in Nepal. In several cases
construction agencies retained informal interest in the supplies they had constructed
but this was primarily oriented towards rehabilitation , as described in Section 3 .2, and
not towards operation and maintenance.

Table 21 Construction and supply authorities in rural Peru

Agency Number of Systems Percentage of all

Systems
Construction and supply agencies

Local Councils 3
SENAPA 4
Constrution authorities

DISABAR 217 70
COOPOP 10 3
Self-funded* 23 8
others/unknown 52 17

• these figures may be under-estimates because of problems in identifying systems of this type.

In the case of Peru I, both situations occurred, although community management was
much more common and direct formal supply authority management was limited to
the larger (still rural) supplies. Local councils and SENAP A represented supply
authorities whilst a number of other agencies were involved only in construction
(DISABAR, COOPOP and self-funding communities). The frequency of
'administration' by each of these authorities is presented in Table 21.

The overall situation encountered in the case studies with regard to the management of
operation and maintenance of rural water supplies is summarised in Table 22. It is

77
evident that direct operation and maintenance by formal water supply and construction
agencies is unusual.

Table 22 Management of rural water supplies in the case studies

Case Study Principal Form(s) of Management of Role of Non-community-based

Rural Water Supplies Agencies in Operation and
Maintenance

Colombia Community committee None after initial orientation by

construction agency
Egypt Local government Local government operation and
maintenance .
Nepal Community member None after initial orientation by
construction agency
Nicaragua Community committee Water supply agency support to
community operation and maintenance
established during the initiative
described in the case study; previously
none
Pakistan I Community None after initial orientation by
construction agency
Pakistan II Variable by region Substantial by PHEDs in some areas
but this considered inappropriate by
them and attempts in hand to reduce it.
Peru I Community committee None after initial orientation by
con struction agency
Yemen Traditional community authority None after initial orientation by
construction agency

An anomalous situation exists in some areas where rural water supplies are
extensively inter-connected, either with one another or with urban conglomerates,
creating large water supply systems which is more amenable to a fonnal
administration. Substantial inter-connection was encountered in some systems in Peru

78
I, where management was still community-based and - despite the additional
complexity of management - no additional support had been provided to community
authorities to assist them in coping with this. In contrast in parts of Egypt and Yemen
inter-connection generally included urban areas and management being subsumed
within management of the urban system. Since this is relatively uncommon and
outside the principal thrust of this thesis it is not discussed further.

3.3.2 Routine monitoring can detect operation and maintenance requirements

Because operation and maintenance requirements are system-specific this hypothesis
is substantially supported by the evidence presented in Section 3. I . I which is not re-
presented here. However the need for standardisation amongst responding staff is less
here than in the case of generation of information for an overview assessment. In all
cases an excess of operation and maintenance requirements were identified and again
this is supported by the evidence presented in Section 3.1.1.

3.3.3 Information links can be established between those responsible for

monitoring and for operation and maintenance and can contribute to operational
planning for operation and maintenance.
One example of routine linkages between different groups of staff responsible for
information generation and routine operation and maintenance was observed, in
Egypt. Govemorate organisation was such that two different Departments (generally
'Health' and 'Housing and Utilities') were responsible for water supply monitoring
and water supply respectively. Whilst monitoring was limited to water quality and
was initially by water quality analysis alone, detection of failure was immediately
communicated to the Housing and Utilities Department and followed up by sanitary
inspection. No direct evidence for the efficiency of this in controlling hygienic risks
was accumulated, but clearly rapid information flow occurred and appeared to be
clearly linked to remedial actions.

79
The overall findings concerning this hypothesis are limited. The information link was
effective and action was taken, but because of limitations to the information collected
by the monitoring programme it is unclear whether this lead to a substantial
orientation of operation and maintenance activities.

3.3.4 The operation and maintenance and monitoring functions can be

effectively integrated
The integration of monitoring with operation and maintenance functions was
attempted in two cases studies. In Peru I an attempt was made to equip monitoring
teams to support community level operation and maintenance directly, in Nepal a
similar approach was adopted. Limited evidence also exists from Pakistan I.

In both Peru I and Nepal broadly similar experiences were obtained:

• Operational planning for monitoring was found to be relatively rigid in practice.
The timetables of work were not amenable to change to accommodate the
(unpredictable) need to remain in a community in response to detected problems.
This was a particular problem in these countries where the cost and time involved
in a follow-up visit were substantial.
• In both cases staff was already extensively multi-tasked, functioning as water
quality analysts, sanitary inspectors and ad hoc educators. To add further
responsibility was badly received by both staff and their supervisors and was of
questionable effectiveness in practice.
• Within the parent organisation, even if responsibility for operation and
maintenance and for monitoring were accepted action areas, relative budgetary
contribution and managerial authority was a theme of conflict in Peru.
• Basic materials for minor repairs were not available in communities. In Peru this
could be readily overcome logistically because four wheel drive vehicles were the
preferred means of transport. In Nepal however where all materials were carried
over periods of days - weeks this was a potentially-important limiting factor.

80
• In both areas the principal of community management existed and authorities
expected communities to take responsibility for operation and maintenance of their
water supplies. Although this was only moderately effective in practice, very
considerable concern existed that a regular and reliable external support function
for operation and maintenance would further reinforce community perceptions that
the water supply system was 'owned' by an outside agency (whether governmental
or non-governmental) and undermine the principle of community responsibility
for operation and maintenance.

In Peru in addition, management was unwilling to 'trust' field staff to organise their
programmes of work on arrival in communities and administrative systems were
inflexible in providing field expenses to such staff.

In the case of Nepal the initiative was further undermined by the rapid turnover of
staff (lost to work in the middle east) and therefore to the high investment in training
of multi-functional staff.

In Pakistan II some PHEDs undertook substantial operation and maintenance

activities. Their mandate for monitoring (as for operation and maintenance) was
unclear and monitoring capacity negligible. No evidence indicated that monitoring by
PHEDs or by other agencies influenced these operation and maintenance activities.

3.3.S The influence of monitoring on externally-managed operation and

maintenance can lead to improved water supply
In light of the very low level of externally-managed operation and maintenance
activity in all study areas no significant evidence is available concerning this
hypothesis.

81
3.3.6 Discussion and conclusions
The following discussion is related to that for Section 3.5 which considers the role of
monitoring in support of community-based operation and maintenance. Some overlap
is inevitable between the two sections, although each is oriented to and emphasises the
specific aspects of relevance to the linkage concerned.

The evidence provided by the case studies indicates that whilst linkages can be
established and can lead to action, the scale of activity of formal water supply and
construction agencies and their (un-)willingness to enter into operation and
maintenance effectively prevented operation of this information-action linkage. In
many countries, responsibility for operation and maintenance remains a grey area. As
long as responsibility for operation and maintenance remains unclear between
agencies and users either in formal terms, or in practice, there will be little incentive
for any agency, community-based or otherwise to take action and in these
circumstances little improvement in sustainability of completed projects has been
detected (Appleton, 1995b).

Despite considerable rhetoric concerning the importance of operation and

maintenance, evidence from the case studies and literature suggests that operation and
maintenance activities receive proportionately less attention than they would logically
deserve (Mather, 1995); especially in light of the high return from investment in
maintenance - nearly always higher than for new investment (Robinson, 1991). This
may be related to the fact that operation and maintenance suffers an image problem. It
is less glamorous and challenging than new construction for engineers and technicians
seeking to develop their career; there are less profits for contractors and entrepreneurs;
and it is less visible for politicians and for external support agencies (Okun and
Lauria, 1992; Mather, 1995). In such an environment it would be unlikely that a
supportive role to operation and maintenance would be effective without substantial
political commitment to operation and maintenance and this would apply specifically

82
to the development of a supportive role developed by a monitoring agency for sector
agency operation and maintenance.

It is clear from the introduction to this thesis (Section 1.2.3) that a potential
contradiction exists between the proposed role of government as regulator and
facilitator and the community management ethic and it has been claimed that attempts
to manage operation and maintenance through centralised, governmentally-controlled
organisations have proven unsustainable (Appleton, 1995a). The concern expressed in
both Peru and Nepal that direct support for operation and maintenance through
monitoring might undermine the principle of community management therefore is an
important one. It would appear unlikely that this could be resolved such that an
agency undertaking water supply monitoring could directly support operation and of
rural water supplies by formal sector agencies. Not only would the effective subsidy
by the (generally public sector) monitoring agency of the water supply sector through
provision of monitoring services be unlikely to be acceptable but such a development
would tend to focus attention on the quality of service provided by means of
established supplies rather than on areas of typically greater public health priority
such as un-served populations, private supplies and in-house contamination.

It is concluded that direct intervention by formal agencies may be possible but would
counter the prevailing political trend towards minimisation of direct government
intervention. Whilst the linkage may therefore be effective through government
agencies, it is highly unlikely to be so in the prevailing political environment
favouring reduction of direct government intervention and no example of a
comparable private sector initiative was detected.

83
3.4 Standards and Enforcement

3.4.1 Failure to comply with water supply standards selects those supplies
presenting greatest public health risk either because the rate of failure is low or
because measures for progressive implementation exist and are used.
In all study areas where data were available the rate of failure of prevailing standards
represented a substantial proportion of all water supplies. Data are summarised in
Table 23 and should be taken as indicative, as some countries require prescribed
sampling frequencies or intervals or re-sampling (daSilva and O'Kane, 1989) and
these were not routinely followed in the studies cited. It is unlikely that following
such procedures would substantially alter the rate of failure from that indicated in the
Table 23.

Table 23 Indicators of the rate of failure of drinking water supplies in the case studies

Case Study Standard Failure Rate

Colombia Water quality I 00% (sample of 8 piped

systems)
Pakistan I Water quality 80% (regular visits to five piped
systems; fifth failed occasionally
and technically also infringed
standards)
Peru I Water quality 79% (sample of 307 piped
systems)
Romania Water quality 43% (sample of 150 wells)
Construction standards I 00% of wells failed water
supply construction standards

In none of the study areas was there legal provision for progressive implementation
and in none was such a strategy coherently articulated by the agency responsible for
enforcement.

84
3.4.2 Rural water supply monitoring can generate legally-valid results
Since enforcement was not utilised in any of the case studies the evidence presented
here is derived exclusively from the published literature.

There are two principal problems associated with the legal validity of monitoring data
concerning piped rural water supplies in developing countries. Both apply
particularly to water quality:
• demonstrable analytical quality
• adequacy of the quantity of data

Demonstrable analytical quality

The conditions under which small community water quality sampling and analysis are
undertaken in many countries are such that their legal validity could be readily
challenged .

The scientific basis for water quality analysis and problems encountered in generating
scientifically-valid data are also of importance for several other hypotheses and are
discussed separately in Section 4.3 .2. That section concludes that, under the
conditions which prevail in rural water supply and quality monitoring in many
countries scientifically valid data can be generated. Nevertheless, most legal systems
would accept a challenge to the assuredness of the quality of water quality data that
were generated in other than well-recognised fixed-site laboratories and where
analyses were performed within a short and sometimes pre-defined time period
following collection (Goldstein, 1995). This situation is likely to become more
exacting as the emerging trend toward laboratory certification will lead to greater
centralisation of testing in fewer, larger facilities (Briggs and Bartram 1993). As
described in Section 4, analysis of the microbiological quality of water samples from
rural water supplies in developing countries often occurs through use of on-site
monitoring equipment, portable testing equipment or in small local laboratories and in

85
many circumstances such approaches may yield better quality data and be preferable
to analysis undertaken in a central facility to which travel times may be prolonged.
There is therefore a conflict between the reality of constraints to the generation of
scientifically valid water quality data for the rural sector and the exigencies of legal
approaches to enforcement (Goldstein, 1995).

Adequacy of the quantity of data

The issue of sufficent quantity of data in relation to regulatory enforcement has two
dimensions: that directly associated with legal enforcement (ie fulfilling regulatory
requirements of sampling and analysis); and that of representativity of data in order
that legal enforcement is based upon a reasonable assessment of relative priority.

Some regulations - for instance in Colombia - provide for minimum frequencies for
monitoring of drinking water supplies which would be both difficult and costly to
fulfil. Whilst the general issue of failure of the monitoring agency to comply with
their statutory obligations is not discussed here, a failure to comply with requirements
for the frequency and timing of sampling would be a reasonable basis for a legal
challenge to any prosecution. The effect of seasonality is well-recognised and
provides a firm justification for the suggestion that this is a significant confounding
factor (Blum and Feachem, 1983; see also section 4.2.4).

Monitoring of small community water supplies is not undertaken at a frequency (and

sometimes an intensity) which would be expected to provide a reasonable estimate of
water quality in distribution (the problems of water quality sampling frames are
discussed in Section 4.2.5. Whilst it might be argued that a gross failure is a gross
failure whether or not it occurs year-round, non-representativity of the results of
monitoring would undermine the capability of legislation to utilise the concept of
prioritisation (ie the system judged to be of highest priority based on samples taken on
a single day might be of intermediate or low priority were the analytical results of
samples taken on other days to be available.

86
Other workers have also emphasised that judgement of the quality of the supply
should never rest upon a single sample and the need for regular testing in monitoring
of small community water supply (see for example Lloyd, 1990).

3.4.3 A legally-definable person or agency exists who may be held responsible for
a water supply and against whom legal proceedings may be instigated
The lack of clarity in responsibility for operation and maintenance of rural water
supplies has been discussed in Sections 3.3.1 and 3.3.6. This refers especially to the
de facto situation and in most case studies a definable person or agency could be
identified who was, in a legal sense, responsibl e for its adequate operation.

Table 24 Legally-recognisable persons or agencies responsible for rural water supplies in the case
studies

Country/Project Name Nature

Colombia Comite de Agua Committee required by the construction agency to

Potable (Drinking legally receive system and ensure collection and
Water Committee) transfer of community financial contribution soon
after construction
Egypt Govern orate Local Government
Department of Housing
and Utilities
Peru I Junta Administradora Committee required by the construction agency to
(administrative legally receive system and ensure collection and
committee) transfer of community financial contribution soon
after construction
Peru II none Whilst existent, the systems were not recognised
by the State and have no legal status.
Pakistan Village Organisation check

It is unclear whether this situation is reflected globally although some commentators

have suggested so (Appleton, 1995a). Visscher et al (1996) note that in Colombia

87
water committees were 'legalised' in 1974 as autonomous entities encharged with
administration, operation and maintenance. Many other commentators note that
community management of rural water supplies is important, common or the
' keystone' (Anon, I 992a; IRC , I 995b, while Gibbons (1996) asserts that ·... the
majority of projects still do not transfer system ownership to the communities as a
matter of Government policy '. The importance of this, if it is the case, is doubtful
given that the same author notes that 'Even when state governments retain legal
ownership of the water system , communities remain responsible for system
management' and that 'it is not clear if projects are moving towards community
management because governments no longer want to assume responsibility for these
services , or because of the belief that management should occur at the lowest
possible level.

It is concluded that whilst not universally true and varying between countries it is
common that a legally-definable person or agency, responsible for the operation and
maintenance of rural water supplies, can be identified.

3.4.4 Legal action or the threat of legal action will lead to improved water supply
in those communities targeted by it.
No examples of use of legal action or the threat of legal action were encountered in
the rural sector in any of the case studies; and this accords with the observation that in
less developed countries laws and regulations are seldom enforced (Okun and Lauria,
1992).

3.4.5 Discussion and conclusions

Institutions concerned with water management generally may be classified according
to function, one of which is recognised to be 'monitoring and inspection' (Caponera,
1992). In the case of water supply, this role is generally recognised to be best
undertakenby an independentagencyand generallythat responsible for public health
- typically within the line structure of the Ministry of Health or the health

88
administration in local government (WHO, 1976; WHO, 1984). In every case study
an institution of some type undertook a function broadly identifiable as the monitoring
and inspection role, normally referred to as 'surveillance' in the context of monitoring
of water supply services.

In general terms, the information generated by the independent surveillance function

could be considered suitable for use to help enforce standards for water quality.
However this must be done sensitively, taking into account the feasibility of carrying
out remedial actions and linking enforcement to strategies for progressive
improvement (Rickards and Bartram 1993).

It should be noted that it is often assumed that village water committees or their
equivalent have legal status (see for example Appleton , 1995a). Although this is not
invariably the case (Gibbons et al, 1996), it does appear to be commonly so.
Nevertheless it is worth emphasising that the legal standing of such committees does
not imply that regulatory enforcement would have value. Conspicuously, it would
often be morally indefensible to treat failure to maintain a safe rural water supply by a
volunteer caretaker or partially-remunerated community member as a criminal act and
it would be unlikely to fulfil the any of the four purposes of basic criminal law
(specific deterrent, general deterrent, incapacitation or rehabilitation); whilst treating
the offence as a civil one would move the burden onto the employer, in this case the
community itself.

The difficulties of applying a regulatory/enforcement approach to small community

water supplies is not limited to the developing world, but is also a well-recognised
problem in the European Union. The principal problems there are perceived to be the
(high) number of criteria, the number of points to control and the cost of control (ie
monitoring) (Irwin-Maxwell, 1993).

89
Clearly this series of hypotheses is substantially unfulfilled and in rural areas outside
the established market economies it is hard to see how this function could be usefully
performed in any routine manner, because of a series of major limitations. These
include:
• the problems of generating information which would not be subject to challenge in
a court;
• the ineffectiveness of seeking to prosecute those responsible for operation and
maintenance of rural water supplies who are typically volunteer caretakers or
partially-remunerated community members ;
• the sometimes confused legal status of water supplies, where for example
government may 'own' infrastructure but make community authorities responsible
for operation and maintenance; and
• the moral imperative upon construction agencies to ensure that community
authorities are prepared to take responsibility for operation and maintenance.

It is concluded that enforcement of water supply standards in community-managed

supplies is generally an ineffective mechanism for securing improved water supply.
This conclusion is not necessarily unusual. Thus for example Sabatier (1977) has
argued that any environmental health agency has to rely primarily upon voluntary
compliance. It is nevertheless contrary to the claims of several sector commentators,
including Lloyd and Helmer (1991) and LeMoigne (1996).

Such a conclusion does not imply that legislation should not be in place that would
enable prosecution in exceptional cases, but rather that such legislation should not
form the basis of monitoring activity and legal enforcement should not be seen as a
significant mechanism through which to promote improvement (Goldstein, 1995).

In light of the above, perhaps one of the most significant general observations
regarding this section therefore concerns the apparent contradiction between
monitoring conception/design and practice in government agency driven programmes.

90
Such programmes included Colombia, Egypt, Pakistan and Romania and is also the
case in Albania. In all cases the principle underlying programme conception and
design was assessment of compliance with (principally water quality) standards and in
some monitoring programme design was stipulated in statutes or regulations. In none
was the use of legal instruments used on more than an occasional basis by the
monitoring agency and not at all in the rural sector.

3.5: Support to Community-based Management

3.5.1 Community management of rural water supplies is significant and

community authorities exist with whom information linkages may be established.
Findings regarding the responsible agency for management of rural water supplies in
Peru I and across the case studies have been presented in Tables 21 and 22
respectively (Section 3.3.1). In Peru, and in all other case studies except Egypt, direct
community management of rural water supplies was , at least in theory, the form of
administration of the majority of systems. The prevalence and lifespan of village
committees established at the time of construction varied within and between
countries

In the case of Peru I, the community drinking water committees were established by
DISABAR (the construction agency) with the main objectives of promoting
community participation in the construction stage (ie to ensure availability of labour),
partial cost recovery and subsequent administrative responsibility for the service. The
committees had to adopt a standard constitution. They received little training or
supervision except visits during the period of cost recovery in which no technical
support was provided. The result of this strategy is reflected in findings concerning
indicators of water supply administration from the Central Region of Peru presented in
Table 25.

91
Notwithstanding the existence of administrative committees, the degree of failure of
this strategy is attested to in part by the rate of occurrence of maintenance
requirements (see Table 4). Furthermore, evidence for failure comes from the
literature. In a study of 50 Colombian rural water supplies reported by Visscher et al
( 1996) it is reported that 50 per cent had trained operators but only one had adequate
equipment to do the job with which they had been encharged.

Table 25 lndicaton of water supply administration as found in rural communities in the Central
Region of Peru, 1986-7

Indicator Percentage of
Communities
Administrative committee 93
Tariff collected 71
Operator 67
Access to tools 43
Operator trained 43

In Nicaragua a survey of 63 supplies, all less than 10 years old, found that the
committees had all disbanded on completion of the construction of their system and
had never assumed responsibility for operation and maintenance.

The observation of low level of training of community operators supports the

assertion by Visscher et al (1996) that those responsible for rural water supply are
seldom properly trained and specifically that this is the situation of the majority of
water committees of Latin America. These authors assert that the situation is
deteriorating with cutbacks in government organisations (see also discussion in
Section 1.2.3).

Whilst responsibility for a water supply may be handed over to a community

authority, such authorities or may formally accept responsibility in receiving the

92
system but not accept that this requires action from themselves . In most of the case
studies there was disharmony with regard to responsibility to operation and
maintenance. Whilst un-quantified, rejection of responsibility for operation and
maintenance by community authorities was encountered in Nepal, Peru I and Pakistan
I.

3.5.2 Operation and maintenance is inadequate at a significant frequency.

Extensive data concerning the rate of failure of rural water supply has been presented
in Sections 1.2.5 and 3.1 where information is presented from the published literature
and case studies respectively . In Nepal for example it was noted that operation and
maintenance failed at an early stage and system failure inevitably followed.

In Peru I, in only a small proportion of cases were administrative failures attributable

to the communities themselves. Survey results assessed the each community's interest
in collaborating in the improvement of their water supply. Ninety seven per cent were
amenable to provide labour and 39 per cent to contribute financially. Similarly in
Nicaragua 56 of 63 communities eventually participated in some form of operation
and maintenance sometimes including substantial rehabilitation. The case study Peru
II is very specific and whilst only two organised water supplies existed or were under
construction at the time of the study, both had been initiated, implemented and were
being managed by community authorities directly. These data imply that with
appropriate support self-help programmes of rehabilitation, repair, operation and
maintenance by communities could realise substantial improvements in water supply
service quality.

3.5.3 Routine monitoring can detect operation and maintenance requirements

This hypothesis is also used in investigating the linkage concerning support for
operation and maintenance by formal water supply and construction agencies (Section
3.3) and this is identical to that of 3.3.2. The findings are not repeated here and the
reader is referred to that section.

93
3.5.4 Communication linkages established with community authorities can lead
to effective community action in operation and maintenance
A component of the monitoring function as practised in Colombia, Pakistan I, Peru I
and Nicaragua was the direct reporting of findings to community authorities. In the
majority of cases reporting of findings of monitoring to community authorities was an
innovation or substantial change during the intervention described in the case studies
and had either not been practised, had only been practised where problems were
identified, or had been limited to the reporting of laboratory analytical results
previously. In these four case studies some form of direct presentation was adopted,
typically through monitoring staff providing written reports and discussing them with
community representatives.

In some case studies (Colombia, Peru I, Nepal) modified reporting was established
indicating various parameters and their adequacy and specific problems where
identified. Such reporting was intended to encourage and facilitate operation and
maintenance and remediation by community authorities (Lloyd and Bartram, 1991).

Evidence from direct follow-up indicated that identified problems were sometimes
acted upon by community members. The likelihood of success in this depended on
feasibility and ease of action and the degree of emphasis and advice given by the
monitoring team when reporting. Follow-up monitoring visits whether routine or
specific appeared to be a strong motivator.

Only in the case of Nicaragua did the strategy amount to comprehensive support for
community-based operation and maintenance. This work combined routine
monitoring with hygiene education and community support including the explicit
objective of supporting operation and maintenance by communities. Over the course
of the programme 56 of 63 villages benefited from some support for community-based
operation and maintenance, 20 of which included a major rehabilitation.

94
3.5.6. Discussion and conclusions
The following discussion is closely related to that for Section 3.3 which considers the
role of formal water supply and construction agencies in operation and maintenance.
Some overlap is inevitable between the two sections, although each is oriented
towards and emphasises the specific aspects of relevance to the information-action
linkage concerned.

The experience of the case studies, which is coherent with the published literature,
shows a rural water supply sector comprising diverse means of supply and with
diverse types of infrastructure, many of which fail either permanently or temporarily
soon after construction and an alarmingly high percentage of the accumulated
infrastructure out of commission at any given time (Section 1.2.1).

Typically responsibility for operation and maintenance is handed over to community

authorities. Community authorities may be ill-prepared to accept this role and/or may
formally accept responsibility in receiving the system but not accept that this requires
action from themselves. Implementing support programmes for community
management is complicated by the perceived lack of clarity regarding responsibility
for operation and maintenance and reluctance of both community and external
authorities to accept responsibility for it. Whilst responsibility for operation and
maintenance remains unclear between agencies and users - either in formal terms, or
in practice - there will be little incentive for any agency, community-based or
otherwise, to take action.

Section 3.3 notes that operation and maintenance suffers an image problem. It is less
glamorous and challenging than new construction for engineers and technicians
seeking to develop their career; there are less profits for contractors and entrepreneurs;
and it is less visible for politicians and for external support agencies (Okun and
Lauria, 1992; Mather, 1995). If this is true of operation and maintenance per se, then

95
it is even more so of a poorly-visible supportive role to community authorities. In
such an environment it would be unlikely that such a role would be effective without
substantial political commitment to operation and maintenance and this would apply
specifically to the development of a supportive role developed by a monitoring
agency .

Despite considerable rhetoric concerning the importance of operation and

maintenance, evidence suggests that operation and maintenance activities receive
proportionately less attention than they would logically deserve (Mather, 1995);
especially in light of the high return from investment in maintenance - nearly always
higher than for new investment (Robinson, 1991). Appleton, 1995b asserts that
'There is growing evidence that, with the right support, community management of
improved water supplies works well'. This statement appears an optimistic
interpretation of limited evidence, and is unsubstantiated and supporting references
are not provided.

In a study from Kenya presented by Gibbons et al (1996), two contrasting types of

community-managed operation and maintenance are assessed , representing the two
most important forms in that country. In the first, piped water supply is a component
of a scheme developed to fulfil economic needs such as agriculture and livestock
watering and which as a result have rates of coverage of around 30 - 40 per cent. In
the second point sources are improved on a community-wide basis with an explicit
health objective. Community organisation is distinct for the two types, but outcomes
are similar in practice: routine maintenance is rarely performed and schemes typically
collapse when major breakdowns occur or as a result of poor financial management.
The case study concludes by noting that the 'development of an institutional
environment and an adequate legal framework supportive of community-managed
rural water supply projects would significantly strengthen the sustainability of such
systems'

96
The logic that the local nature of community water supplies makes it quite practical
for community-based organisations (such as village water committees) to take
responsibility for operation and maintenance has an obvious appeal (Appleton, 1995).
Nevertheless (and as noted in Section 1.2.4), whilst the thrust toward community
management has now been increasingly in fashion for more than 20 years and is rarely
questioned, the observation levelled by Feachem at the beginning of the Water Decade
remains valid: most positive experience with community management of water
supplies in rural areas remains at the level of pilot or demonstration projects (Feachem
1980). The costs of extrapolating to comprehensive national coverage may well be
prohibitive and where this is the case the international community is failing to provide
a direction for effective provision of water supply services to rural areas.

It is therefore conspicuous that there are very few published reports of critically-
evaluated large scale rural operation and maintenance programmes. Two are of
particular relevance here since they address the role of monitoring and assessment:
that from Western Province, Zambia reported by Sutton and Sutton (1991) and Sutton,
(1994); and the case study from Nicaragua.

The Zambian programme provides a nine year profile of operational and non-
operational wells (Figure 4) and clearly demonstrates the effectiveness of the
intervention. These authors ascribe the evident success of the initiative to four
factors:
• the adoption of construction techniques appropriate to the geological environment
• the adoption of proven hand-pump technology;
• the adoption of an approach to implementation based on principles of community
education and participation; and
• integration of project activities into the local government structure.

97
 Number of wells
900

800 NOT OPERATING

r:.il li..'!OPERATING

700

600

500

400

300

200

100

1980 1981 1982 1983 1984 1985 1986 1987 1988 1989

Figure 4 Well construction and operation in Western Province, Zambia (Sutton and Sutton,
1991)

Of a special relevance is the fact that a comprehensive support system requiring

increased involvement of many sectors of local government, resulting in a strong
support structure (which included monitoring and assessment) was considered
important. The authors emphasised the need for a strong structure involving all levels
of government and local structures. Such a conclusion is also supported by other
commentators (see for example Visscher et al 1996).

In the Nicaraguan case study, the available information would indicate that a
successful system was developed and implemented jointly by the Ministry of Health
and the water supply agency. The system was supportive of community-based
operation and maintenance and achieved significant and sustainable improvement in
water supply services. In doing so interventions were substantial, including for
example training courses for community members and preparation, printing and
dissemination of maintenance manuals to communities. Longer-term evaluation of

98
 effectiveness and sustainability is unfortunately impossible due to changes in the
political administration in that country and with it commitment to the approach
adopted .

Ironically, these successful interventions (Zambia and ~icaragua) might be considered

'inappropriate' by those supporting adoption of the 'new paradigm' described in
Section 1.2.3, since they were based upon substantial governmental intervention. In
this case, those supportive of the new paradigm of limited governmental intervention,
whilst encouraging government to adopt a 'facilitating' role are now therefore
struggling to identify a route forward, given the need to ensure skill training and
technical backstopping to communities (which also need to make decisions on the
levels of service and organisational arrangements for implementation which they can
sustain), whilst identifying means to achieve at low cost an effective mechanism for
intervention. Combined with the current polemic concerning decentalisation and
deconcentration, it would appear likely that responsibility for support to community
management will, in many cases, filter down to levels of local government which are
grossly under-resourced in both technical and financial terms and with little support
from central government (Visscher et al 1996).

At an operational level, logistical costs (such as staff time and transport costs) are a
major element of the cost of supporting any community managed activity by a central
government agency and also of rural water supply operation and maintenance. It is
therefore tempting to investigate the possibility of combining such functions.
Nevertheless there would appear to be substantial practical problems with this in
practice, especially the further extension of responsibility of field staff and the
intensity of visits to communities that would be required for an effective support
function. Improved relations with communities without direct action would
undoubtedly require well-trained monitoring teams as used in Peru I and Nicaragua
but could contribute to community operation and maintenance.

99
effectiveness and sustainability is unfortunately impossible due to changes in the
political administration in that country and with it commitment to the approach
adopted.

Ironically, these successful interventions (Zambia and ~icaragua) might be considered

'inappropriate' by those supporting adoption of the 'new paradigm' described in
Section 1.2.3, since they were based upon substantial governmental intervention . In
this case, those supportive of the new paradigm of limited governmental intervention ,
whilst encouraging government to adopt a 'facilitating' role are now therefore
struggling to identify a route forward, given the need to ensure skill training and
technical backstopping to communities (which also need to make decisions on the
levels of service and organisational arrangements for implementation which they can
sustain), whilst identifying means to achieve at low cost an effective mechanism for
intervention. Combined with the current polemic concerning decentalisation and
deconcentration, it would appear likely that responsibility for support to community
management will, in many cases, filter down to levels of local government which are
grossly under-resourced in both technical and financial terms and with little support
from central government (Visscher et al 1996) .

At an operational level, logistical costs (such as staff time and transport costs) are a
major element of the cost of supporting any community managed activity by a central
government agency and also of rural water supply operation and maintenance. It is
therefore tempting to investigate the possibility of combining such functions.
Nevertheless there would appear to be substantial practical problems with this in
practice, especially the further extension of responsibility of field staff and the
intensity of visits to communities that would be required for an effective support
function. Improved relations with communities without direct action would
undoubtedly require well-trained monitoring teams as used in Peru I and Nicaragua
but could contribute to community operation and maintenance .

99
Based upon both experience from the case studies and the published literature it is
concluded that the evident complementarity of governmental support for community
management of rural water supplies and responsibility for the independent monitoring
role can be translated into comprehensive support programmes. This however
requires substantial political commitment and suitable partners may not be readily
available. Very limited information is available regarding the cost of this approach
and a limited range of experiences are available upon which to draw for extrapolation
to other environments. Nevertheless, the present policy environment and pressure to
reduce governmental intervention renders it extremely unlikely that interventions of
this type will receive significant support in most countries or from external support
agencies. It is therefore essential to resolve fundamental problems of institutional
arrangements for the support structure for operation and maintenance by community
authorities can be developed and implemented. This is in accord with other
commentators such as Robinson (1991) and Appleton (1995b ).

100
 Section 4:
Data Acquisition

'Experience has shown that progress towards implementing the

actions and achieving the goals of water programmes
requires follow-up mechanisms for periodic
assessment at national and
international levels ... '
(Anon, 1992a).

The emphasis of Sections 2 and 3 of this work has been on the linkages between
information and actions tending to improve the provision of water supply services.
Having investigated the effectiveness of individual linkages, this Section addresses
experience with and implications for data acquisition. In doing so the experience
obtained from the case studies is reviewed in the context of the published literature.

This Section is divided into four principal parts: indicators, which reviews the
experience with the use of the five indicators of water supply service quality
introduced in Section 1.1.4; approaches to data acquisition, which explores the

101
implications of the observation that full coverage monitoring is not necessary to
' drive' the effective information-action linkages and assesses information
requirements for estimation of each indicator; and data collection methods which
looks at the approaches adopted and lessons learned.

4.1 Indicators of Water Supply Quality

The proposal made in 1987 to utilise five quantifiable indicators of water supply
service quality (coverage, quantity, continuity, quality and cost) has been described in
Section 1.1.4. Experience with the use of these both in the case studies and from
elsewhere is reviewed below and conclusions drawn regarding indicators of
preference for operational water supply monitoring and assessment programmes.

4.1.1 Coverage
It is widely accepted that 'coverage', that is a division of populations into 'haves' and
' have nots', represents the most useful single measure of water supply as illustrated by
the emphasis upon coverage targets in the IDWSSD (Anon, 1977; Anon, 1990) and
subsequently at the Noordwijk Conference (IRC, 1994c). This concept of 'coverage'
is a myth. Except that tiny proportion of the global population which has an absolute
lack of water, coverage is 100 per cent. Everyone drinks water, the differences relate
to the nature and quality of provision and the adequacy of these with respect to basic
needs and principally needs for health. "Coverage' refers to access to an organised
water supply of some type, whether an improvement or not on traditional sources and
does not necessarily imply the adequacy, reliability, convenience, acceptability or use
of the supply. Two particular problems are encountered with national data sets were
especially common: firstly for small rural communities the unit of assessment is often
the community. Thus a community is 'covered' if it has benefited from an
intervention, whatever percentage of the population actually attained an improved
water supply. The assumption of 100 per cent coverage within a ' covered' village is

102
common (Appleton. 1995b) . Secondly ' improvement' is permanent: often no capacity
exists to remove a community from the list of those 'covered·. whatever the scale of
deterioration or breakdown of water supply which. Furthermore since 'official'
interventions are generally the basis for coverage calculations. many community or
private initiatives. especially if small scale are ignored in the calculation of coverage .
Such fundamental problems in coverage figures have been reported from India (Anon ,
1990a) and were found in the case study Peru I.

In the case study Peru I, 'rural coverage' in the central region was claimed to be 54.4
per cent by the national construction authority (DISABAR) as of 1984. On
investigation it was found that this figure referred to the percentage of communities
within a given size range with a water supply rather than the percentage of the total
rural population actually supplied with water. Following correction for actual
coverage within communities, for all rural centres of population (defined as those of
less than 5000 inhabitants) this amounted to a population coverage of 20 per cent.
This figures failed to take into account the disperse population living in settlements of
less than 200 inhabitants. If coverage amongst such communities was assumed to be
zero then the overall population coverage with improved water supply in the rural
sector (defined as population centres of less than 5000 inhabitants) was only 8.1 per
cent in the central region. Even this extremely reduced figure, fails to take account of
the proportion of supplies which are out of commission at any given time because of
breakdowns or maintenance failings.

In other areas, similarly misleading statistics have been quoted. Thus in the case
study from Yemen it is noted that coverage figures are based upon the population
intended to benefit from improved supplies and were likely to be a considerable over-
estimate; in Nepal - whilst a national database of both government and non-
government water supplies was in preparation - it was not uncommon to find more
than one supply system per village; finally Taylor (1993) notes that in Zimbabwe,

103
coverage is purely theoretical and based on the assumption that one borehole 1s
adequate for 250 people. regardless of the real level of functioning or use.

The issue of usage is vital if health gains are to be secured from interventions in water
supply. Several case studies and notably that from Egypt note the frequent use of
secondary sources. Other workers have noted that contaminated - but more accessible
- water sources are frequently used because convenience is more important to
consumers than quality (Smith, 1991 ). Thus for example, Caimcross (1990a)
describes the influence of time taken to collect a bucket of water on the average
quantity used for domestic purposes in litres per capita per day as illustrated in Figure
5. He notes that whilst the height of the plateau depends on local circumstances, the
general shape of the curve seems not to vary.

so

,I()

,S'
::.
.£ JO

..
i
:s
0
20

10

0
0 10 20 JO 50

Time(min)

Figure 5 Schematic representation of how the time taken to collect a bucket of water affects the
average quantity used for domestic purposes in litres per person per capita per day.

Note the plateau for times less than 30 minutes. Although the exact height of the plateau depends on
local circumstances, the general shape of the curve seems not to vary (Cairncross, 1990a).

104
The implication is clearly that volume used decreases very rapidly for even the most
accessible (ie household) source and even the difference between multiple taps in
house - single tap in house - yard tap may influence the volume used. Whether this
change in volume used is translated into health gain remains unclear from the
published literature.

Emphasis on monitoring of coverage has proven to be one of the greatest real

impediments to the development of an understanding of the situation in the water
supply sector. The focus upon coverage during the IDWSSD has been blamed for an
emphasis on installation, not sustained utilisation (Anon, 1990a) and it has even been
argued that since 'few of the goals (of the Water Decade) were achieved ... the
credibility of national coverage goals as a mechanism for encouraging water and
sanitation improvements suffered' (Anon, 1995, p3) .

There is no clear health gain-related basis for simple coverage monitoring.

Nevertheless there is good reason to believe that means of provision (level of service)
has a link to health. Thus for example:
• different means of provision lead to increased or decreased use of water for
personal and domestic hygiene and evidence has been presented to relate, for
instance, transmission of some pathogens with service level directly (McJunkin,
1982 for Shigel/a; Esrey et al, 1991 for Ascaris and diarrhoeal disease; Edungbola
et al, 1988 for Dracunculiasis);
• certain means of provision are associated with greater or lesser difficulty in
maintaining water quality (regardless of the quality of water at source) (Bartram,
1991); and
• different levels of service are associated with different quantity use characteristics
and, by implication, increased use for personal and domestic hygiene and thereby
health (discussed in Section 2.3 .2)

105
A change in monitoring approaches is therefore needed from 'who has water?' to
' how do people obtain water?'. Such a change would reflect the development of
sector thinking more broadly during recent decades. Until the I 970's those concerned
with public health engineering tended to emphasise the need for a comprehensive
solution to water supply: either nothing should be done or a filtered and chlorinated
supply to multiple taps should be provided (Bradley, 1993). During the period leading
up to and throughout the IDWSSD increasing attention was paid to intermediate
interventions (Anon, 1990; IRC, 1995b). This was in part driven by the recognition of
the balance between the roles of water as a carrier of disease and as a mediator of
personal and household hygiene (Section 1.1.2). Undoubtedly the effect of this on
reducing the unit cost of establishing supply enabled improved supply to be provided
to a greater number of persons. Thus the term and concept 'coverage' should be
replaced by 'means of provision/service level'. Whilst the unit of assessment used in
water supply monitoring would remain the village or community, for many purposes
the findings would be expressed in terms of the proportion of (village or total)
population receiving water by each means of provision/service level , with the
objective of describing the prevalence of different means of provision and levels of
service to the population as a whole . Such an argument does not contradict the
obvious benefits and desirability of maximising coverage with improved water supply,
the evidence for which is overwhelming.

Pragmatically a limited number of different means of provision/levels of service may

be recognised. These will depend to a large extent on national practice and relative
development in the country or region under consideration, but could breakdown, for
instance, as follows:
• multiple tap in house
• single tap in house
• private well or tap in yard
• public standpost, well or spring within 30metres
• public standpost , well or spring beyond 30metres

106
 • surface water source

None of the case studies included systematic analysis of means of provision/service

level and only one (that from Nicaragua) specifically integrated diverse means of
provision (from hand dug wells to piped supplies) . Apart from the potentially
embarrassing discovery that coverage rates with improved supply are, in practice,
considerably lower than had been believed, the principal objection to this approach
probably relates to its high perceived.

There is reason to believe that such information can be reliably and rapidly collected
by sanitary technicians after minimal orientation and information such as that in Table
2 generated (Lloyd et al 1991).

Table 26 Percentage coverage by supply type in the Health Department of Callao, Peru, first
quarter, 1989

Supply Type Percentage coverage

Domestic connection 78 .0
Tanker trucks 10.8
Public standpipe 6.0
Individual collection 2.8
Mixed (tanker truck and personal collection) 1.8
Private wells 0,6

Moving emphasis to the proportion of the total population with different levels of
service serves to emphasise under-provision, high-risk population groups and the de
facto means of provision where supply systems are non-operational.

107
4.1.2 Continuity

'Few communities in the developing countries

of Asia, Africa and Latin America
maintain 24 hour service·
(Okun, 1993)

There are few published studies which look at the impact of discontinuous water
supply on health and for the majority it is impossible to distinguish between effects
due to quantity, quality and continuity. Amongst the few, Edungbola et al (1988)
found that the beneficial impact of improved water supply on dracunculiasis incidence
was reduced where water supply was erratic (and also where unpalatable and more
distant). Similar findings have been reported by Bhatt and Palan (1978) and Stelb and
Mayer ( 1988) associated with failure of supply. No studies have been encountered
which address the effects of discontinuity arising from system breakdown . Given the
high prevalence of breakdown (Section 1.2.1) this is a significant omission and the
publication of findings on health gains arising from improved water supply, such as
Esrey, 1991, may be interpreted too positively if this is not taken into account.

The continuity of piped water supply impacts upon health through restricting water
availability for hygiene purposes and increasing the likelihood of contamination:
• restricting access for hygiene purposes. Continuity is therefore a conditioning
factor for the means of provision/service level;
• especially in piped supply to household connections, discontinuous supply may
force consumers to store water in the home. With increased manipulation of
water there is an increase in the risk of contamination (Bartram, 1991);
• discontinuous supply leads to an increased risk of in-pipe contamination in piped
water supply systems (Mahmood and Tahmir, 1988); and
• long-term (seasonal) discontinuity may force consumers to collect water from
alternative sources. Lesser volumes may be collected and used and may also be
of inferior quality.

108
There are socio-economic implications of several of the above as well as health
consequences, principally resulting from the increased time required for water
collection and its household management. Whilst of general importance, they are
beyond the scope of this thesis and are not discussed further.

Analysis of continuity data requires consideration of three principal variables:

breakdown, regular daily discontinuity and regular seasonal discontinuity. The
combination of the latter 'regular' types of discontinuity gives four classes of
continuity (Lloyd et al 1991):
• year-round supply with no disruption at tap;
• year round service with daily variation;
• seasonal service variation; and
• compound discontinuity (both daily and seasonal interruptions to supply).

Regular daily discontinuity typically arises from rationing, pumping regimes and daily
conflicts between supply and demand volumes whereas regular seasonal discontinuity
often arises from decreased availability of water at source or from seasonal demands
outstripping suppl y capacity. This resulted from washing of coffee 'cherries' in
Colombia and from watering of household vegetable plots in Nepal and Peru.

Nevertheless, and as discussed in Section 1.2.5, discontinuity due to breakdown is

likely to be that of greatest importance. Experience from the case studies indicated
that breakdown was not investigated or recorded systematically. Rather it was seen as
a failure in sampling which must be remedied by a return visit at some time.

Discontinuity was found to be common, although un-quantified, in the case study

from Egypt and lead to the common and frequent use of secondary sources. Taylor
( 1993) notes that operation of piped water supplies in Africa may be intermittent.
Experience from the case studies and notably those of Peru I and Colombia indicates
that information concerning continuity of supply may be readily and rapidly collected

109
at household level. The information is not perceived to be contentious. It is of
importance to the respondents where they are responsible for household management
(as is most frequently the case) and therefore well-recalled. Considerable accuracy in
responses from the public is therefore to be anticipated (see also Pickering, 1990).
Whilst requiring interview skills on behalf of the person collecting data, they are not
exacting.

Continuity is likely to be a robust indicator. Breakdown will generally be experienced

similarly by all households while other forms of discontinuity will generally affect all
or large proportions of the population similarly. The principal limiting factors
affecting the quality of information generated therefore relate to the representativity of
households visited and the reliable recall period of the persons interviewed . The
latter is not considered to be a major limiting factor where the person interviewed is
responsible for household mana gement , even for relatively extended periods (such as
one year) since breakdowns normally impact significantly upon household
management and are therefore well-recalled whilst both types ofregular continuity are
also likely to be well-recognised by recipients.

It is concluded that continuity of supply is likely to be a robust indicator, of clear

relevance to health which may be readily and reliably assessed with reasonable
likelihood of precision. It should be considered essential for the monitoring and
assessment of piped water supplies.

4.1.3 Quantity
During recent years considerable emphasis has been placed on 'quantity' and a
substantial literature on this theme exists. Some of this relates to the concept of 'water
stress' (Falkenmark and Widstrand, 1992), addresses general demands for water
(agriculture, industry, domestic etc) and has received wide acceptance (see for
example World Bank, 1992; Gleick, 1993). A significant literature also concerns the
relationship between quantity of domestic water supply and health indicators (see for

110
example Cairnross and Cliff, 1987; Esrey et al 1989, Freij and Wall, 1977, Lindskog
eta/ 1987; West eta/, 1989)andreviewed(forexampleEsreyeta/ 1991). The
quantity of water per se rarely has a direct impact upon health, although when access
is restricted it has a major impact upon personal and domestic hygiene (and thereby
health). Where access to water is extremely limited, the volume used per capita per
day therefore acts as a useful indicator of accessibility.

There is general agreement that there is a cut-off value, typically somewhere in the
range 20 to 40 lpd at which water quantity becomes an absolute limiting factor for
personal hygiene (see for example Anon 1995; Anon, 1992c; Mara, 1990). Evidence
also exists for incremental health benefits beyond this range. Thus Lloyd (pers comm)
found an inverse relationship between rates of dysentery and water use in the range
20 to 50 lpd in Bangladesh.

The issue of effective use of small volumes of water for health gain is illustrated by
the study reported by McCauley et al (1992). In the community in Tanzania which
they surveyed, 60 per cent of all pre-school children had active trachoma and 10 per
cent severe eye disease. Children with unclean faces were found to be at an increased
risk compared to children with clean faces, suggesting that the transmission of
trachoma amongst children might decrease if faces were kept clean. Eye disease was
considered a serious problem by the population which understood that it was linked to
poor sanitation; 80 per cent of pre-school children had unclean faces. The authors
found no association between the total volume of water in the home and face
cleanliness and some children living further from water sources were cleaner than
those living closer. Remedial action was initiated through hygiene education but
output indicators were not available at the time of reporting. The authors
hypothesised that the amount of water available in the home was not the major
determinant of cleanliness; rather water use priorities and perceptions regarding the
volume of water used in face washing.

111
The emphasis upon quantity has been driven by a legitimate scientific quest to
understand the nature of the linkages between water and health. The importance of
adequate volumes of water for achieving health benefits is widely accepted and some
evidence of threshold values and for volume-related health benefits is available. This
does not imply that estimation of quantity used per capita per day is a useful
monitoring tool. Thus:
• assessment of quantity use requires household-level investigations. This is true
both for piped and non-piped water supplies and the information may be
considered sensitive by those providing it, especially since any hygiene education
is likely to have addressed water use and hygiene (WHO, 1996; IRC, 1995b;
Feachem, 1984);
• extreme inter-household variations in volume used may exist with similar levels of
access to water as illustrated in the above-mentioned study (McCauley et al,
1992); and volumes collected in a single household may vary on a day-to-day
basis, especially in response to the health of the principal collector;
• since the impact upon health is indirect, small quantities may be used effectively
or large volumes ineffectively (McCauley et al 1992);
• even if volume use per capita is estimated, the uses to which the water is then put
is then an important confounding factor. Clothes washing represents an important
example which may be undertaken from the estimated volume or separately Piped
supplies are often used for non-health related purposes (watering of domestic
animals and household plots are generally accepted as legitimate uses of piped
water supply for example: Caponera, 1992);
• most estimates of volume needs are related to threshold effects amongst
populations with very restricted access to water supply (see Esrey et al 1985;
Esrey et al, 1991). Evidence exists for incremental health benefits with increasing
volume usage but as usage increases confounding factors dominate the
assessment;
• Finally , 'quantity' is subject to seasonal variation in both supply and demand .

112
Information concerning quantity of diverse types was collected in some of the case
studies. Most frequently an instantaneous measurement of flow entering supply
(sometimes corrected for detected overflows) was linearly extrapolated over 24 hours
and expressed per inhabitant (Peru, Colombia, Nepal); or at household level
information regarding collection was sought from those responsible for household
management (Nepal, Nicaragua). This involved questions regarding the nature of
container used, the number of journeys made and the number of persons using the
water collected. Both of these approaches are likely to be open to gross error unless
extensive data collection and verification are undertaken.

Flow entering supply varies greatly over a 24 hour period (Jordan, 1984), many
systems suffer gross leakage and neither volume delivery nor usage will be equally
distributed across households . Similarly it is unlikely that reliable information could
be collected at household level without very significant investment in observation and
interview and even if collected it is unclear whether it would be of significant use for
management purposes

For monitoring purposes and when considering piped supplies specifically, quantity is
dependent upon service level and continuity - both indicators which are more readily
and rapidly assessed. Certainly a 'quantity' estimate based upon a short-term
measurement of volume entering piped distribution expressed per inhabitant provides
negligible useful information for assessing the adequacy of water supplies for health.

It is concluded that for the purposes of health-based monitoring - especially of piped

rural water supplies - quantity is an inappropriate indicator of water supply service
quality. The data is difficult and time-consuming to collect and interpret , of poor
reliability and of limited relevance for health or decision-making . Means of
provision/service level and continuity of supply provide a reasonable indication of
access.

113
4.1.4 Quality
This section is specific to the issue of water quality as an indicator of water supply
service quality . Aspects of data collection , quality and presentation are presented in
following sections.

Information concerning the health impact of water quality has been reviewed in
section 1.1. It is clear that faecal pollution of drinking water supplies has a significant
impact upon health and that interventions to improve microbiological quality can have
a significant impact upon the control of diseases transmitted by the faecal-oral route.

The issue of identifying adequate indicators of water quality in the context of

monitoring rural water supplies is complex. WHO has consistently advocated sanitary
inspection as a vital and complementary measure to microbiological and residual
disinfectant water quality analysis (WHO , 1976; 1984; 1993) and their
complementarity has also been emphasised by Lloyd and Bartram (1991), Wheeler
and Bartram ( 1990), and Lloyd and Helmer ( 1991). These two tools for investigating
water quality are distinct . One relates to the susceptibility of a water supply system to
contamination and the other is an instantaneous measure of actual contamination (see
for example Lloyd and Bartram, 1991; Rojas et al, 1994 and Bartram, 1996). The
relationship between them and their results represents an area of debate (see for
example Lloyd and Bartram, 1991; Lloyd and Helmer, 1991)

Information concerning water quality was collected in some way in all case studies.
In all, water quality analysis for faecal indicator bacteria (thermotolerant coliforms or
E. coli) was employed and in some sanitary inspection by a range of methods,
primarily based upon WHO Guidelines (WHO , 1984). No case study utilised general
bacterial indicators of system hygiene or integrity.

The need to address service quality from the viewpoint of the recipient is important
(see for example Rojas et al, 1994). WHO has suggested that 'safe water implies

114
protection of water sources as well as proper transport and storage within the home '
(Anon 1995 p4) thereby supporting the idea that monitoring extends from source to
point of use. Few of the case studies systematically investigated quality throughout
supply to point of use. Water quality supplied will be different to that consumed
(Feachem et al, 1978; Shiffman et al, 1978. Most monitoring schemes were not
oriented so as to include investigation of household-level contamination and yet there
is good reason to believe that this is sometimes the principal source of faecal
contamination (El Hennawy, 1987; Beg and Mahmood. 1991; Government of
Pakistan, 1993). By separating and assessing different sources of contamination their
relative importance can be assessed and resources allocated to preventive and remedial
measures accordingly. This approach was adopted in some case studies (such as
Nepal) but not systematically. Most monitoring programmes are designed to assess the
quality of water in distribution, or retain vestiges of such an approach and water
samples are collected from taps, public collection points or occasionally dedicated
sampling locations. Where service quality (especially continuity) is poor, or where
the means of provision does not provide water within the dwelling, this provides no
indication of the quality of water as consumed. Many water quality sampling
programmes insist that taps are cleaned and water left to flush for a significant period
before sampling in order that the quality of water is not influenced by stagnation and
tap materials. Whilst valid as a procedure to investigate the quality of water in
distribution, the quality of water consumed is that water which has stagnated and
which has been influenced by tap materials, attached debris and subject to re-growth
(Payment et al 1993).

The value of water quality analysis and of sanitary inspection both in problem
identification and in promoting remedial action has been clearly illustrated in Section
3.1.1. In light of their successful application in the case studies, it is concluded that
the proposal that the indicator 'quality ' should be assessed by both water quality
analysis and sanitary inspection is sustained.

115
4.1.5 Cost
Technical thought and political stances are at present evolving regarding the
consideration of water as an economic and/or social good. Whilst this thought is
perhaps predictable in a decade which has seen dramatic changes in the political world
order , it also reflects a re-evaluation amongst the world's 'expert community'. Thus
for example the Dublin Conference on Water and Environment, preparatory to the Rio
Conference, considered as one of four guiding principles that water had an economic
value in all its competing uses and should be recognised as an economic good.
Importantly in expanding upon this the 'Dublin Statement' notes that 'within this
principle it is vital to recognise first the basic right of all human beings to have access
to clean water ... at an affordable price' (Anon, 1992a).

From a health viewpoint and as proposed previously (Lloyd et al 1987) , cost is only
relevant once it becomes a limiting factor in procuring adequate volumes of safe water
for personal and domestic purposes and this discussion will not therefore extend into
cost recovery .

Studie s abound demonstrating that costs paid by poor peri-urban dwellers for small
volumes of water of doubtful quality would be sufficient to finance loans for
household piped water supply (Briscoe, 1987). Bradley (1993) for example notes that
in Uganda unskilled urban workers may spend 10 per cent of their income on
acquiring very poor quality water in limited quantities whereas a person in a town in
the USA will require 1-2 days income a year to finance an abundant water supply.

Nevertheless, whilst considerable work has been reported in recent years in relation to
high expenditure s for procurement of water in urban areas, there is no parallel
development in rural areas; Lloyd and Helmer ( 1991) omit the indicator 'cost' for
monitoring of rural water supplies and restrict their analysis to coverage, continuity,
quality and quantity . In rural (in contrast to urban) areas, cost is rarely of concern as a
barrier preventing access to water. Thus is likely to be generally true: it is hard to

116
conceive of a rural (ie agriculturally-oriented) community where the availability of
water would be such that sale of small volumes at exorbitant rates in the way now
recognised to occur in some urban areas would occur except in exceptional (disaster)
circumstances. Cost is therefore principally of concern in terms of cost recovery.
Whilst financial aspects are of vital importance to the sustainability of rural water
supply systems, it is therefore beyond the scope of this thesis. It is concluded that cost
is an inappropriate indicator of rural water supply service quality.

4.1.6 Conclusions regarding indicators of preference

It is concluded that the preferred set of indicators of the adequacy of the adequacy of
a water supply system from a health viewpoint and for collection in an operational
(rather than research) driven programme of monitoring and assessment of water
supply service quality for rural areas would be:
• service level/means of provision (ie percentage of the population, by area or
community, served by different means);
• continuity of supply: proportion of time which supply is available (presented in
terms of each of the service levels in the above and where necessary sub-divided
into breakdown, daily and seasonal discontinuity);
• the susceptibility of the supply system to contamination as assessed by systematic
sanitary inspection with or without additional hygiene indicators; and
• the presence of faecal contamination as assessed by water quality sampling and
analysis at source, representative points of supply and representative points of use.

4.2 Approaches to Data Acquisition

The fact that critical dimensions of many water sector monitoring programmes are
derived without visible statistical basis has been noted previously (Nixon et al, 1996,
daSilva and O' Kane, 1989, Pipes , 1990).

117
The two information-action linkages demonstrated to be effective through this work
do not necessarily require a pre-determined minimum frequency of community visits
beyond that necessary for statistical representativity. This simple conclusion should
be contrasted with much current practice in drinking water supply monitoring which is
typically oriented towards assurance of I 00 per cent coverage in a 12 month period or
less, sometimes combined with an exclusion for certain supply types to be attended
' when the situation demands it' or 'according to circumstance' (Sandoval, undated;
Anon, 1983, daSilva and O'Kane, 1989, Lloyd and Helmer, 1991). This also applies
to WHO recommendations (WHO, 1976; WHO, 1985). Amongst the case studies this
was the case, although not necessarily fulfilled wherever guidance regarding
frequency of sampling existed. In some idea the of 'sampling' was introduced (for
instance Pakistan) and in some this was successfully applied (eg Romania) whilst in
others the de facto inability to adopt such a procedure or to achieve full coverage
monitoring led to either sampling-based assessment (eg Nepal) or a rolling approach
where most recent data were used per community (eg Peru). However these linkages
require a broader information base than is commonly generated in practice , for
instance including:
• a population-wide rather than supplied population only coverage; and
• consideration of risk factors throughout supply to the point of use.

The need to address the provision of drinking water to the population as a whole is
recognised (Ludwig and Browder, 1992) and would appear to be a common-sense
consequence of recognition of the universal need for drinking water; the de facto
diversity of means of provision (including that within a single country) and the often-
cited desire to target more needy populations, whether for egalitarian or public health
reasons or for those of cost. Nevertheless, none of the case studies reported included
an element of systematic analysis of means of provision population-wide and in some
it was noted that no attention was paid to monitoring of non-piped supplies (eg Egypt,
Peru I). In Egypt for example, piped drinking water supply was through both
household connections and public standposts. For both types, secondary sources

118
(such as shallow wells or irrigation canals) were commonly used because of
discontinuous supply and problems with public standposts and also sometimes by
preference (El Azab Water Works et al, 1993).

Similarly, the need to address service quality from the vie"Wpointof the recipient is
important. WHO has suggested that 'safe water implies protection of water sources as
well as proper transport and storage within the home' (Anon 1995 p4) thereby
supporting the idea that monitoring extends from source to point of use. Water quality
supplied will be different to that consumed (Feachem et al, 1978; Shiffinan et al,
1978; Payment et al, 1993) and from a public health viewpoint continuity is only
meaningful in terms of the continuity of supply experienced by consumers

4.2.1 General approach

It is possible to develop a rationale for design of an optimised programme of data
based upon the conclusions from Section 3 regarding the effectiveness of information-
action linkages and from Section 4.1 concerning indicators. In some areas this subject
has been little researched and there is a paucity of literature for reference and
comparison. The implications are summarised in Table 27 and discussed below.
They should be viewed as tentative in detail, but substantial in indicating the need for
a significant changes in approach and how that might be achieved. In particular they
imply that a change in approach from full coverage annual monitoring or reactive only
'as the situation demands it' approaches to a programmed periodic low-intensity
survey and assessment approach would be recommended and this is analogous to a
similar call concerning monitoring of the water environment (General Accounting
Office, 1981).

In the following sections the implications of adopting a rational basis to data

acquisition are explored, based on a programmed two-stage sampling approach,
stratified as necessary.

119
Table 27 Part I Principal conclusions concerning approaches to data acquisition

Purpose Indicator Assumptions Approach Conclusions

(linkage)
Overall Means of Prevalence assessment for Two stage sampling to hannonise Frequency can
situation provision/ each of initial N° of supply data collection ...,ith second be IO\\ if large
assessment service types/service levels single linkage . Stratified sampling likely numbers of
level service level1means per to be needed. correct for equal systems or
household probability sampling villages under
Sample size determined by consideration.
requirementsfor community
characterisation
Continuity Acceptable recall at Two stage sampling to hannonise Frequency can
extended periods . data collection with second be low if large
Underlying distribution linkage. Stratified sampling likely numbers of
normal. to be needed. correct for equal systems or
probability sampling. villages under
Sample size determined by consideration.
requirements for communil) ·
characterisation
Prevalence Binary variables with Two stage sampling to hannonise Frequency can
of sanitary underlying binomial data collection with second be low if large
hazards and distribution determine linkage. Stratified sampling likely numbers of
other sample size to be needed, correct for equal systems or
problem s probability sampling. villages under
Sanitaryinspection consideration
Data acquisition +/- binary data
Water Highly variable, underlying Opponunistic data collection ie Address
quality distribution not understood . collect when possible for data seasonality
analysis Diverse sources of collection for other variables . and
contamination: no simple Recognise weaknesses (poor stratification
statistical behaviour. representativity of data, especially in interpreting
Seasonality confounds. seasonality). data.
Analytical data highly Sample source • distribution - use.
valued by practitioners and
decision-makers.

• Two stage sampling refers to the initial selection of villages or water supplies and second stage selection of
dwellings (or taps) within that village. The assembled data can be used to characterise villages or supply systems
and also aggregated to characterise the overall situation.

120
Table 27 Part 2 Principal conclusions concerning approaches to data acquisition

Purpose Indicator Assumptions Approach Conclusions

(linkage)
Characterise Means of Prevalence assessment
community provision/ for each of a limited
or water service level number of supply
supply types/service levels
system for simple supply
prioritisation type/service level per
household
Continuity Acceptablerecall at
extended periods.
Underlying distribution
normal
Susceptibility Binary variables with
of system to underlying binomial
contamination distribution
Water quality Highly variable,
analysis underlying distribution
not understood. Diverse
sources of
contamination : no
simple statistical
behaviour. Seasonality
confounds. Analytical
data highly valued by
practitioners and
decision-makers. For
piped supplies sanitary
inspection alone
unreliable
Characterise community, random Proportion of
selection of households dwellings to be
visited very
high compared
to current
practice
Characterise community, random Proportion of
selection of households dwellings to be
visited high
compared to
current practice
Sanitary inspection
Data acquisition +/- binary data
Opportunistic data collection ie Increased use of
collect when possible for data hygiene
collection for other variables. indicators in
Recognise weaknesses (poor addition to
representativity of data); use specific faecal
especially to identify failures in indicators.
sanitary inspection approach, Recognise
requires greater use of hygiene seasonal
indicators than specific faecal variation.
indicators.
Sample source - distribution -
use.

• Two stage sampling refers to the initial selection of villages or water supplies and second stage selection of
dwellings (or taps) within that village. The assembled data can be used to characterise villages or supply systems
and also aggregated to characterise the overall situation.

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4.2.2 Community selection
Many of the parameters investigated in rural water supply monitoring are binary in
character. Thus for example a storage tank does or does not have a lock on its lid;
there is or is not a plinth around a well and so on. Some others are numeric (such as
the number of household connections). Reducing observations during sanitary
inspection to a yes/no format was a conscious decision in several case studies (Peru I,
Peru II, Nepal, Romania) in order to reduce problems of interpretation and subjectivity
during field work.

It is the binomial distribution of binary variables which will generally determine

minimum sample size for variables investigated at the level of the village of water
supply system (in the first instance the number of villages to be visited in order to
assess the situation). For the binomial distribution, minimum sample size is
determined by the prevalence ("proportion') and population size (since the number of
villages or supplies is finite and generally known). Experience obtained during the
case studies indicates that prevalences range very widely, effectively from zero to 100
per cent. Given the broad range of prevalence the required sample size is determined
by the proportion at which sample size is greatest: P = 0.5. The consequence for
sampling is a sample size of 50 per cent for a population size of 100 (villages),
decreasing with increasing number of villages/systems as summarised in Table 28, if a
maximum tolerable error of P/5 is accepted (this is equivalent to a maximum tolerable
error ofO.l at P=0.5 and is more precise away from this central value.

Table 28 Maximum sample size (number ofvillages or supply systems) to be visited to estimate
prevalence ofvariables with a binomial distribution according to population size (total number of
villages or supplies) with a maximum tolerable error ofO.l (at P=O.S)

Population Size (Number of Villages or Supply Systems)

20 50 100 200 500 1000
17 33 49 65 81 88

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Several case studies identified significant strata within villages and especially with
regard to type of supply (for instance with or "Withouttreatment). This was important
in problem identification in some cases such as Peru I and Peru II. Sampling should
take this into account and stratified sampling may therefore be required. The need to
ensure adequate sample numbers in each stratum may require greater sample numbers
overall than indicated above and in interpreting results correction made for equal
probability sampling. The same would apply where village size varies widely and is
associated with tendencies to depend upon different means of provision.

At a practical level the implication of the above for monitoring programmes would be
likely to be manifest through the assignment of all villages to 'year groups'. All
villages or systems in a given year group would be visited during the course of a
single year and the results obtained used to prepare an assessment. The number of
year groups may be estimated from the table above, based principally upon the total
number of villages. Since a list or census of villages is generally available, assigning
villages randomly amongst year groups represents a simple step organisationally and
procedurally. Thus in a country with 1000 villages (and not taking into account any
additional demands arising from stratified sampling), 87 villages would need to be
visited each year. Rounding to 100 villages per year, villages would be assigned at
random to 10 year groups and year groups visited in rotation. Even in a region or
programme with 100 villages or supplies, the minimum sample size would be such as
to allow distribution of work into two year groups in this way.

A long-term monitoring programme working on this basis would be able to produce

estimates based upon the most recent year group, or on the most recent data available
from all supplies. The latter would, of course, tend to mask the onset of changes due
to interventions and trend monitoring should take this into account. Furthermore, very
long sampling intervals might inhibit the use of information for prioritisation of major
rehabilitations. In practice a 'ceiling' of perhaps five years might be found to be

123
appropriate for 'improved' supplies ie those where some investment in infrastructure
has been made which would justify further investment to ensure it continued
functioning and no more than five year groups therefore established.

For data collected at village/system level it would in many cases represent a

significant reduction in workload. In any location where a clear and strong direction
for support to operation and maintenance were identified then the potential to adopt a
supportive role for monitoring and assessment would merit investigation and might
modify this.

In many countries a substantial proportion of the rural population is dispersed and

failure to recognise this group is a common aspect of the work described in several of
the case studies. Whilst the unit of sampling (household rather than village or
community) differs and the process of random sampling may be more complex, this
group is nevertheless amenable to a similar approach to that described for
communities and, subject to correction for equal probability sampling, may be readily
integrated into the described approach.

4.2.3 Within-community sampling frames

A second stage of sampling is undertaken within villages in order to investigate
variables that differ between households. Such data are collected both in order to
assess the overall national/regional situation and in order to characterise each
community. This applies for example to means of provision, continuity of supply and
observation of household conditions of water storage.

Data of this type are used in aggregate to assess national/regional trends and also to
characterise communities for prioritisation. Minimum sample sizes (ie numbers of
households to be visited) are determined by requirements of data to characterise
individual communities. Tables 29 and 30 indicate minimum sample sizes for
assessing different aspects of community (daily discontinuity and breakdown

124
respectively) and Table 31 indicates minimum sample size for use in assessing means
of provision. All three tables illustrate conditions which are likely to be encountered
in programmes of the type discussed in this work, and indicate a considerably higher
rate of household visits than was observed in the case studies.

Table 29 Minimum sample sizes (households to be investigated) for estimating daily discontinuity
of supply according to illustrative conditions of range of reporting and maximum tolerable daily
error.

Maximum Number of Range of Reporting of Discontinuity (Hours per Day)

Tolerable Error Households in
(Hours/Day) Village 4/24 8/24 12/24

0.5/24 50 44 47 48
500 212 298 344
2000 31I 539 712
1/24 50 32 39 42
500 78 135 178
2000 88 169 243
2/24 50 16 24 29
500 22 42 61
2000 23 45 67

In practice it would be desirable that any data collected at household level be used in
aggregate to assess overall trends (such as in continuity of household water supply.
Since stratified sampling may act as a confounding factor for this, correction would be
necessary to approximate equal probability sampling, otherwise minor strata may be
over-represented in overall statistics.

125
Table 30 Minimum sample sizes (households to be investigated) for estimating breakdown
according to illustrative conditions of range of reporting and maximum tolerable error.

Maximum Number of Range of Reporting of Breakdown (days per year)

Tolerable Error Households in

(days/year) Village 7/365 14/365 30/365

1/365 50 49 49 50
500 415 454 477
2000 I I02 1421 1680
7/365 50 25 33 41
500 46 83 150
2000 49 95 194
14/365 50 10 17 26
500 12 24 48
2000 12 25 52

Table 31 Minimum sample size (households to be investigated) to determine prevalences of

different service levels/means of precision according to illustrative conditions of range of
reporting and maximum tolerable error.

Maximum Tolerable (1,2) Number ofHuseholds in Village

(%) 50 500 2000

5% 44 217 322
1.5% 39 126 155
10% 33 81 92

Notes l. The minimum sizes are conservative and may be reduced in practice because there is a
limited number of alternative means of provision/service levels.
2. In practice it would often be possible to adopt apparently high tolerable errors since the
sample size will give greater precision at extreme prevalences.

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4.2.3 Seasonal problems with water quality data
Numerous authors have described seasonality in faecal contamination of drinking
water supplies or their sources, most frequently in the context of investigation of
seasonality of disease.

In work undertaken in 'typhoid villages' in Lesotho, Feachem et al (1978) questioned

the link between wet season peaks of diarrhoeal disease and typhoid and
contamination levels in drinking water, since such peaks were also detected in villages
with improved supplies and in a city with a chlorinated water supply. It is significant
to note that a five fold increase in contamination levels in the wet season for
unimproved sources was not considered significant. In a study of an urban
environment (the Lima-Callao conurbation) with negligible rainfall year-round, Lloyd
et al (1989) demonstrated a correlation between water quality (indexed by
thermotolerant coliform and residual chlorine data) and health (indexed by the product
of disease incidence for three potentially water-borne diseases) in the 26 urban
districts. Their findings support the assertion that a principal factor influencing
elevated numbers of cases of diarrhoea , typhoid and hepatitis was water quality.
Work from two separate populations in the Western Province of Zambia (Wheeler and
Utkilen, 1987) shows ratios of wet season to dry season contamination from 1.00 to
41.3 (median 3.34). The authors interpreted the results as indicating that in rural areas
depending on a variety of protected and unprotected sources, contamination levels in
the wet season tend to be significantly higher than in the dry season. Finally, in
analysing the phenomenon of seasonality of water contamination and health impact in
rural areas, Wheeler (1989) concludes that:
'In isolated rural communities, elevations in levels of bacterial contamination in
small water supplies during the wet season may actually be very modest. There
is simply not a large volume of contaminated material waiting to be washed into
the sources to sustain high levels of faecal micro-organisms for long periods in
these sources '

127
Whilst average levels may be insufficiently elevated to produce a sustained increase,
the ratios reported from both of the rural studies cited above represent a significant
confounding factor in the context of water quality monitoring; and it is likely that the
average values (ratios) fail to recognise transient high levels of contamination in many
systems or sources. In the case study from Nicaragua, increases from zero to more
than 400 thermotolerant (faecal) coliforms between dry and wet season measurements
were found. Such short term elevations may be more important in terms of health
impact than minor long-term deterioration in water quality (Havelaar, 1996) and the
impact of short-term variation, whether seasonally-derived or otherwise, may have
been consistently under-estimated in studies to date.

4.2.4 Sampling frames for water quality sampling

Design of monitoring frameworks for microbiological monitoring of drinking water
quality in distribution is conceptually flawed and hampered by a fundamental lack of
understanding of the causes/sources of contamination and their individual and
combined statistical behaviour. Microbes in distribution may arise from four sources
(this classification is based partially on Pipes, 1990):
• they may enter distribution with source/treated water
• they may enter through pipes and cross-connections
• they may arise from growth on surfaces in the distribution system
• they may arise from aerial deposition into storage tanks and other open structures

The first two of these sources are likely to be important in rural water supply systems
world-wide, the third primarily in areas of high ambient temperature; whilst the
importance of the last will depend on supply and construction practice.

Much of the available literature addresses concerning the statistical distribution of

microbes in water concerns simple environments. Thus the microbiological analytical
results of 'split samples' typically follow a Poisson distribution (Haas 1993; Haas and
Heller per McFeters). However repeat samples collected from the same location (such

128
as a finished water well) demonstrate a greater variability and most commentators
have described, even for such simple situations, a considerable variability for
heterotrophic populations in general and total and thermo-tolerant coliforms in
8
particular (such as up to I 0 fold across the supply: Gale, 1996) and have indicated
that the log normal or negative binomial distributions approximate the observed
distribution (Thomas and Woodward 1955; Pipes et al 1977; Christian and Pipes
1983; Haas and Heller, 1986; Gale, 1996). Knowledge however remains extremely
limited and there is for example as yet little insight into the relative importance of
spatial and temporal variations in 'good' quality systems compared to knowledge
concerning seasonality elsewhere (Section 4.2.3). It should be recalled that such
observations of behaviour according to statistical distributions are empirical and do
not prove or indicate an underlying mechanism (Haas and Heller, 1990).

Various explanations have been proposed for such increased variability, such as
clumping (Pielou 1977; Douglas 1980); sample preservation and deterioration (Tillett,
1993); analytical interferences from materials (Margolin et al 1981) or otherwise
(Tillett, 1993); dilution error (Chase and Hoel 1975); microbial interference
(LeChevallier and McFeters 1985); and differential selectivity (Bissonnette et al 1975;
McFeters et al 1982).

A common observation for water supply systems of 'good' quality is that whilst most
samples show the absence of total or therrnotolerant colifonns, they occur in large
numbers in a few samples, even though the mean for the water system is low (Pipes et
al, 1977; Christian and Pipes, 1983; Pipes and Christian, 1984; Gale, 1996).

The value of quantitative estimates of faecal indicator bacteria ('colon bacilli') in

water was recognised early in the history of sanitary microbiology and referred to by
Smith (1893) and Pakes (1900). Smith noted during the design of a study that using a
volume of 1 litre for analysis would lead to the condemnation of many 'good waters'.
He in turn cited Miquel (unreferenced) as having found colon bacilli in almost every

129
sample of drinking water if only a sufficient portion were taken for analysis. Pak.es,
on the strength of examination of 'about 300 samples of water' stated that water from
a deep well should not contain Bact coli at all, but that water from other sources need
not be condemned unless the organism was found in 20cc or less; and that when colon
bacilli were found only in greater quantities than 100cc the water might be considered
probably safe. The value of quantitative determinations has been introduced in Section
3 .1 and is reinforced by these observations from the tum of the century. These, in
identifying the need for quantitative estimates in order to clarify and prioritise, are as
valid now as when they were first made. Equally the conclusion of Prescott and
Winslow (1931) that 'the number of colon bacilli in water rather than their presence
should be used as a criterion of recent sewage pollution' (their emphasis) remains
valid. Since the tum of the century therefore, quantitative estimates of faecal indicator
bacteria have formed a cornerstone of sanitary bacteriology and safety assessment of
drinking water supplies. In all of the case studies. microbiological water quality
analysis was undertaken by quantitative methods

In parts of the world where the majority of analyses for faecal indicator bacteria
register 'zero' results (strictly <1 per volume of analysis) it has been reasonably
questioned whether quantitative analysis provides the best means to estimate water
quality in distribution, and considerable evidence has been generated regarding the
value of presence/absence testing (Clark, 1968; Clark 1969; Clark and Vlassoff 1973)
and a number of evaluations have demonstrated its worth (Clark, 1985; Fujioka et al
1986; Jacobs et al 1986; Pipes et al 1986a) including evaluation of its worth as a field
technique for field inoculation (Pipes et al 1986b). The author of much of this work
has however emphasised that it was developed for use as an adjunct to quantitative
techniques where submissions of routine samples had all or almost all samples
regularly giving negative results (Clark, 1990). Nevertheless some workers have
attempted to apply presence/absence testing elsewhere and specifically to point
sources of poor quality (Hewison et al, 1988). In doing so prioritisation becomes

130
impossible and the concept of relative public health priority lost (Lloyd and Bartram,
1991).

The available evidence suggests a significant 'clustering' of microbes in distribution

occurs. Much of the discussion of this phenomenon relates to breakthrough of
particles containing many bacteria from treatment processes (Gale, 1996). However
similar statistical behaviour would also arise from individual sources of
contamination, such as cross-connections, leaks or local areas of re-growth. Such a
hypothesis is further supported by the greater variability in drinking water samples in
distribution than in source waters (Gale, 1996) and bimodal frequency distribution for
coliform counts from water in distribution (ibid). Stated simply it appears likely that
distributions of indicator organisms in distribution systems are composed of at least
two sub-distributions: one representing the microbes entering the system with water,
and the other representing subsequent contamination. In systems of generally good
quality the latter appears to be of underestimated importance; and monitoring
effectively measures the distribution of such 'clusters', calling into question the value
of repeat sampling as an important follow-up action following failure.. Where water
quality entering distribution is poor it is likely to be the former which is of greatest
importance to health and may be assessed through measures of central tendency from
analytical data. Nevertheless, it is unclear whether the phenomenon of low numbers
of samples with elevated results is repeated under such conditions and if so its
consequences for public health.

The phenomenon of clustering, if valid for pathogens as well as indicator organisms,

brings into question the assumption that transmission of relatively high infectious
dose pathogens through drinking water supply of other than grossly inadequate quality
is unlikely, since clusters of such organisms would be expected to pose a greater
health risk than dilute homogenous dispersions. A standard based upon occurrence of
indicator organisms will therefore be more effective in protecting public health against
some pathogens than others and a debate is starting to emerge concerning the nature of

131
microbiological standards and what they protect against (see for example Tillett, 1993.
Gale, 1996).

In light of the above it is perhaps unsurprising that whilst requirements of sampling

(such as frequency, intensity and choice of location) are often laid down in legislation
or regulations (Sandoval, undated; Anon, 1983), there is no statistical basis for this.
This has been discussed by daSilva and O'Kane (1989) with respect to the European
Union and by Pipes (1990) with respect to the position in the USA.

In light of the above discussion, that concerning seasonality (Section 4.2.3) and the
observation of abrupt changes in microbiological quality from week to week (Pipes et
al, 1987). it is unlikely that adequate sampling densities will be achieved (either
temporally or spatially) to provide a reliable estimate of water quality in distribution
by water quality analysis without multiple sampling occasions per year . Such a
frequency is most unlikely to be achieved for rural water supplies outside the
established market economies (Lloyd and Helmer, 1991 ). Sophisticated analysis of
small numbers of data derived from infrequent sampling occasions therefore imply a
solidity in the quality of the analytical database which does not really exist. It should
be recalled that WHO for example makes recommendations for frequency of sampling
between 'as the situation demands' to 'every five years' for such populations (WHO,
1976; WHO, 1985). It is therefore inappropriate to seek a rigorous statistical basis for
such sampling, but to take an opportunistic approach to data acquisition and to
recognise and address the statistical weaknesses when analysing data .

4.3 Data Collection

'Thefirst attempt of the expert called in to pronounce

upon the character of a potable water should be
to make a thorough sanitary inspection'
(Prescott and Winslow, 1931)

132
This Section does not include an exhaustive review and analysis of observation.
analytical or interview techniques of data acquisition or of approaches to quality
assurance and quality control. It describes the particular conflicts and contradictions
encountered in collection of drinking water supply service quality data from rural
areas outside the established market economies; the approaches adopted toward data
acquisition in the case studies and discusses the adequacy of data quality for the
purposes of rural drinking water supply monitoring and assessment.

4.3.1 Sanitary inspection and interview

As noted in the quotation above from Prescott and Winslow ( 1931) and earlier the
earlier work ofDitlevsen (1887) and others, there was no doubt of the value of
sanitary inspection in investigating water supplies for many years. Indeed the latter
clearly indicates the complementarity of sanitary inspection and bacteriological
analysis. The role of sanitary inspection in water quality monitoring and assessment is
nevertheless now under-researched and a very limited recent literature on the theme
exist (see for example Jensen 1966, Jensen, 1967). The more recent work on
development and standardisation of sanitary inspection has evolved from WHO
guidance materials (WHO, 1976 and WHO 1985 in particular) and includes Bartram
( 1990b); ?Lloyd and Bartram, 1991?; Lloyd et al 1991. The findings of these latter
workers have been integrated into the second edition ofWHO's Guidelines for
Drinking-water Quality Volume 3 (WHO, 1996).

It is germane to note that whilst sanitary inspection has received very little attention
from the western scientific community over an extended period, this should be
contrasted with the analogous 'Hazard Analysis Critical Control Point' (HACCP)
assessment in the food sector (Brian, 1992). What is common to these approaches (ie
to sanitary inspection and HACCP) is:
• recognition that microbiological contamination varies widely and rapidly and is
therefore difficult to estimate by analytical regimes unless sampling density and
frequency is high (with attendant cost implications and logistical problems);

133
• acceptable levels are zero or very low and therefore monitoring fails to identify the
degree of acceptability;
• that in light of the above some reliance must be placed upon the susceptibility of
systems to contamination; and
• the implicit recognition of the multiple barrier principle.

Sanitary inspection was used extensively as a primary monitoring tool in a number of

programmes including Colombia, Nicaragua, Peru I and Peru II. In all cases
procedures were initially based upon those proposed by WHO and included elements
of information collection by interview . Also in all cases, and as reported by Lloyd
and Helmer ( 1991) following a three country review of experience with surveillance
of drinking water supplies in Indonesia, Peru and Zambia, those proposals were found
to be very deficient in practice. Whilst to some extent this was related to adaptation to
national circumstances, fundamental problems encountered in the case studies
concerned subjectivity in reporting.

The work undertaken in Peru illustrates the problems of standardisation of response

amongst different data collectors encountered in the case studies. The problems were
overcome through:
• Careful design of inspection forms, substituting questions requiring subjective
assessment or interpretation by unambiguous requests and eliminating questions
for which it was not realistic to expect a response.
• Selection of appropriate personnel to undertake the work. Whilst this will
obviously vary between countries and regions clear indications were received that
the nature of the work required both careful selection and training of staff. Initial
activity employing laboratory staff for sanitary inspection and interview-related
information collection was unsuccessful and the approach was moved to the use of
'sanitary inspectors'.

134
• Provision of training immediately followed by field work and consolidated by
field supervision for inspectors. Since this approach was used in all interventions
described in the case studies it is difficult to critically evaluate its impact.
• Development of procedures manuals for sanitary inspectors which could be used
for reference where there was doubt (Gobierno del Peru. 1990a).

The success of standardisation was verified by extensive direct observation of nine

teams totalling 35 staff in the case of Peru I and also by direct observation in Nepal,
Peru II and Colombia. In Pakistan a specific and more complex inspection schedule
for water treatment systems was developed and successfully applied by a monitoring
officer after joint application in only three treatment plants. A visit 12 months later
indicated that the process continued to be applied correctly.

In Peru II the opportunity to closely observe four technicians working together to

complete sanitary inspection was a valuable opportunity to investigate the time
required to achieve standardisation. Whilst the work was intensive and this may have
facilitated rapid convergence of criteria, the technicians themselves had little previous
exposure to the material being investigated. After a period of one week intensive
work, the four technicians reached effective convergence and all four would reach
similar conclusions through direct observation. A quantitative measure of
convergence is difficult to determine, but after five days of field work, disagreement
was rare, not exceeding one observation in 20. Since this was amongst a group of
technicians it is equivalent to one in 120 comparisons, although working in a group
may render this an underestimate.

General (ie non-systematic) observation in Peru II indicated that hand washing before
eating or after defecating was rare, but that it was normal to wash hands after eating.
General standards of personal hygiene were high and whilst household water hygiene
was poor, the storage of 'masato' (cassava beer) in the home could provide a model
for hygienic water storage. The importance of general education of technicians and to

135
provide opportunity for non-standardised responses was highlighted by this latter
series of observations. Strict adherence to the rigid sanitary inspection form would
not have provided opportunities for such wider observations. Whilst it might be
argued that a more rigorous field testing would overcome this, such a conclusion is in
danger of transferring information generation into the field testing, eliminating
opportunities for subsequent lesson-learning.

The finding that sanitary inspection can be successfully undertaken by sanitary

inspectors is in accord with the observations of Lloyd, ( 1990) who further claims that
in addition to public health inspectors 'successful surveys have been undertaken in
small communities by personnel with a limited education and who have undertaken
intensive practical courses '.

4.3.2 Water quality analysis

Despite widespread recognition of the importance of faecal contamination, in two case
studies (Egypt and Pakistan II), evidence collected suggested that most analytical
effort in rural areas was being placed upon physical and chemical analyses of little
public health importance - and little used for management purposes - to the expense of
basic hygiene related monitoring.

Analytical approaches
A major limiting factor for the implementation of water quality monitoring as a
component of rural water supply monitoring has been the feasibility of undertaking
water quality analysis (Lloyd et al, 1987). Sample deterioration in transport and
storage is a greater problem than previously recognised (Bartram and Ballance 1996;
WHO, 1996a). This is in addition to the logistical problems of actually ensuring
transport and storage. Both sample deterioration and logistical problems have been
emphasised by others (Belbin, 1992).

136
In many of the case studies, travel times from communities to the nearest laboratory
testing facility were such as to preclude successful laboratory-based analysis. This
was demonstrated in for example in Nepal, some areas of Peru I, Peru II, and Pakistan
I. In many cases travel times from sample site to nearest laboratory were measured in
days rather than hours (Nepal, Peru II, Pakistan I).

There is a continuum of approaches to water quality analysis, between large

established laboratories, local laboratories, portable equipment used at a central site
(such as hotel or office), portable equipment used for sample processing on site; and
dedicated on-site testing equipment. Across this continuum a range of factors favour
more centralised or decentralised testing. The factors include sample deterioration,
quality of laboratory analytical environment, more or less specialised staff
undertaking analysis, reliability of electricity supply, feasibility of reporting and the
influence on the quantity of analysis performed (analytical capacity) and are
summarised in Table 32. Many of these factors can be influenced and there is no
simple technical means to determine the preferable approach under even specific
circumstances.

Poor reliability of electricity supply was a common and significant problem in the
case studies, especially for analysis of thermotolerant (faecal) coliforrns where
temperature control is important. Even a relatively short electricity failure (such as 1 -
4 am) during which the temperature dropped from 44C to 25C would reduce
selectivity and introduced a substantial error into results. Such interruptions to
electricity supply were a common feature in the case studies. Portable/on-site
categories of analytical resource are sometimes associated with battery back-up and
may therefore be less affected by problems of electricity supply.

137
Table 32 Factors affecting microbiological analytical quality in more or less centralised testing
facilities

< More centralised More de-centralised >

Central Regional or Process On-site On-site
laboratory local samples using sample testing
laboratory portable processing
Factor equipment in
office or hotel
Sample Depends on travel time and Depends on Negligible
deterioration storage time in laboratory travel time

Quality of Generally good Intermediate Generally poor

analytical
environment

Type of staff Generally laboratory staff Often non-laboratory staff

undertaking
analysis

Impact of Generally severe Null if equipment used has battery power or back-
poor up
electricity
supply

Ease of Reports forwarded after analysis Reports can be

reporting delivered if
timetables
allow
overnight stay
in village

Reporting of the results of monitoring was problematic in several case studies. In all
case studies affected it was inclusion of the results of water quality analysis which

138
was the limiting factor. A further factor encouraging the adoption of portable or on-
site testing equipment concerns reporting to communities (Belbin, 1992). Where
travel problems restrict the ability to transport samples to laboratory facilities they
also often restrict or render costly the travel of staff to deliver results of testing and of
other means by which such results might be sent. In three programmes this was
effectively overcome by on-site testing and delivery of results before travel on to the
next community (Peru I in the Department ofHuancavelica, Peru II and Nepal).

Evidence to support the feasibility of on-site water quality testing was obtained from
many of the studies (Nepal, Nicaragua, Peru I, Peru II, and Pakistan I) and has also
been encountered elsewhere (Pickering, 1990; Zimbabwe (Robens Institute. 1993).
Experience from the case studies concerned two different items of equipment, the
results of a two year evaluation of one of which has been reported (Emes et al, 1990)
and the overall experience is supported by the positive position adopted \\'ith regard to
field testing by other commentators (Belbin, 1992).

One of the items of equipment used in one of the programmes was designed to operate
an incubation cycle of four hours at 30C followed by 14 hours at 44C. Repeated
observation in the (cold) environment of the project area of Pakistan I indicated that
despite power from a new car battery the equipment was unable to attain a
temperature greater than around 40C. In an area where mains electricity is generally
unreliable, the availability of equipment that can reliably operate from a regularly
recharged car battery is a basic pre-requisite.

In other programmes, experience was different. Using different equipment with an

internal rechargeable battery, the desired operating temperature was reached (44C) in
all operating conditions (including cold high mountainous environments) with a
weekly recharge at 'base'; whilst in Peru II recharge of the same equipment was
successfully achieved from a generator and - later - a solar panel (Johns pers comm) in

139
a less stressful (ie warmer) environment. In one programme. even five day intervals
between the needs to recharge batteries was found to be a limiting factor (Nepal).

Despite widespread mistrust of on-site testing (Ballance. pers comm; Wihuri, pers
comm), there is little reason to believe that even Government reference laboratories in
some of the study areas would achieve better analytical quality than the simple on-site
testing adopted in many. Thus for example in no laboratory in any of the case studies
was inter-laboratory comparison or analytical quality control practised in any
systematic way and in one of the Government reference laboratories used in the case
study Pakistan I scientifically impossible results (faecal coliforms greater than total
coliforms in a single sample) were seen to have been reported.

The issue of analytical quality control and inter-laboratory comparison in water

laboratories has been highlighted at a series of international meetings for the Nile
Basin countries (Bartram, 1992), Southern Africa (Bartram, 1994) and the East
Mediterranean region (Bartram and Nash, 1995). Its importance was re-emphasised at
a Nile basin workshop on the theme (Bartram and Briggs, 1995 and has also been
highlighted in a series of meetings of the Black Sea littoral countries (WHO, 1994b;
WHO, 1995) and in the Pakistan Environmental Health Action Plan (Government of
Pakistan, 1993).

Introduction of formalised quality systems in microbiological laboratories outside the

established market economies is a relatively recent phenomenon but is rapidly
attaining a substantial profile (Briggs and Bartram, 1993). In water microbiology
quality laboratories it differs fundamentally to approaches used in laboratories
undertaking chemical analyses. In particular it is increasingly recognised that
international standardisation systems should be oriented less towards the detailed
description of standardised methods and more towards the establishment of minimum
performance criteria (Havelaar et al 1993).

140
Systematic observation of analysis by field staff was undertaken in Peru I, Peru II and
Pakistan I. Criteria used in determining the quality of work (and by inference data
generated) were limited to observation of correct procedure and aseptic technique and
verification of interpretation of results on the conclusion of the analysis. In Peru II,
after a period of one week of intensive work the four technicians were, independently,
conducting analyses by correct procedure, following aseptic technique and recording
results accurately. This was equivalent to around 20 supervised analyses each within
a five day period. It should be recalled that these staff had already received extensive
training with regard to laboratory work and procedures generally and some specific
training in use of the field equipment employed.

It is concluded that under the exacting conditions which prevail in rural water supply
and quality monitoring in many countries, scientifically valid data can be generated.
This may involve 'moving' analysis closer to the point of sampling and encharging
non-laboratory specialists with analytical responsibilities; facilitated by use of
portable or on-site testing equipment.

Faecal indicator bacteria

The use of indicators of faecal pollution in water quality monitoring has a long and
substantial history. The rationale for such an approach is well-documented (WHO
1996a; Bartram and Ballance, 1996) and is not repeated here. Neither is a review of
the various indicator organisms, their characteristics, advantages and disadvantages
presented which is also widely reported (WHO, 1984; WHO, 1996a; Bartram and
Ballance, 1996). The analysis of faecal indicator bacteria provides the most reliable
means of assessing the safety of a water sample with respect to faecal pollution and
was the preferred means of investigation of microbiological quality in all case studies.
However the ability of a measure of safety of a (number of) sample(s) to estimate the
safety of a supply system over a period of time is open to question as discussed in
Section 4.2.5. Faecal contamination (or at least the detection of faecal indicator

141
bacteria) in rural water supplies is highly variable (Pipes et al 1987) and often
seasonal (see Section 4.2.4).

Experience collected from the case studies indicates a marked seasonality in

monitoring activity. In the case of Nepal and Pakistan I this was manifest as a
'monitoring season' when it was physically possible to undertake visits. In others
(such as Peru I) a seasonal variation in target areas occurred because of programming
more inaccessible areas during the season in which travel was easier. Whatever the
cause and manifestation, the result is a significant bias built into 'real scale' rural
monitoring activities and is recognised to be significant (Blum and Feachem, 1983).

In the case of piped rural water supplies outside the established market economies,
where dosing of a residual disinfectant is rare, it should therefore be questioned
whether direct assessment of faecal indicator organisms alone is the most appropriate
means of investigating microbiological quality. Because of seasonality in monitoring
systems may be more likely to be visited when there is a low risk of detecting faecal
contamination, regardless of the risk of indicator bacteria occurring during the period
of high risk. Indeed it is conspicuous that support for the use of sanitary inspection as
an indicator of risk of contamination is readily accepted by the scientific community,
and yet the same argument is not accepted with respect to microbiological indicators
of (the risk of) contamination. This argument is supported by the work of Jensen
( 1966; 1967) who interpreted his findings as verifying the general assumption that the
occurrence of thermotolerant coliforms was a sign of recent faecal pollution and
indicating that total coliforms are a better indicator of general sanitary status and
therefore important for monitoring. Too little information is available with which to
draw concrete conclusions and in light of the low level of research on the theme this is
likely to continue.

142
Relationship between the results of sanitary inspection and water quality analysis
It has been argued that it should be possible to identify a ·broad band' of correlation
between the results of sanitary inspection and of water quality analysis, with systems
at greatest risk of contamination tending to show higher levels of contamination
(Lloyd and Bartram, 1991; Lloyd and Helmer, 1991).

The conceptual problems of scientific analysis of the relationship between sanitary

inspection and water quality analysis I related to the fact that faecal contamination is
rapidly variable (Pipes et al, 1987) and seasonal (Section 4.2.4); thus a single water
supply system with a constant sanitary status may vary very widely in its faecal
contamination during the course of a year; whilst the microbiological indicators most
frequently employed are specific for faecal contamination. The statistical problems of
scientific analysis of the relationship between sanitary inspection and water quality
analysis may be readily illustrated through the concepts of sufficiency and necessity.
In the case of sanitary inspection, each factor is necessary, but insufficient to cause
contamination. Thus for example whilst it is necessary that a spring protection box
have a secure lid in order that the system is not susceptible to contamination, the
presence of a secure lid on the box is not sufficient to ensure that the system is not
susceptible to contamination.

It is conspicuous that successful attempts to correlate sanitary status with water

quality have all occurred in the context of simple source (such as well) evaluation.
This is true of the work of Lloyd (Lloyd and Bartram, 1991; Lloyd and Helmer, 1991)
as well as earlier studies cited above (Whipple, 1903; Jensen, 1966; Jensen, 1967) and
others such as Pickering, ( 1990) and Sutton ( 1994).

Whipple (1903), examined a large number of surface water supplies by the

•presumptive test', classified the waters into six groups according to the results of
sanitary inspection and obtained striking results as shown in Table 33.

143
Table 33 Percentage of samples of waters of various sanitary grades giving positive tests/or Bact
coli when different amounts were examined (Whipple 1903)

Sanitary
Inspection 0.1cc 1.0cc 10cc 100cc 500cc
Group
I 0.0 3.5 20.8 50.0 50.0
II 5.0 7.3 15.0 60.0 60.0
III 0.0 7.0 50.0 50.0 60.0
IV 4.0 6.8 41.7 67.0 75.0
V 5.0 13.0 75.0 100.0 100.0
VI 5.0 20.2 75.0 80.0 100.0

As noted above, no such correlation was found in piped water supplies in using an
extensive data set derived from the case study Peru I. Such an observation is readily
explained by the complexity of piped water supplies in comparison with simple point
sources such as wells. There are multiple potential points of entry of contamination
and many will not be detectable by sanitary inspection or are less likely to be detected
by sanitary inspection (there is more to inspect, some parts are difficult to access,
being in remote areas or on private land and much of the system is buried). It is also
conspicuous that arguments related to the role of water (seasonal rainfall) in re-
distributing accumulated excreta to water sources, as described in section 4.2.4, are
less likely to be valid in areas of piped water supply where water transferred by the
system may perform the carriage role - both in flushing away faecal contamination
and in transmitting it to weak points in the integrity of the system.

Given the claims for correlation between the results of sanitary inspection and water
quality analysis, it might appear that a simple combined index of 'water quality' could
be assembled and indeed that investment in one or the other activity might be
redundant. As indicated above, the claim for a 'broad band' of correlation is not
universally upheld and specifically appears to be un-sustained for piped supplies.

144
Such a conclusion does not detract from the obvious pragmatic value of combined
grading schemes of this type. It does however indicate the low likelihood of
demonstrating a statistically valid relationship between the two indicators in other
than occasional well-defined environments, and where water quality analysis is
undertaken such as to provide a quality estimate of year-round validity.

Several commentators have proposed or investigated weighting factors as a means to

improve the quality of information derived from sanitary inspection data, anticipating
an improved correlation from resulting integrated sanitary inspection scores
(Pickering, 1990). Whilst the idea of deriving weighting factors for individual
components of sanitary inspection appears attractive, such an approach ignores the
fact that any single risk factor may be unimportant or of overwhelming importance in
a given situation. The importance of individual risk factors is specific to
circumstances such as the water supply system and its immediate short term
environment. It is unlikely that a valid relative weighting may be derived for different
risk factors by statistical analysis of data. Intuitively it appears unlikely that a single
weighting factor could be applied to correct for both the likelihood of contamination
occurring and resulting intensity of contamination which would be appropriate to
more than a very narrow range of circumstances. Local land use, population
distribution and similar factors would be expected to have a major influence and
themselves vary widely. Thus resulting contamination is not a dependent variable on
susceptibility but a co-variable dependent on both susceptibility and other factors.

145
 Section 5:
Information

'it is often necessary to make a decision on the basis of knowledge

sufficient for action, but insufficient to satisfy
the intellect'
(Kant).

5.1 Information for Decision-makers

Both of the mechanisms judged to be effective in promoting improvement based upon

the outputs of monitoring have specific target audiences for definable information
products. The experience from the case studies indicated that little effort was made by
those responsible for monitoring and assessment to communicate with these groups;
but that these groups were open to receive and act upon information products which
they perceived to be useful.

146
In no cases was an attempt made to consult decision-makers regarding the information
required or sought by them and thereby define objectives and sampling frames,
despite the recognised importance of this (daSilva and o·Kane, 1989). In only one of
the case studies was an explicit attempt to involve information users included in
strategy and then only in the later stages. This was in the case of Peru I, where short
seminars were organised and summary information sheets prepared and distributed for
this purpose. The seminars were well-received, but insufficient time elapsed between
implementation and the end of the period of external support for and monitoring of the
programme to determine whether they had an impact on activity.

The apparent lack of awareness of those generating data of the need to condense and
present ('sell') it is conspicuous. In Egypt for example. no data flow between local
levels and central levels occurred in practice and the only perceived value of data was
for limited local management purposes. This is likely to be. at least in part, a
reflection of the low perceived need for analysis of data at macro levels and is likely
to have inhibited the development of policies and strategies for improvement of
drinking water supply. These observations tend to support the idea that the
monitoring being undertaken by governmental systems is driven by a regulatory
enforcement and/or scientific ethic. In a different context (freshwater quality
monitoring in the Nile basin, with staff most of whose responsibilities extended into
water supply), practitioners fully-recognised the importance of involving decision-
makers and recommended 'the need to enhance the awareness of decision-makers
regarding the importance of water monitoring, assessment and management issues '
(Bartram, 1992). Similar recommendations have been registered from southern African
countries (Bartram, 1994) emphasising the need for linkages between monitoring,
assessment and improved environmental quality, for programme managers and policy
makers.

Excepting the example of Peru I, noted above, involvement of decision-makers in the

governmental monitoring and assessment activities described in the case studies was

147
coincidental. Because of their nature, NGOs are unlikely to undertake monitoring or
assessment without significant commitment to it and awareness of decision makers is
therefore the norm rather than the exception. It is noteworthy that both of the NGO
monitoring programmes described in the case studies (Nepal and Pakistan I)
demonstrated significant policy shifts in response to monitoring outputs.

Whether there is significant interest amongst potential users in the products of

monitoring and assessment is difficult to infer. Interest in drinking water supply and
quality information was detected amongst senior staff and in some case studies such
as Yemen, the desire to increase attention to this was expressed, in other cases
animosity to the function was expressed, most commonly by those with poor
experience of the quality of information ('quality' as suitability for purpose),
particularly amongst engineers responsible for construction frustrated by
condemnation of systems wholesale, in some cases despite their perceived adequacy.
In the case of Peru, where this was the case at the outset, the products of monitoring
were eventually accepted and used by the regional engineers concerned In Pakistan a
clear indication of the perceived need of policy makers for objective and up-to-date
information through monitoring was detected though the Pakistan EHAP. Whilst
water quality-orientated it provides a clear feedback from decision-makers. Ironically,
parallel changes in that country are likely to have rendered the health sector incapable
of responding effectively to this challenge .

The lack of attempts to outreach to potential information users and sometimes lack of
interest of potential users in receiving information from monitoring are aggravated by
the lack of mechanisms supportive of such a linkage. On no occasion were
mechanisms detected which effectively enabled decision-makers to input their
information needs to operational water supply and quality monitoring programmes; or
which effectively facilitated transmission of information products to decision-makers;
and no examples of legislative frameworks supportive of this type of information flow
detected.

148
Nevertheless in several case studies inter-sectoral co-ordination committees existed
who could receive and act upon suitable assessments; whilst at regional level although
such co-ordination mechanisms were less common, the target audience is commonly a
single individual such as a regional engineer . It was rare however that such agencies
or individuals at national or regional level actually received information from the
monitoring agency. The issue of intra and inter-sectoral coordination is addressed in
Section 6.3.1.

Such observations are also supported by specific recommendations including for

example those of Gibbons et al ( 1996) who note when discussing local decision-
making that 'The main role of higher-level government agencies should be to
establish institutional rules, regulations and processes that encourage such local
decisions'.

5.2 Data Presentation and Decision Aids

The existence of fundamental problems with reporting and presentation of monitoring

data is recognised (Ward, 1995) and a substantial literature has developed in recent
years regarding decision-making aids which assist in bridging the gap between
analysts and decision makers. Much of this literature derives from and is oriented
toward the market economies and a spur to its development has been the need to
address the existence of 'other affected people' as well as analysts and decision
makers (Snell, 1994). Little literature refers to situations similar to those discussed in
this thesis. Nevertheless it is clear that some attempts have been made to develop
graphic means to present the outputs of monitoring in a form amenable to use by
decision-makers (Lloyd and Bartram 1991; Lloyd and Helmer, 1991). In none of the
case studies were such presentational aids used except where recently-introduced as
part of a programme of external support and in none were they amenable to feedback

149
from decision-makers regarding, for example, relative weighting of major
components.

5.2.1 Interpretation and presentation of data concerning water quality

Substantial advances have been achieved in recent years in the field of quantified
microbiological risk assessment (see for example Regli et al 1993). Whilst much of
this work was developed in the context of low dose exposure, it is of relevance also to
the situation of higher doses and rates of exposure.

The approach described by Regli et al (1993) for risk management, which includes
decision trees for the degree of treatment needed to ensure microbiological safety,
represents an increasingly-accepted trend amongst the risk management professionals
but systematically ignores the susceptibility of water supply systems to contamination
and focuses on the quality of water at the point of entry into distribution.
Nevertheless Havelaar provides a scientific basis for the common-sense conclusion
that systems are as strong as the weakest component and that the health consequences
of contamination of reasonably-well protected systems are principally derived from
(even very short periods) of sub-optimal functioning (Havelaar, 1996).

The analytical basis upon which such risk assessment and risk management is based is
grossly deficient for rural water supplies and outside the established market
economies in particular. This arises from both the total analytical effort and the
confounding factor of seasonality for example. Nevertheless, decisions are made and
will continue to be made based upon limited information sets and the use of both the
findings of sanitary inspection and of results of waterquality analysis for faecal
indicators as adopted in several case studies and elsewhere would appear a pragmatic
compromise.

It is interesting to note that during the first part of the century the mutual compatibility
of field survey and laboratory analysis seems to have been generally recognised. Thus

150
Whittaker ( 1917) reported that out of 344 water supplies classified as polluted, 52 per
cent were condemned on the grounds of both field survey and laboratory analysis; 40
per cent from the survey although the analysis on the date of examination was
satisfactory and in 8 per cent the danger was revealed only by analysis, the first survey
indicating nothing suspicious. The high proportion of systems condemned by sanitary
inspection in the absence of microbiological evidence might be seen to support the
essential and complementary nature of sanitary inspection and indicate the weakness
of depending on water quality analysis alone and is supported by earlier declarations
by WHO (ie no longer in publication) such as the recommendation that: 'It should be
emphasised that when sanitary inspection shows a water, as distributed, to be
obviously subject to pollution, the water should be condemned irrespective of the
results of chemical or bacteriological examination' (WHO, 1961). Similarly, on the
basis of the combined results of sanitary inspection and water quality analysis (Table
34 ), Whipple proposed the following provisional scheme of interpretation.

Table 34 Provisional scheme for interpretation of water quality and sanitary inspection data
(Whipple, 1903)

Sanitary Quality Presumptive test for Bact coli

0.01cc 0.1cc 1.0cc 10.0cc 100cc

Safe 0 0 0 0 +
Reasonably safe 0 0 0 + +
Questionable 0 0 + + +
Probably unsafe 0 + + + +
Unsafe + + + + +

5.2.2 Combined indices of service quality

In light of the introductory discussion concerning decision-aids in the chapeau to this
section, a simple means to combine information concerning the preferred indicators of
water supply service quality (means of provision/service level, continuity of supply,
susceptibility to contamination and water quality analysis) would do much to

151
commend the outputs of monitoring to those making decisions based upon need. This
should have the ability to address widely different service levels and provide a means
to rank new construction alongside system rehabilitation and extension. The ideal
scheme would enable all communities to be considered and ranked against one
another and not pre-select supplied communities for consideration and ignore those
others with no recognised 'improved' supply. It would therefore contribute to
overcoming the perceived conflict between construction of new supplies and
maintenance of existing infrastructure.

Such a system would need to be based upon the principle of supporting the selection
of 'needy' communities to which other factors (such as cost and demand) would be
added, in incorporating its outputs into operational planning. It would also need to
take into account the fact that ensuring availability of water was the first priority
(whether lack of improved supply was due to no prior intervention or long-term
breakdown) and the fact that any single parameter may assume overwhelming
importance if sufficiently bad. Such a scheme may be readily generated using a
multiplicative approach . This would contrast with the additive approach adopted
during the case studies from Nepal and Peru I) but is logical given that all are
necessary, but no one is sufficient to ensure a beneficial health outcome.

Whilst the exact nature of such a scheme would require adaptation in light of local
circumstances and could take diverse forms, it may be readily constructed similarly to
the following:

Service quality = Service level x Continuity x Quality

where (for example):

152
Table 35 Example scheme for scoring overall water supply sen·ice quality

Indicator Score*

0 0.25 0.5 0.75 1.0

Service level No organised Collection Collection Single tap in Multiple tap in

(aggregate for supply and no from a public from a public yard or house house
community) improved point source point source or protected
source greater than within 30 source in yard
30m from metres
house
Continuity Long-term Supply exists Discontinuous Discontinuous Continuous
breakdown (eg but supply forcing supply but supply
greater than discontinuity population to population
three months) forces year- use secondary stores water in
round use of sources the home
secondary periodically without need
sources (seasonally or to resort to
because of secondary
regular sources
breakdown)
Quality n/a Gross Medium-level Low-level No
(Combination contamination contamination contamination contamination
of water and/or poor and/or and/or low detected, no
quality and sanitary moderate number of sanitary
sanitary inspection number of sanitary defects noted
inspection as score sanitary defects
described defects
previously)
• The precise definitions of each score will be determined by local conditions in the country or region
concerned, those provided are illustrative

It should be noted that the omission of a zero category for water quality recognises the
primary importance of securing supply; whilst the wide range of service levels
considered, as discussed in Section 4.1.1 reflects the state of knowledge regarding

153
health aspects of service level generally; and also the fact that real coverage with
improved supplies is likely to be considerably lower than that reported (discussed in
Sectionl.2.5). Experience indicates that the resulting index would be best expressed as
a percentage for easy comprehension.

A scheme of this type would also support the present trend away from pre-determined
service level targets and towards supporting communities to select a service level
appropriate to their capacity to operate and maintain (see for example Gibbons et al
1996), whether achieved through initial construction or through rehabilitation. The
negative impact of coverage targets on the water supply sector as a whole has been
referred to already (Section 4.1.1) and such a scheme would help to overcome this
influence.

In discussing such an approach it should be recognised that the few attempts to

provide a relative weighting of the health impact of different indicators show a
remarkable convergence ofresults (see Section 1.1.2). The (additive) ranking system
used in Peru and Nepal allocated a relative weighting accessibility: quality of 4
(80:20) whereas the studies previously mentioned would both give a relative ranking
of 1.6 (22: 14 or 25: 16). It might appear tempting to use such a weighting in
formulating a scheme of the type discussed here. However these studies and
proposals represent the average health gain from an average intervention in an average
environment. They are therefore an unsuitable basis upon which to develop rankings
for specific circumstances where any single factor may be of overwhelming
importance.

In practice, the weighting provided by a scheme of this type would be taken into
account alongside other factors beyond public health priority, both specific to the
intervention and of a general (often political) nature. Specific aspects might include,
for example, cost, and assessed community motivation. More general factors might
include, for example, two contradictory factors:

154
• giving higher priority to maintaining infrastructure functioning for reasons of cost-
effectiveness or need for political commitment to this; and
• it may be considered politically important to have increased coverage with
improved supply, whatever the implication of this for maintenance of
infrastructure.

Finally it should be recognised that, because of the lack of an output measure, a

number of subjective value judgements are made. Whilst an apparent weakness in the
process, this is closely aligned with much sector thinking. Snell (1994) for example
cites the need for decision-making aids which:
• help analysts to structure and verify their work;
• communicate the complex analysis to decision-makers;
• enable decision-makers to guide and influence the analysis (for instance in deciding
upon criteria and weighting factors); and
• facilitate communication with other interested parties

A decision-making aid such as that described above readily fulfils these criteria and is
particularly strong with respect to the first three. In developing and assessing the
value of such aids, Snell (op cit) and others argue that scientific precision is less
important than criteria such as the above.

5.3 Information Management Systems

The consequences of poor information availability and use in sector orientation and in
supporting management decision-making have been discussed in Section 1.2.3. The
generation of monitoring data alone does not lead to the improvement of water
supplies or health. It is the management of the data produced which should ensure
maintenance and improvement of overall water supply provision. One result of the
'data-rich, information-poor syndrome' is that many of the case studies demonstrate

155
considerable ESA activity in support of information management systems. It is
conspicuous that in the majority of cases there was no e\idence that such systems
were significantly used and no evidence that they had facilitated decision-making was
accumulated. This worrying conclusion is also reflected in a 1981 World Bank
publication (cited in Robinson, 1991):
'A great deal of emphasis has been placed in many Bank-assisted projects in the
application of modern management systems for planning, programming,
budgeting, scheduling, control and data collection, and it is difficult to avoid the
conclusion that it has all been overdone. In some instances, the management
information systems introduced by consultants have simply proved too complex to
function or to be used beyond headquarters. In others they were excessively
dependent upon computers that were unavailable or functioned poorly. More
often, elaborate reports have continued to be produced at lower levels of the
hierarchy, but there has been no effective system for checking them, and they have
been little used, for lack of qualified headquarters personnel to handle them or for
lack of interest. The effort seems to have been spread over too many systems, with
too much detail, and with insufficient attention to the structural constraints on the
ability of management to act. '

This is not to claim that no evidence for successful use of information management
systems exists. Indeed the contrary is the case (see for example Constantinides and
Kolovopoulos, 1996). Nevertheless, examples of successful use of management
systems to facilitate the linkage between monitoring and assessment and actions
tending to improve water supplies were absent from the case studies and are rare
elsewhere.

Development of information management systems (generally computer software) and

accompanied by appropriate computer hardware is a common feature of external
support to water supply and sanitation sector institutions and was a component of
external support to the programmes described, especially for Peru and Egypt.
Nevertheless in practice there is no evidence that programmes supported by such
software performed better than those without it and in Egypt, the databases in question

156
had not been used. This probably reflects in part insufficient attention. but it is
conspicuous that information systems can only function where mechanisms for the use
of information are in place. In the case of Peru external support was concluded before
implementation of the database outside the national agency and the database therefore
suffered dislocation from both information generators and many potential users. In
Egypt the same occurred and in addition no national forum for sectoral co-ordination
at national level (which took the form of CONCOSAB in Peru) existed. Too little
evidence exists to draw substantial conclusions, but common sense would indicate
that information users, their perceived information needs and mechanisms for sector
co-ordination and administration should be defined before database development can
be effective.

Whilst two case studies (Pakistan II and Peru I) indicated the existence of proposals
for clear mechanisms for information exchange and cross-validation, no successful
examples of this in practice were identified. Furthermore, even in the case of Peru it
was proposed that for the rural (ie small community) sector that the monitoring
function be adopted by the independent surveillance agency alone and that cost-
sharing be established with the water supply construction agencies who were to be co-
users of the information collected.

The proposed Pakistan EHAP notes that 'Operational mechanisms for co-ordinating
environmental policies and management require adequate and accurate information
on which to base decisions and actions. This implies a system to collect, process and
distribute information. '; nevertheless no systematic recording of drinking water
supply or drinking water quality data was found in any of the agencies visited during
the study and none of the persons interviewed was aware of such an initiative or
activity, and this situation is likely to deteriorate with the institutional changes
described n the previous section.

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Amongst sector information, it is common that ESA project reporting is through the
ESAs own mechanisms. Such information cannot be considered easily-available in
the beneficiary country. Neither does it present the long-term successes and failures
or place them in the context of the national situation in a format which the national
community may fully exploit (Mather 1995). A movement toward a more assessment-
based approach would be beneficial to the sector, thereby reducing total data
collection, it would also require amplification, in capturing and disseminating the
experience of these interventions. The need for positive strategies for sectoral co-
ordination is discussed in section 6.3.1 and such mechanisms might provide a suitable
means to both seek ESA and NGO input and to disseminate information generated to
decision-makes in these important groups.

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 Section 6:
The Organisational
Context

'Large institutional and cultural shifts are needed

to create an efficient system for allocating
scarce public and private resources to
improve the household environment.'
(World Bank 1995 p95).

The purpose ofthis work, as described in Section 1.3, is 'to critically appraise and
make proposals regarding the re-alignment of water supply monitoring activities with
particular reference to piped rural water supplies outside the established market
economies'. The findings of the work with regard to the specific hypotheses for
testing identified infonnation-action linkages have been discussed in Section 3 and
conclusions drawn regarding their use, efficiency and optimisation. Experience
related to data and information have been critically reviewed in Sections 4 and 5. This
section focuses upon the implications of the findings including those from preceding
sections for the organisation of monitoring and assessment. The implications are

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discussed at three levels: policy, legislation and regulations. and institutional
frameworks. In exploring the implications of the work, further evidence, both from
the case studies and from the literature is presented and discussed.

6.1 Implications for Policy

At a policy level, the findings are relevant with respect to the impact of monitoring
and assessment upon policy. An important conditioning factor is the series of
pronouncements on environmental issues by the international community in recent
years and resulting trends in governmental organisation. This section is therefore
divided into two themes:
• present trends in policy frameworks globally; and
• the likely impact of monitoring and assessment through policy change.

The role of legislation and regulation, including their role in supporting monitoring
and using its products is considered in the following section (Section 6.2).

6.1.1 Present trends in policy

One of the most visible world-wide changes in policy frameworks related to
environment and health in recent years has been the trend towards establishment of
dedicated governmental departments and agencies with an explicit mandate for
environmental issues, most frequently seen as Ministries of Environment and/or
Environmental Protection Agencies or their equivalents (Ongley, 1995). This trend is
global in impact and has been supported by a series of decisions and statements from
major international meetings such as the 'Rio' Conference. The case studies provide
examples of this from Pakistan and Egypt. Whilst these two case studies are very
diverse, they provide a common indication of the problems that may result in relation
to the status and position of drinking water supply monitoring when such changes are
implemented.

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In the case of Pakistan, responsibilities for environmental monitoring were being
transferred wholesale to an environment sector which was at the same time being
established. The environment sector organisations and senior staff interviewed had no
interest in assuming responsibility for monitoring of drinking water supply and quality
and considered it at best peripheral to their interests. In parallel, having transferred
much of its environmental health monitoring capacity (laboratories, staff) to the
nascent environment sector, the health sector lacked serious capacity in this regard.
This latter observation is reinforced by recent communications (Howard, pers comm)
that the Health Sector had declined opportunities for external support in this area
because they did not have the capacity to respond to the work demand that an
initiative would generate.

In Egypt, against a background of confused and overlapping responsibilities, two

potential scenarios for organisation of environmental policy development were
emerging at the time of the assessment: a planned law which would give the Egyptian
Environmental Affairs Agency (EEAA) a policy-development role; whilst discussion
were also ongoing regarding the creation of a Ministry of Environment (with the
implication of this adopting a policy-development role). Whichever were to emerge
(and the two are not mutually exclusive) the relationship between them - especially
for policy making - would become a key issue and the relative responsibilities of the
Ministries of Environment and Health for drinking water would require urgent
clarification. Whichever emerged, it would appear likely that responsibility for
drinking water supply surveillance would remain with the Ministry of Health as an
isolated activity and separate from other areas of environmental monitoring and
environmental protection.

It is conspicuous that in both countries the ongoing changes are likely to leave the
position of drinking water monitoring as weakened, nebulous or both. At best drinking
water monitoring will either be seen as a marginal activity to an environment sector

161
responsible for it or will be the responsibility of an under-resourced health sector with
very limited monitoring expertise or capacity.

The establishment of formal environment sector institutions does not necessarily

represent substantial 'new money'. In the case of Pakistan for example, much of the
environment sector laboratory infrastructure in the provinces was developed through
transfer of existing facilities between authorities. In Lahore for example the EPA
laboratory was established by separating the air, solid waste and wastewater
laboratories of the PHED; whilst in Baluchistan the EPA was developing its analytical
capacities by purchase from other already-established laboratories. In neither case
was a substantial increase in monitoring activities the result and - given the peripheral
nature of interest in drinking water supply and quality monitoring - the net result was
likely to be a decrease in scale of activity and health orientation in this important field.

It has been observed, albeit in the established market economies and therefore outside
the principal area of focus of this work, that environmental health considerations were
distinguished primarily by their complete absence in most government decisions
(Wolman, 1971). Whilst the words generally appeared in legislative pre-amble,
budget allocations were negligible and rigorous public health criteria were rarely
applied (Steensberg, 1989; Hufschmidt, 1977). Whilst it is difficult to judge whether
this remains true, or whether it was or is true outside the established market
economies, it is most likely to be the case if responsibility for monitoring and
assessment of environmental health is under the aegis of an environment, rather than
public health agency, since it is common to see public/environmental health
arguments are often used to justify activities more strongly associated with
environmental protection per se.

6.1.2 The impact of monitoring and assessment on policy

'For all practical purposes, the results of governmental action in
the representative democracies can be lumped together
with the effects of earthquakes and hurricanes'
(Meehan, 1981).
162
 'Public policy is whatever governments
choose to do or not to do '
(Dye, 1972).

It is often assumed that Governmental decision making is analogous to the purposeful

acts of individuals and this provides a simple 'handle' with which to consider aspects
of policy. Unfortunately it disregards the fact that government policy is not the output
of one calculating decision-maker, but a conglomerate of large organisations and
political actors. As a result different models of decision-making have been proposed.
Whilst diverse, they are not mutually exclusive and most are compatible with the idea
of their being four stages in the process of problem solution (Steensberg, 1989):
• the immediate pressures on the decision-maker;
• the analysis of the type of problem and its basic dimensions;
• the search for alternative solutions; and
• the consideration of the consequences of the alternative solutions.

Not all decision-making involves these stages in a structured sense and the stages are
influenced by various factors such as the organisational context. Nevertheless it is
valid to note that, in the context of rural water supply, the monitoring function might
reasonably be expected to contribute to the first and be supportive of the second and
possibly third and fourth stages.

Models for decision-making in the context of governmental policy development are

extremely diverse and few reasonably approximate functioning even under specific
conditions. The models include systems analysis (emphasising the idea that the
dispassionate mind of the scientist can assist in the process of decision-making);
rational approaches (relying on quantified trade-offs of the consequences of action or
inaction in linking means to ends); incremental change (based on the observation that
public administrators and policy analysts in general limit analyses to incremental or
marginal policies that are chosen to differ only incrementally; and democracies change
their policies almost entirely through incremental adjustments); and extra-rationality

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and organised anarchy (which, at the risk of simplification, recognise that when
representative bodies are populated by status-seeking persons whose position depends
on continued approval from a small population, then flagrant disregard for the social
consequences of collective action is bound to occur).

Work in most environmental health administrations generally seeks to follow a

rational approach, utilising much of the scientific reasoning which characterises the
systems approach. Nevertheless, certain types of activity, and typically those with a
high public profile or 'disaster' connotation adopt a more political character and
follow a more disorderly course in policy development. The nature of water supply
world-wide and especially outside the established market economies is such that it has
both a high profile and often enters the public view in a 'disaster' context. As a result
sectoral policy may often be more political than logical in its development and there
are therefore greater limitations to the role of scientifically derived assessments
including the outputs of monitoring than might otherwise be the case.

Whichever - political or logical - influences on policy development dominate, it

should be recalled that a substantial contribution occurs from 'soft' social values and
the total scope for impact of logical scientific inputs is therefore limited. Furthermore,
the inherent conservatism of systems and institutions means that radical policy change
is a rarity. Most policy change will, in practice, occur through relatively small
increments, even where ethical and logical arguments would suggest that radical
change would be warranted. The poor development of operation and maintenance of
rural water supplies, despite all evidence of its importance and supportive rhetoric,
provides one perhaps graphic sectoral example.

Whilst the above introduction serves to underline the limitations to the impact of
scientific analysis on governmental policy, the potential of this mechanism for
improvement remains evident. It is therefore relevant to note that the successful case

164
studies in this area presented in Section 3.1 concern relatively circumscribed
interventions, with nevertheless potentially large impacts .

Governments are ill-suited to studying the impact of their own activities. At the same
time there is suspicion amongst those who govern of academic intellectuals, often
based upon past experience (Meehan, 1981) and it is generally felt unlikely that the
academic community will provide the raw material for reasoned action. The
conclusions of Section 3.1 clearly illustrate the capacity of routine monitoring and
assessment to provide objective information which, if used appropriately by national
authorities could provide the basis for not only programme evaluation, but reasoned
action on the basis of its findings.

6.2 Legislation and Regulations

The certainties and uncertainties of the relationship between water supply and health
impacts have been described in Section 1. From a regulatory viewpoint the
conclusion of this may be simply summarised: even a complete review of the available
scientific evidence is unlikely to provide adequate information for regulators
(Goldstein, 1995). Notwithstanding the moderate contribution oflogical analysis as
described above, those who use logic in making practical decisions cannot afford the
scientist's luxury of calling for further research and decisions must be made on the
basis of inadequate knowledge.

The proposed change in roles of government from service provider to promoter and
facilitator of water supply and sanitation has been discussed already (Section 1.2.3).
In creating legislation supportive of the development of drinking water supply in rural
areas central government should retain certain powers and responsibilities (Appleton,
1995b ). Whilst most observers argue that this should include standard-setting and the

165
protection of public health (IRC, 1995b), it is common to encounter the reference to
'enforcement' in such commentaries (see for example Appleton, 1995b).

In broad terms much of the monitoring undertaken by the public sector is driven by
legislation (Steensberg, 1989) which is in tum generated by a paradigm of assessment
of regulatory compliance (daSilva and O'Kane, 1989). It has been noted in Section
2.4 that this is an area in which the legislators have failed to keep pace with the
pragmatism of those involved in water supply programmes and projects, 'some for all'
instead of 'all for some' (IRC, 1995b).

The enforcement approach requires measurement, comparison, reporting and,

occasionally, legal intervention. Because 'reality' is so far removed from the ideal
situation proposed in many water supply standards and legislation (Okun and Lauria,
1992) and because these are effectively unenforceable in rural areas, standards and
legislation have often lost all real credibility (Jensen, 1967). Whilst it appears likely
that enforcement can have a place in a revised scheme, emphasising assessment,
information sharing, target setting and inter-sectoral collaboration, convincing
examples of successful application of this in the rural sector remain absent. This does
not imply the irrelevance of or lack of need for legislation, but a recognition that its
role is far broader than the commonly-encountered formal compliance monitoring
approach allows.

Making generalised recommendations about legislative frameworks is complex, not

least because of the diverse environments in which they operate (Islamic law, common
law etc) and because countries are rightfully reluctant to accept foreign interference in
anything connected with their own legislative powers. The differences are extreme
and it should be noted that in Yemen for example only traditional water regulations
govern water management. Countries may be reluctant to adopt foreign practice
because of its limited perceived relevance to their national situation (Caponera, 1992).
This is especially valid in the case of drinking water supply, where legislation in the

166
established market economies, oriented principally toward the regulation of
established water supplies administered by recognisable entities may have little
relevance to other countries where the role of regulation might be argued to be to
support the best use of available resources in the provision of incrementally improved
service standards to the population as a whole. Nevertheless, much environmental
health legislation and associated standards remain in place in developing countries
dating from the colonial era and often represent 'utopian engineering' and fail to
reflect the need for practical, low-cost approaches to improved service provision
(Holland, 1991).

Notwithstanding the above, it is possible to identify certain principal characteristics of

the legislation needed to support the development of rural water supply and the role of
monitoring and assessment in this. The following paragraphs therefore explore
aspects of water law as relevant to the subject of the thesis, on the basis of the findings
outlined in previous sections, additional experience in the case studies and the
published literature.

It is nonnal practice that a general 'water law' exist, providing basic principles and the
framework within which regulations may be established by defined competent
authorities. This basic law may take diverse forms (constitution, act, code etc) and
may be wider (as part of a natural resource law for example) or narrower, although it
is preferable that all provisions concerning water are contained in a single law. It
would normally include a statement of purpose (policy) which would refer to the
intention to protect human health and welfare and define priorities amongst different
uses. As such, water supply would represent a part of a whole, and the monitoring
function only a part of that.

Different aspects of the water field are closely interconnected and the field is in tum
connected with other environment and health issues more generally. The basic law
should refer to the jurisdictions, responsibilities and authority of specified competent

167
agencies in relation to water and to their relationships to one another. This should
include water users, those constructing and administering water supply systems, those
regulating different aspects of water and having responsibilities in related domains
and agencies involved in data and information management and sector planning.
Kandiah ( 1995) refers to the legal and policy frameworks which assign responsibility
to agencies to implement and co-ordinate their programmes as one of the key factors
affecting the sub-optimal performance of all types of water schemes. For rural water
supply it is especially important that ownership and responsibility for example for
operation and maintenance of systems constructed by one agency and operated by
another (often local) one (such as a water users association) are clear and
unambiguous. Thus Appleton (1995a) refers to the need for legislative changes to
provide the authority and autonomy for decentralised operations to function
successfully. The basic law should therefore be as comprehensive and clear as
possible in order, providing a wide framework for the execution of water policies
within a framework of more flexible directives . Thus for example, water source
protection measures are related to sanitary inspection (ie the monitoring of the
protection of the sources) both when the monitoring is to determine the effectiveness
of the required measures in protecting water supply and when it is to determine the
extent of compliance, whether the monitoring is used for enforcement measures or
not.

Embedding detail - such as service quality standards - in the basic water law is
generally problematic since the process of legal approval, normally requiring
parliamentary process would restrict flexibility and capacity to upgrade in light of new
knowledge of a changed situation. Such detail is therefore normally covered in
regulations which may be handled by one or more Ministries empowered to do so by
the general law. Without such flexibility it is more difficult for standards to function
as targets for progressive improvement and the conflict between utopian standards and
progressive improvement emerges (Steensberg, 1989).

168
Such detail should not be restricted to water quality, but water supply service quality
more generally, although other aspects are more likely to function as ·target setting'
than to be used in enforcement action. It should also extend beyond the simple
assessment of water supply service and include the adequacy of structures and
systems, for instance including definition of protection zones around water sources,
minimum standard specifications and minimum standard operating systems, hygienic
practice in construction and minimum standards for health protection. In some
countries this is embedded in a 'sanitary code' or 'code of good practice'. This was
the case in Peru where this was a function of the Ministry of Health. However it is
worth noting that such measures are most likely to receive support in their
implementation if consultation with supply agencies and professional bodies (for
example) have occurred and the obligation to undertake such consultation may itself
be embedded in legislation.

The issue of information management and information flow for management has been
discussed in Section 5. Nevertheless it is germane to note that in most countries data
relevant to water, including water supply are collected by a number of organisations,
operating and different levels and for different purposes (Troare, 1992). As discussed
in Section 1.2.5 in many, possibly most, cases the data is not published or indeed may
be jealously guarded, and little co-ordination exists between these organisations. As a
result, the information produced may be out of the reach of both the public and policy-
makers and the latter in particular have little opportunity to input to the process
through definition of their information needs. Often policy makers will then require
additional 'studies' to guide their deliberations which might reasonably have been
derived from established monitoring and assessment activities at less cost and to the
increased recognition of the value of the latter. Legislation might reasonably therefore
include provision to ensure data and information sharing. Such simple exchange
however rarely functions unless it is target driven.

169
A functionally-useful target which could coalesce such actions would be to include in
legislative provisions the obligation to produce an annual sector review of status and
trends (WHO, 1986). Where a sector plan exists, the review might also serve as an
annual review of its progress (op cit). Such a review would not only promote
information sharing, but would focus the thinking of monitoring agencies on the
information needs of policy makers and also on the definition of problems and
priorities and information needs for their definition. It might also promote the
establishment of more centralised, shared data repositories which is often cited as of
importance (see for example Caponara, 1992) and may be directly required in
legislation. Finally it may assist in overcoming the 'filing cabinet' mentality to
monitoring which is so often seen and may in some cases act as a spur to increased
public access to such information. Interestingly, one example of this applied to small,
usually rural water supplies exists, although it is from an established market economy.
The example refers to the legislative requirements of the 1989 Water Act in the United
Kingdom and embodies the characteristics described above (Clapham and Horan,
1991). In particular this example requires:
• annual reporting;
• particulars of an improvement programme; and
• prioritisation of problem areas.
And the authors cite the advisability of:
• the ability to support public access; and
• the ability of supporting software to manipulate information, make comparisons,
produce statistics and highlight priorities.

The issue of sectoral and inter-sectoral co-ordination is also discussed elsewhere and
the interdisciplinary nature of environmental health in general and drinking water
supply in particular and the need for inter-sectoral co-operation in addressing its
problems are described (Section 6.3.2). Legislation can usefully oblige co-ordination
amongst agencies at various levels. This is common at national level (as seen for
example in the case study Peru I) and also sometimes occurs at a sub-national level

170
(see for example the case study Pakistan II). Health preservation has a long legal and
institutional tradition and it is generally accepted that it is essential that the water law
provide for close institutionalised co-operation between the public health authority
and those other authorities concerned. Nevertheless the Ministry of Health or its
equivalent may be poorly prepared to participate in envirorunental health activities
and drinking water supply and quality standard setting and monitoring in particular.
This situation was encountered in the case studies from Pakistan and Yemen for
example. Target orientation can usefully focus the activities of an inter-agency co-
ordinating body and assigning responsibility for preparation of the sectoral review
described in the previous paragraph to such a co-ordinating body may usefully serve
this purpose.

The special problems of the rural sector are recognised by those specialising in water
law (Caponera, 1992), both because of the specific relationship of rural populations
with water resources and in terms of water supply and sanitation and their relationship
to health and disease transmission. In a book otherwise couched in relatively specific
legal terms, Caponara (op cit) indicates that:
'In such areas legislation by itself is not sufficient to abate the occurrence. It is
necessary to educate the users of water points in proper operation and
maintenance practices. This often requires a minimum training background in
public hygiene and health, in operation and maintenance of the facilities, and in
other basic aspects relating to water management. Water legislation should
contain the necessary provisions, as well as provisions tending to promote the
organisation of water users associations.'

Perhaps the most visible part of many laws and regulations relates to penalties or
sanctions imposed for committed offences. The low credibility of this in the real
situation of water supply in rural areas has been discussed in Section 5.2 and that
discussion is not repeated here. It is hoped that the above discussion clearly indicates
the positive, supportive role that legislation may make in target setting and
facilitation. Nevertheless it is perhaps unavoidable that provisions for legal

171
enforcement are included in law and will occasionally be used. In order to moderate
their use, it is appropriate that explicit schemes for enforcement implementation are
provided for and pursued (Jensen, 1967). Such a scheme might note that legal
enforcement of water quality standards would not normally be pursued in the case of
community-managed rural water supplies unless occasioned by wilful abuse or
damage for example, or the case or repeated infractions by a construction or
maintenance agent.

There is a tendency for health-oriented participants in decision-making, leading up to

the point of definition of laws and regulations to consider their work done once this is
achieved, whilst in reality eventual impact will generally require that they continue to
act as a 'constituency' reminding the administration of the letter and spirit of the law.
It is therefore germane to move attention from the act of policy making, to that of
policy implementation. The dangers of separating policy design from implementation
is fatal (Pressman and Wildawsky, 1973) and for this reason Dye (1972) distinguishes
between 'policy output' and 'policy impact'. Legislation should foster improvement
and not only censure failure (WHO, 1984; Wheeler, 1990). A revised approach is
needed emphasising target setting for the sector and fully recognising that monitoring
should address the population as a whole and all aspects of the procurement and
management of drinking water, not only service quality in established, formal water
supply systems. The logical conclusion is that provision for implementation must be
considered as a part of the formulation of policy and legislation and not as a process
following and independent of formulation of legislation (Bardach, 1978; Steensberg,
1989; Cofino, 1994).

6.3 Institutional Frameworks

Two conspicuous global trends concerning institutional frameworks for water supply
and sanitation have been visible in recent years: that of decentralisation (the principle

172
of devolving decision-making to the lowest appropriate level); and the recognition at
governmental level that effective policy development and management requires multi-
sectoral co-operation. Furthermore. whilst little practical support is provided there is
general acceptance of the principle that central government should retain
responsibility for public health and maintaining quality standards (see for example
Appleton, 1995a; IRC, 1995b).

Much of this section leads on from the previous sections concerning policy aspects
and legislation and regulation. This is logical since the institutional/administrative
framework should be developed in order to support policy, principally as embedded in
legislation. Furthermore, Lloyd and Helmer ( 1991) in reviewing experience with pilot
programmes in rural water supply surveillance in Indonesia, Peru and Zambia note
that - despite an institutional structure to support implementation being one of the two
main components for the development of corrective action - none of the three projects
demonstrated this aspect to have been dealt with effectively. This section therefore
addresses the following principal themes:
• sectoral and inter-sectoral co-ordination;
• institutional responsibility for monitoring; and
• training and human resource development.

6.3.1 Sectoral and inter-sectoral co-ordination

The health aspects of human-environment interaction represent one of the principal
inter-sectoral dimensions of environmental policy and management. As a result of
inter-organisational fragmentation, environmental health programmes that are inter-
related may be assigned to different specialised agencies. Monumental problems of
achieving programme co-ordination seem to exist in most countries regardless of the
relative sizes of the public and private sectors (Schaefer, 1974).

Environmental health is, of itself a broad discipline and the practice of environmental
health requires inter-disciplinary and inter-sectoral co-operation.

173
The possibility of bringing together disciplines into a single Ministry, Department or
Service has been discussed (WHO, 1970) but concluded to be impractical. The
reasons for this include the fact that health activities form only a small part of the
functions of the Ministries or Departments concerned. the consequences of
withdrawing technical experts from their peers and associated resources; and the fact
that many established systems were considered to be functioning effectively.

The inter-sectoral nature of co-ordination necessary for effective action in

environment and health is however considerably more complex. In addition to inter-
disciplinarity, it also addresses the diversity of institutions that may play a role in
policy (such as health and environment), in regulation and control (health,
environment, local government); and in influencing positively or negatively
environmental health quality (industry, agriculture, local government, transport) as
well as the service providers themselves.

The need for inter-sectoral co-operation has arisen repeatedly in discussion in recent
events of both a technical and political character and is a theme of unusual accord.
Considerably less harmony exists however with respect to the practical measures
needed to ensure such co-ordination. That there is little agreement on a single master
framework, is to be expected given the extreme diversity which exists amongst
constitutional, legislative and administrative systems and the diverse social, cultural
and religious influences upon them. One of the few areas of general agreement is that
since the Ministry of Health (or its equivalent) has the final responsibility for the
health and well-being of the nation, it must be in a position to advise on the
desirability and adequacy of any proposed action from that point of view (Steensberg,
1989).

A further dimension to the need for inter-sectorality is demonstrated by the

observation that governments may 'parcel out' parts of major issues for special

174
treatment by each competent Ministry with the attendant risk of losing overall
perspective and coherence (Steensberg, 1989). Such parcelling is aggravated by the
competition that frequently exists between such institutions. Whilst prepared prior to
the IDWSSD and experience gained during it, Schaefer's conclusions regarding
conditions that should be met if co-ordination is to be more than a gesture merit
repetition:
Simply lo promulgate laws and designate responsible officers will not suffice. It is
first necessary to build an effective political base of opinion and power and then to
design adequate systems, assign authority, provide resources and translate plans
into action; finally the development of the systems must be monitored, so that they
can be adapted as required. In most countries sectoral bureaucracies have to be
brought under a considerable degree of control and given clear, consistent and
persistent policy direction, if co-ordination schemes are not to flounder. ·
(Schaefer, 1981).

A recurrent theme amongst the case studies was the inadequacy of sectoral
information flow and co-ordination. It was conspicuous that in most cases
information flow between data generators and information users was extremely weak
and this is in agreement with previous experience (WHO, 1986). Several case studies
and notably Egypt, Peru I and Pakistan II noted specific governmental initiatives to
address this, in the latter case addressing co-ordination at both provincial and national
levels including reference to the need for systematic data collection at both of these
levels. Although in parallel it was recognised that existing structures and systems
were inadequate in this regard (for example Egypt, Pakistan and Yemen). There is
therefore good reason to believe that improvements in sectoral co-ordination could
substantially potentiate this mechanism. The breadth of concerned actors should not
be under-estimated, both in monitoring and supply and construction organisations
should be represented and the other obvious sectors of importance include finance
ministries and higher and further education.

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Chapter 18 of Agenda 21, the plan for action arising from the Rio Conference,
addresses protection of the quality and supply of freshwater resources and includes
seven programme areas, including drinking water supply and sanitation. In the
programme on integrated water resources development and management however it
notes that 'The fragmentation of responsibilities for water resources development
among sectoral agencies is proving, however, to be an even greater impediment ...
than has been anticipated Effective implementation and co-ordination mechanisms
are required' (Anon, 1992c).

Several case studies describe the need for a strong health sector participation in policy
and strategy development (eg Pakistan II) if health priorities are to be addressed
adequately. This is true both at national and regional levels. These case studies also
specifically identified the breadth of actors required if monitoring findings are to
successfully impinge upon policy.

It is therefore encouraging to note that an increasing 'bundling' of developing country

requests for technical and financial assistance in the water sector generally in a
manner that crosses sectoral lines has been reported (World Bank and UNDP, 1995).
However, no example of this in practice were detected in the case studies used in this
thesis and it is unclear whether this represents a real change in attitude or a style of
presentation adopted to increase acceptability of proposals to ESAs. Furthermore
none of the examples cited by the World Bank and UNDP (op cit) refer to drinking
water and sanitation.

Despite this extensive evidence for and recognition of the need for inter-sectoral co-
ordination and information flow, evidence from the case studies and literature
indicates that such co-ordination is rare in practice, despite the existence of positive
action or systems to encourage it in some cases. Only in Nicaragua, where the
programme itself was a joint initiative of two institutions was efficient co-ordination
and information flow achieved. The two information-action linkages demonstrated to

176
be effective in Section 4 both require inter-institutional co-ordination. In order to
encourage this it is advisable that positive provision be made for it in legislation as
described in the previous section and that means to demonstrate the benefits of such
co-ordination (such as sectoral reporting. also as described in the previous section) be
pursued.

6.3.2 Institutional responsibility for monitoring and assessment

The establishment of a drinking water monitoring system is, in principle an inter-
ministerial concern (WHO, 1986). And often in preparing a report on the 'State of
Drinking water' as described above multi-sectoral participation will be required.
Nevertheless there is a substantial issue with regard to institutional responsibility for
the conduct of monitoring

Most 'models' for organisation of monitoring, including that proposed by WHO

( 1976; 1985) envisage two, complementary roles: service quality control by the
supply agency and an independent surveillance function.

WHO has indicated that 'the water supplier and surveillance agency should be
separate and independently controlled' (WHO, 1976; WHO 1985). Whilst such a
model is both reasonable and often viable in urban areas world-wide, it has obvious
shortcomings in the rural sector where community management of water supply is
common and where even where formal agencies are involved, any routine monitoring
is rare. A rigid division between surveillance and quality control is little applicable
for small community supplies in developing countries (Helmer, 1990), except where
privatisation has occurred to a definable responsible agency or where a small
community is supplied by a formal utility as sometimes occurs near major cities or
where several rural communities are supplied through a single centralised system as
seen in Egypt, Yemen and several countries of central and eastern Europe.

177
Nevertheless it is not inevitable that the surveillance function should fall under the
direct supervision of the health sector (WHO, 1985 and 1996). In the United
Kingdom for example, Local Government assumes responsibility for much
environmental health monitoring and assessment and a similar model was followed in
Yemen. Where no conflict of interests exists this model would appear a viable
alternative and may in some instances facilitate inter-agency co-ordination at
local/regional level, as was found in Egypt, since local government is generally more
active in such co-ordination than the health sector.

Nevertheless it should be recalled that the structures of few ministries are such that
they could reasonably be expected to support a routine water supply monitoring
programme for rural areas. The Ministry of Health often has a structure capable of
this; albeit within a segment that has a long history of under-resourcing (Cajina,
1978). In this context it is conspicuous that the monitoring programme in Nicaragua,
which was part of an effective strategy for support of community-based operation and
maintenance, was based on a collaborative effort of the Ministry of Health and the
water supply agency.

Lloyd and Helmer (1991) suggest that it will be necessary for rural water supply
surveillance to depend at least in part upon the activities of the rural construction
programme for the foreseeable future. It is difficult to envisage how this will assist in
supporting improvement in water supply services given the virtual absence of
monitoring activity by this sector in many countries, especially of older supplies, and
the focus it has upon service to supplied populations rather than the under- and un-
served.

Whilst it may be argued that bringing drinking water and environmental protection
into a single entity would provide added opportunities for complementarity between
both monitoring and alternatives for ensuring environmental quality in these two
areas, practice in both Egypt and Pakistan indicates that the entities assuming

178
responsibility for environmental quality are not assuming responsibility for drinking
water supply and quality which remains a 'rump' responsibility of the health sector. It
is therefore in danger of suffering a lack of expertise as trained staff are attracted to
environmental monitoring and to become yet further laboratory orientated as the
activity adapts to the organisation and structure of the Ministry of Environment.

It is conspicuous that requirements of rural water supply monitoring and assessment

extend considerably beyond the reasonable remit of any supply-sector organisation
(for instance in assessing coverage, use of secondary watersources and household-
level recontamination). Furthermore supply sector monitoring could be seen to
represent a conflict of interests were such an organisation to adopt a major role; for
instance because of the need to detect and report on supply sector failures and
deficiencies as manifest by continuity data and through information concerning the
sue of secondary sources. As such the activity required more closely resembles
traditional definitions of 'surveillance' such as that proposed by WHO in 1976: a
'policing function on behalf of the public, to oversee operations and ensure the
reliability and safety of drinking water' and it is argued that for these reasons and in
order to enable inclusion of public health priorities such as un-served populations it is
inevitable that the public sector assume this role.

Experience in Egypt demonstrates the inherent risk associated with assigning

responsibility for routine monitoring of formal drinking water supplies to a non-
supply sector agency and to the Ministry of Health in particular. The outcome was
that limited health sector resources for monitoring were used to support the supply
sector and diverted intellectual, infrastructural and material resources away from
assessment and reporting of high priority issues for health such as under-served rural
(and urban) populations, household recontamination, shallow and private wells and
other secondary sources. Similarly in Pakistan the need for stronger participation of
public health authorities in monitoring drinking water quality was well-recognised
(Anon, 1986).

179
The above comments are particularly appropriate \\ith respect to a monitoring
function orientated toward orientation of policy and regional and are well-recognised
(Anon 1986). Development of monitoring linkages to operation and maintenance,
whether by fonnal supply agencies or communities makes additional demands of
institutional arrangements. In particular very close co-operation would be required
between health authorities and the agency providing community support (if not the
health authority itself) and arrangements for implementation would need to be clear
and unambiguous.

6.3.3 Training and human resource development

Based upon a major study undertaken by the British Council on behalf of the World
Bank, Blackwell ( 1991) noted that there is little evidence of the application of science
on a large scale in a manner appropriate to the alleviation of the problems of hunger,
drought and disease that prevail in much of the less-industrialised world. He also
noted the predominance of out-dated single-subject curricula and that little
environmental work had found its way into curricula. He concluded by stating that
'the major change needed if we are to implement more mu/ti-disciplinary curricula is
too difficult for the entrenched single subject specialist to embrace ', that 'The
importance of encouraging the implementation of curricula more appropriate to the
real needs of developing countries can therefore hardly be overstated' and that
'unwillingness to abandon "pure" academic values [favours J higher education at the
expense of technical education, [and] often makes the task exceedingly difficult.'

The situation encountered in the various case studies with respect to education and
training is summarised in Table 35. In several cases, training and human resource
development was identified as a high priority by national authorities (Egypt,
Romania) and is also supported by other sector commentators (Lloyd, 1990)..

180
All case studies showed very extensive external input to sector training and education
- representing a significant proportion of the total - and a similar observation is made
by Lloyd and Helmer ( 1991) in reviewing experience with water supply monitoring
from Indonesia, Peru and Zambia. However, in none did external support address the
root problems of technical education or of integrating relevant themes into the
professional curricula in a multi-disciplinary context and much expert comment
continues to focus upon development and delivery of specific short courses outside
the framework of human resource development or staff development more broadly
(see for example Lloyd, 1990b).

The multi-disciplinary nature of environmental health has been discussed in Section

6.3 .2 in the context of inter-sectoral co-ordination. At the level of technical staff
(sanitary inspectors, environmental health officers or their equivalents) it might be
argued that this represents perhaps the broadest vocational training qualification
commonly encountered world-wide. Even where those technical staff involved in
rural water supply monitoring were considered 'specialists', it was generally the case
that they required inter-personal, observation, diplomacy, laboratory analytical,
interpretation, presentation and occasionally practical repair skills. Frequently these
skills had to be deployed in isolation and considerable on-site decision-making was
required of them. The conflicts that this multi-tasking generates in attempts to
integrate operation and maintenance tasks into the monitoring function has been
discussed in Section 3.3. This group of staff form the backbone of most of the
monitoring activities undertaken in most of the case studies, and also those reported
by Lloyd and Helmer ( 1991) and Young (1989), yet their training is generally minimal
and real commitment to in-service training or supervision conspicuously absent
(Lloyd, 1990). As a group, they have low status, low remuneration and poor career
prospects (Lloyd and Helmer, 1991) and yet receive negligible technical training.
This series of observations is paralleled by those of a three country study of
environmental health human resource development in Cuba, Mexico and South Africa
(Anon, 1995c).

181
Table 35 Situation encountered in the case studies with respect to staff education and training
Case Study Technical Education (for
Sanitary Inspectors or
Equivalent)
Egypt Was stopped in 1987, some
in-house training continues
Overall academic or vocationally trained personnel less than 20 per cent of total
Indonesia* One year general course
offered by 13 colleges
Pakistan II Lack of general sector
technical training seen as a
national issue (Anon 1986).
Certificate for sanitary
inspectors followed by circa
100 students/year, leads to a
recognised qualification. No
public institutions offer
refresher or top-up training
Peru I Reduced from two years to
less than 6 months, no
programmed refresher or
top-up training; Institute of
Public Health, Lima
Yemen 30 - 40 health inspectors per
annum (weak water supply
and quality component to
course) from two institutes
Occasional courses for
assistant health inspectors.
Zambia* Three year course for health
assistants in Lusaka
* Reported by Lloyd and Helmer, 1991.
Professional Education Level of External
Support for
Training and HRD
Dip PH to l 0-15 students per 18 chemists and 20
year sanitarian each
MPH to 5-8 students per year received 2 training
inputs during 1980s
? ?
Relevant courses under- Several initiatives
subscribed. known of by the
One Msc in PHEng and one author but
in Env Eng totalling 35 inadequate
graduates/annum . information base for
Dip PH 30 students/annum, quantitative
most become DHOs. assessment.
MPhil Community Medicine,
few students.
Specific sanitary engineering Very extensive
curriculum along USA lines
Sanitary engineering course unclear
in development with
significant water supply and
quality components
? ?
182
The extent of external support provided through short courses for both sanitary
inspectors and for laboratory staff reflects both the willingness of external agencies to
support training activities; the low level of use of skills acquired relevant to
monitoring in present programmes (and therefore the need for refresher training) and
the poor orientation of basic training of sanitary inspectors in relation to the needs of
the monitoring. Any skills related to water quality analysis in particular were found to
have become 'stale' and sanitary inspection and development of interview skills were
often entirely un-addressed.

In discussing technical training Lloyd and Helmer ( 1991) consider the use of teams of
staff comprising both sanitary inspectors and laboratory technicians to have been an
important element in the success of the case study in Peru I (also analysed by them).
This conclusion was particularly derived from the poor initial experience during pilot
testing in this project with the use of laboratory technicians as field staff who proved,
despite training, unreliable in the conduct of sanitary inspection. Whilst it is
undeniable that in the case ofthis project the team approach was successful in
ensuring the quality of both analytical and sanitary inspection data, this approach was
not adopted in all bases of the programme. Furthermore, the use of membrane
filtration as the analytical technique required training of all laboratory technicians in
this. Such training was provided to both laboratory technicians and sanitary
inspectors and no evidence was found that laboratory staff conducted the analyses
more correctly after such training. Similarly, the introduction of systematic,
quantified sanitary inspection to sanitary technicians was found the require substantial
time inputs. Sanitary inspection occupied the largest single amount of training time
during courses in this programme, included both theory and practical field work and
was followed up with field supervision in order to ensure success.

183
A critical review of experiences in the case studies and with the various mechanisms
for improvement based upon monitoring indicates that regional and national decision-
makers and policy makers represent an important client group for the information
product of monitoring and yet may be significantly unprepared to demand, or use such
information. It is tempting to conclude that an appropriate orientation should be
incorporated into the primary professional training curricula of concerned
professionals (typically medical doctors and engineers).

Two particular experiences from the literature are relevant to the discussion of training
and HRD for those who are not technicians involved in the monitoring process: one
related to the introduction of environment aspects into a medical training curriculum
(Guidotti, 1995) and the other to the increase in health issues in engineering curricula
(Anon, 1995b). Whilst the former is from a country with a developed market
economy, it does provide insights into the acceptability of increasing coverage of
environmental themes within medical curricula, generally already perceived to be
crowded courses of study.

The author of the former study concludes that the experiment (of introducing a
curriculwn element of ecosystem health) was well received by students but did not
mean that the existing, overloaded medical curriculwn could accommodate extensive
new material. The noted that it was not clear whether their then current medical
curriculwn could sustain environmental health as an 'add on', but that a remodelled
medical curriculum might profitably incorporate some of this content where it fits
with basic science or clinical content. The same study cited (but failed to reference) a
survey of deans of US medical schools the results of which indicated that 71 per cent
admitted that their medical schools placed little emphasis on environmental health,
mostly (as 88 per cent responded) because the curriculwn was already too crowded.

The second study concerning introduction of a health component into engineering

curricula was tested in five engineering schools and it was found that only the shortest

184
- aimed at awareness-raising was useful, because of curriculum overload. The major
lesson learned was perceived to be that one should not aim to make mini-health
experts of engineers (Anon, 1995b).

A further issue of particular important to the re-orientation of monitoring activities

concerns the paucity of continuing professional education (CPE). Toe prevailing
environment encountered in the case studies was one in which no systematic CPE
whatsoever existed. Professional updating was generally through specific, narrow and
target-orientated activities by ESAs. The result, in the absence of organised national
professional organisations or significant membership of international professional
organisations was a professional community which was disjointed, uncoordinated and
inaccessible. Secondary benefits may accrue from continuing professional education
and development of greater coherence amongst the professional community which
may then tend to function as a constituency or pressure group (Steensberg, 1989;
Robinson, 1991).

In practice it was common that the majority of senior professional encountered had
progressed following degree qualification from junior professional, supervisor,
professional, to programme manager, senior scientist or engineer or equivalent with
little or no further professional development except occasional, narrow, specific
courses or seminars. Undoubtedly this has contributed to the creation of a group of
professionals with extensive issue-specific expertise but has done little to effectively
develop a broad understanding amongst sector professionals of the context, conflicts
and priorities in their national situation. The absence of CPE in countries and regions
with no effective membership of professional associations, makes re-alignment of
sector activities most unlikely without major governmental financial commitments
and/or donor activity. Both appear unlikely to emerge in the present environment.

Finally, whilst much of the discussion serves primarily to underline the need for
appropriate training, this need has been well-recognised since before the Water

185
Decade (Pickford, 1991). Nevertheless. for training to be effective it requires an
appropriate institutional structure. career structures and a general educational context.
One reason that training has failed to live up to the unreasonable expectations of it has
been that it has been seen in isolation of the broader issue of human resource
development (Robinson, 1991 ). In this context it is germane to note that Table x
illustrates a de facto decrease in attention to training of sanitary inspectors or their
equivalents whilst in only one of the countries considered in the case studies
(Pakistan) was any form of national certification scheme for this cadre of staff in
place.

186
 Section 7:

Summary of Conclusions

The development of arguments in this work has been highly structured, commencing
with information-action linkages; then assessing data and subsequently information
requirements of monitoring and assessment; and finally discussing the implications of
the work at various levels. Because of this structured nature, conclusions have been
drawn in various sections and utilised in subsequent discussion and argument. This
section therefore provides a brief revision of the principal conclusions.

1. Monitoring and assessment can make a significant impact upon the quality of
water supply services.

2. Of the five linkages between the information derived from monitoring and
assessment and improved water supply, two were found to be significantly used
and effective. These concerned overview assessment and prioritisation of major
interventions. For both of these linkages considerable scope for increased use and
optimisation existed.

187
3. One information-action link was considered inherently unusable in normal
practice: that of legal enforcement.

4. The n:rn information-action linkages related to operation and maintenance and

were found to be afflicted by a series of similar limiting factors , including:
• the lack of clarity in responsibility for operation and maintenance in
practise;
• unwillingness of institutions (community-based or otherwise) to accept
responsibility for operation and maintenance;
• general lack of interest in operation and maintenance from the professional
and technical community; and
• low political profile of operation and maintenance.

5. Notwithstanding the above , some evidence to indicate the effectiveness of the

linkage concerned with provision of support for community-based operation and
maintenance of rural drinking water supplies was found. To be effective this
requires political commitment, which is unlikely to be forthcoming in the present
environment favouring reduced governmental intervention in water supply
provision.

6. Monitoring schemes are generally poorly optimised in terms of 'driving' the

information-action linkages shown to be effective. It is possible to substantially
improve systems for information generation but this requires a radical change in
the approach adopted towards monitoring. Approaches to data acquisition must be
re-orientated towards pre-defined information needs and an information-rich
environment created in contrast to the data-rich, information-poor environment
often encountered at present.

7. The preferred set of indicators of the adequacy of rural water supply for health for
use in routine monitoring programmes are:

188
 • service level/means of provision (ie the percentage of the population. by
area or community. served by different means or with different levels of
service);
• continuity of supply (the proportion of time which supply is available,
presented in terms of each of the service levels in the above and where
necessary sub-divided into breakdown, daily and seasonal discontinuity);
• the susceptibility of the supply system to contamination (as assessed by
systematic sanitary inspection with or without additional hygiene
indicators); and
• the presence of faecal contamination as assessed by water quality sampling
and analysis at source. representative points of supply and representative
points of use.

8. Data concerning these indicators may be reliably collected by field staff using
robust data collection methods.

9. A two stage sampling approach to data acquisition, stratified as necessary, could

assist in generating high quality information. It would require less community
visits for data acquisition than is sought in many programme plan at present, but
increased breadth and quantity of data collection within communities visited.

I 0. Data acquisition should encompass the population as a whole, rather than

concentrate attention upon those already benefiting from improved supply, and
thereby address together the served and un-served segments. It should also
address the process of provision as a whole and not be restricted to the supply
system per se. Existing monitoring and assessment schemes often lack this
breadth of information collection and collect inadequate and insufficient data with
which to characterise communities and supplies.

189
11. Even if adequate and appropriate information is generated, present monitoring
schemes generally fail to create linkages \\1th decision-makers, either in order to
provide them with information products of monitoring, or in order to seek their
comment on the nature of the desired information products. In order to improve
existing monitoring and assessment programmes and projects, increased
involvement of decision-makers at national and regional levels is critical.

12. Despite substantial evidence of the limited scope for impact of rational analysis on
national policy, water supply monitoring and assessment can impact substantially
upon activities at a nation-wide level.

13. Decision-makers at regional level are often receptive to information products of

monitoring which assist them in managing and prioritising activities.
Presentational aids which integrate different components of water supply service
quality and which may be adjusted by such persons have proven value. They are
typically used for pre-selection, following which other criteria will be taken into
account.

14. To operate effectively, general as well as specific measures for information

exchange are advisable. Mechanisms for sectoral co-ordination are important, yet
rarely encountered and less rarely effective. Coalescing co-ordinating actions
around a functionally-useful target such as production of an annual sector status
report would encourage information sharing, co-ordination and information for
decision-making and may be embedded in legislation.

15. Optimisation of monitoring methods is largely meaningless in isolation of the

policy, legislative and institutional framework in which implementation of
monitoring takes place. Notwithstanding the limited scope for regulatory
enforcement note above, the existence of a supportive policy, legislative and

190
 regulatory environment may substantially facilitate the impact of monitoring and
its absence may effectively preclude it.

16. The case studies presented demonstrate similar learning process being followed by
diverse projects and this may be aggravated by the weak training and educational
environment and negligible information base available to support activity in the
field.

17. The conclusions represent a rationale for a radical departure from established
approaches to rural water supply monitoring. Such a departure would re-vindicate
this activity amidst its decreasing perceived value and provide a clear future
direction for governmental action. It would do so in an area increasingly
dominated by non-governmental and private sector agencies, where - in practice, if
not by intent - government action has been marginalised by processes arising out
of the recent series of international conferences; but where there is a clear need for
a governmental role in ensuring that co-ordination and that health concerns are
adequately addressed. Such a departure would also provide a positive basis and
approach for a critical and positive scientific input to sector development for the
foreseeable future.

191
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226
Volume II:

Annexes
 Annexes

For eight of the case studies used in this work, descriptions are included here as
Annexes 1 to 8. Some of these have been partiall y reported previously and where this
is the case references are provided. The case study concerning Colombia has been
reported previously and a copy of the paper concerned (Bartram et al 1991) is
included as Annex 9. The case study from Nicaragua to which the author provided
advisory support, principally with regard to information management, has been
reported at length by Young (1989).

A standard format has not been adopted in the case studies because of their inherent
diversity and contribution to different elements of the thesis.

227
 Annex 1: Egypt

Status Assessment for Egypt

Al.I Introduction

In 1993 a series of national status assessments of drinking water quality monitoring in

Egypt, Pakistan and Yemen were prepared on behalf of the East Mediterranean
Regional Office of the World Health Organization (Bartram, 1993a; Bartram, 1993b;
Bartram 1993c; Bartram, 1993d). This activity involved observation of current
practice through interviews with national, regional and local level staff, field visits
and visits to laboratories and offices of environmental inspection agencies and training
agencies.

The aspects relevant to rural water supply monitoring from the three studies are
presented as separate annexes here and provide insights into the organisation and
practice of drinking water supply monitoring in the three States concerned.

Al.2 Area and Population

The population of Egypt has increased dramatically over recent years and was
estimated to be of the order of 54 million as of 1991 (Mullick, 1991). Annual
population growth was estimated to be 2.3 per cent in 1989 with about 44 per cent
living in rural areas (WHO, 1989).

Ninety nine per cent of the population live in the Nile valley and delta. Although the
population outside this area is sparse there was a desire to locate populations outside
this area and national initiatives such as the 'New Valley' project reflected this.

228
Overall about four per cent of the country is covered by arable land. To the east of the
Nile is the eastern (Arabian) desert - largely barren and bounded to the east by a ridge
of mountains . To the west is the Western (Libyan) desert. To the east of the Suez
canal is Sinai, varying from mountains to the south to desert coastal plains in the
north.

Al.3 Institutional Aspects

Egypt was organised into 26 Governorates, four of which were urban. Rural
Governorates were lead by the Governor as executive chief supported by an elected
Popular Council. Governorates were divided into Markaz, the executive head of
which was the chief who was also supported by an elected Popular Council. The
structure was repeated at village level, with the chief, an elected Popular Council and
an executive Council appointed by the Govemorate.

Al.4 Water Supply Context

There were two principal sources of water for the country: the River Nile and
groundwater. Water supply to much of the country was problematic and in desert
Govemorates such as Red Sea, North and South Sinai and Matrouh, Nile water was
supplied through extended pipelines and booster pumping. Desalination was
sometimes practised, for instance in Matrouh and Sinai.

Estimates of coverage with access to safe drinking water varied widely. Urban and
rural water supply coverages were estimated to be 100 and 90 per cent respectively in
1989 (WHO, l 989) and 95 and 75 per cent respectively in 1991 (Mullick, 1991).

As of 1991 there were more than 70 large conventional plants for the treatment of
surface water (Mitwally, 1991). Videnov (1991) stated that there were more than 500
compact package plants of more than seven makes.

Rural water supplies derived from surface water, typically from the River Nile, were
supposed to be chlorinated , but those derived from groundwater were not.

Integrated water supply systems which supply water to multiple centres of population
were important in Egypt. These included the water authorities of Greater Cairo and
Alexandria. The General Organisation for Greater Cairo Water Supply (GOGCWS)
had a population in excess of 12 million in the area it supplied. The Alexandria Water
General Authority (AWGA) is the water supply agency to all of the Governorate of
Alexandria, all of the Govemorate of Marsa Matrouh (through extended pumping) and
about a third of the Governorate of Beheira, supplying water to a stable population of
about 4 million which swelled to five to six million in summer. In the Upper Egypt
Govemorate of Fayoum the El Azab water works (supplied with water from a central
conventional facility and a number of decentralised compact plants) supplied water
through a single distribution network to half of the city of Fayoum and most of the
229
rest of the Govemorate (a total population of the order of 1.9 million (El Azab Water
Works et al 1993).

In contrast to these large. integrated systems. very many small, principally rural water
supplies also existed. Thus for example in 1987 ORDEV had overseen construction
of some 2,177 water supply systems throughout the 22 rural Govemorates.

Some areas (such as Sinai) depended heavily on groundwater and groundwater quality
(both related to naturally-occurring substances and anthropogenic contaminants) was
an issue of concern. For groundwater-derived water supplies chlorination and aeration
to remove dissolved iron and manganese were sometimes practised. In Daqahliya
Govemorate (one of the largest and most densely populated Delta Govemorates) it
was decided in 1991 not to plan development of any further groundwater sources due
to poor quality and aquifer depletion (Videnov, 1991).

Piped drinking water supply was through both household connections and public
standposts. For both types , secondary sources (such as shallow wells or irrigation
canals) were commonly used because of discontinuous supply and problems with
public standposts and also sometimes by preference (see for example El Azab Water
works et al 1993).

Al.5 Water Quality Issues

At national level, the principal water quality issue as regards human health continued
to be faecal contamination. This was true in a range of circumstances:
• Contamination of systems supplied with treated surface water. All systems are
subject to occasional contamination, whether due to treatment breakdown or
failures in distribution and the risk was considered high in the many smaller water
supply systems (both rural and urban). This was particularly so where the system
was un-chlorinated and/or supplied from small-scale conventional plants or
package plants where quality controls tend to be less adequate.
• Groundwater is generally assumed to be of good quality. Nevertheless,
chlorination was not universally practised and groundwater was said to be
becoming increasingly affected by faecal pollution due to soakpits and discharge
of domestic waste into drainage systems (Mullick, 1991). The risk of faecal
contamination of systems supplied with water from groundwater sources may
therefore have been underestimated.
• Because of recontamination at household level in all situations; thus for example a
study cited by El Hennawy ( 1987) indicated that 42 per cent of household roof
tanks in Alexandria were contaminated by faecal coliform bacteria though water
quality in the distribution system was generally good.
• Finally, because of the common use of secondary sources such as shallow wells
or irrigation channels which may generally be assumed to be of inferior
microbiological quality.

230
Al.6 National Policy and Strategy

The situation regarding national policy towards drinking water quality and drinking
water quality monitoring was unclear, as was responsibility for policy development.
Thus for example:
• The remit of NOPWASD referred to policy, but it had no authority for water
quality policy over - for example - the Ministry of Health or indeed over the three
large water authorities. Furthermore were it to have exercised a policy-related
mandate it would have had a conflict of interests as both policy maker and
implementation agency. NOPWASD had an internal sanitation policy, but no
water supply equivalent
• The High Committee for Drinking Water had apparently not met for around ten
years but retained legal status. It was not possible to determine the extent of its
responsibilities or authority, although they were said to encompass drinking water
policy, specifications and standards.
• A law was due to be issued in September 1993 regarding the role of the Egyptian
Environmental Affairs Agency (EEAA) which was likely to have given it a
policy-development role. Since the EEAA was to be accountable directly to the
Council of Ministers and would not be an implementing agency this would have
been a conceptual improvement on the then existing situation.
• Discussions were ongoing regarding the creation of a Ministry of Environment.
Were this to occur its relationship to EEAA - especially for policy making - would
have become a key issue and the relative responsibilities of the Ministries of the
Environment and of Health for drinking water in general and drinking water
quality in particular would have required urgent clarification

Al.7 Institutions with a Role in Water Quality Monitoring

Although many of the roles necessary for effective water quality monitoring were
assigned and to a greater or lesser extent fulfilled there was no effective agency to
support sector-wide co-ordination or information sharing. For the purposes of rational
sector planning the lack of a co-ordinating institution with general responsibility for
policy development based upon a general overview including drinking water quality
in the general context of drinking water supply was conspicuous.

The principal players involved in drinking water quality monitoring in Egypt were as
follows:
• Water supply systems in Egypt were the responsibility of three big authorities, 26
Govemorates and major industries. In the rural sector, the National Organisation
for Potable Water and Sanitary Drainage (NOPWASD) was not a supply authority
per se but played a supporting role to the Housing and Utilities sections of the
Govemorates, which performed this role throughout the country.
• The Ministry of Health was responsible for surveillance of drinking water quality.
It was stated by several individuals that the only agency with legal responsibility
and authority to monitor drinking water in distribution was the health sector (ie
Ministry centrally and equivalent within the Govemorates). The anomalous
231
 situation therefore arose that the suppliers who are responsible for water
distribution are not responsible to monitor their o~n undertaking and resourcing
for this activity was derived from the public sector and not the supply agency. A
knock-on effect of this was to focus the health sector monitoring activities on the
piped distribution network rather than on those sectors and systems presenting the
greatest health risk such as household contamination. shallow and other private
wells and secondary sources.

The Organisation for the Development of the Egyptian Village (ORDEV) is also of
relevance to the rural sector. It is part of the Ministry of Local Government and was
established in 1973 to improve the quality of life of rural communities. Its strategies
are based upon integrated rural development; co-operation and co-ordination with
Ministries, authorities and national and foreign agencies; and working through the
local administration system to achieve decentralisation (El Shaabeiny, 1991). It has
no technical duties in the field of water quality monitoring but co-ordinates the
implementation of water supply at village level between central government and the
Governorates

Al.8 Sector Co-ordination

Responsibility for overall sector co-ordination and policy development was unclear.
Thus for example the remit ofNOPWASD referred to policy, but it had no authority
for water quality policy over - for example - the Ministry of Health or indeed over the
three large water authorities. Furthermore were it to exercise a policy-related mandate
it would have had a conflict of interests as both policy maker and implementation
agency. Similarly, the High Committee for Drinking-water appeared not to have met
for around ten years but retained legal status and was said to have responsibilities that
include drinking water.

The position was even less clear because of the imminent issuance of a law regarding
the role of the Egyptian Environmental Affairs Agency (EEAA) which was likely to
give it a policy development role. The EEAA was to be accountable directly to the
Council of Ministers and not an implementing agency.

Discussions were ongoing regarding the creation of a Ministry of Environment.

In practice at the time of the assessment there was no inter-sectoral forum or

mechanism to ensure information exchange and broad participation in policy
development. This position appears to be similar across all aspects of sector co-
ordination .

The national water quality seminar held in Alexandria in 1987 (Commins 1987) noted
amongst its conclusions that:
'overall co-ordination of effort of different bodies seems essential;
improvements in the feedback of information to take needed action was
considered to be most important'
232
and that
'the lack of proper co-ordination of various activities involved in ... water
supplies is hampering progress in improving the quality of drinking water·

Al.9 Laws, Regulations and Standards

The Egyptian Standards for Drinking Water Quality valid at the time of the
assessment were those approved in 1975, with the bacteriological aspects updated in
1984.

Revised national standards had been prepared as part of the UNDP/UNICEF/WHO

Drinking Water Supply and Sanitation Sector Support Programme in 1989 and were
scheduled for release in 1994. This Sector Support programme addressed water
quality standards per se; recommended analytical methods; recommended sampling
methods; reporting; and water resource protection ; and also included
recommendations regarding the need for staff training and the need for a three tier
laboratory network. It was noted that additional useful components would have
included:
• Requirements for sampling regimes (sample numbers , frequency and selection of
fixed and variable sampling sites; sample preservation and maximum storage
times before analysis).
• Requirements for conditions under which chlorination should be practised and for
minimum chlorine concentrations to be maintained throughout distribution.
• Clarification of responsibility for monitoring: both supply agency quality control
and independent surveillance, including mention of information sharing.
• Procedures to follow in case of non-compliance, including obligation to notify the
public.
• Responsibility for certification of new sources.
• Quality assurance requirements of any lab which intends to undertake AQC.

Al.10 Information Management

Information management was found to be problematic and/or deficient in all of the

institutions visited.

Al.10.1 National information management

According to Mullick (1991) as part of the UNDP/UNICEF/WHO Drinking Water
Supply and Sanitation Sector Support Programme, a sector information system linking
village, Markaz and Govern orate to three central levels in Ministry of Health,
NOPWASD and ORDEV was established and its implementation supported by
extensive training. Similarly, according to El Shaabeiny ( 1991) an information
system was established as part of the USAID-supported BVS programme (1979 -
1986) covering all villages in all Govemorates except Matrouh , North Sinai and South
Sinai.

233
Despite the efforts outlined above, most water-quality related data were found to be
managed at a local level where reports were produced on paper and not fed into a
computerised system. Furthermore, in practice, the databases described above
appeared to have served only for demonstration purposes and were not in use. This
was likely to have been, at least in part. a reflection of the low perceived need for
analysis of data at macro levels and had inevitably inhibited the development of
policies and strategies for improvement of drinking water quality.

Al.10.2 Local-level information management

At a local level, water quality data were managed for process control only by supply
agencies and were graded as acceptable /not acceptable in the health sector. Little
comprehensive data analysis was undertaken and data management was almost
exclusively paper-based.

Al.11 Laboratory Infrastructure

There was found to be considerable water laboratory infrastructure nationally, both

within the health sector and within the water supply sector although the quality of
health-sector water quality laboratory infrastructure varied widely. A number of the
premises visited were unsuitable for use as laboratories and the level of equipment and
its state of repair varied widely.

There was a clear tendency for laboratories to be operative rather than supportive and
thus for example even where the health sector was equipped with laboratory facilities
they may have become a de facto water treatment plant quality control laboratory
with the resulting potential conflict of interests that this generated.

The responsibilities of the central Ministry of Health laboratories included support for
and supervision of Govemorate laboratories.

Nationally there was little or no experience with on-site testing equipment and the
frequency of testing of basic hygiene related parameters was generally low in all but
the major cities.

Al.12 Actual Level of Monitoring Activity

The theory and practice of water supply and water quality monitoring were somewhat
confused throughout the country and especially within the Governorates.

In theory the 'water supply agencies' (whether one of the three large Authorities or the
secretary of housing and utilities at Governorate level) retained responsibility for
production and distribution. Outside the three large authorities it was only responsible
for monitoring the quality of finished waters, not distributed waters . Thus outside the
three large authorities, monitoring of water in distribution was the sole responsibility
of the Health Sector.
234
In practice. production-side monitoring was limited to the three large authorities and
some (about 20) of the country ' s large conventional treatment plants and limited
monitoring in a small proportion of the country·s more than 500 compact treatment
plants.

The Ministry of Health centrally monitored the distribution system of Greater Cairo
while the Secretaries of Health in the Govemorates perfonned the same function - to a
greater or lesser extent - elsewhere.

Overall, considerable activity dedicated to the analysis of water samples was

observed. However there appeared to be no monitoring of non-piped supplies,
whether from hand-pumps or tanker trucks, both of which were significant primary or
secondary sources of drinking water. Furthennore little of the overall activity could
be considered as 'surveillance' rather than quality control, although it may have been
undertaken by the health sector. Finally, a disproportionate amount of routine
monitoring was dedicated to routine physico-chemical control parameters and too
little to basic hygiene-related aspects.

Whilst sanitary inspection was the general response to detection of a water quality
problem, it appeared to be unused as a primary monitoring tool. Given the low
frequency of monitoring of smaller supply systems in practice, sanitary inspection
could readily and usefully have played a greater role in routine monitoring - both in
surveillance and in quality control.

Al.13 Staffing and Training for Water Quality Monitoring

There were a limited number of institutions concerned with training related to the field
of drinking water quality monitoring. These include a training centre at Damanhur (an
initiative of the Ministry of Housing, Reconstruction, New Communities and Utilities)
and the Higher Institute of Public Health (HIPH) at the University of Alexandria.
HIPH organised various short courses including one for water treatment plant
operators but was not routinely concerned with the training of technical staff. Its
Diploma in Public Health (a one year course) was awarded to about 10 - 15 students
per annum and its masters in Public Health (a two year course with the first year
common with the Diploma) to about five to eight students.

Until 1987 the Ministry of Health was directly active in provision of courses for
sanitarians and physicians working in environmental health. This was no longer the
case although the reasons behind the change were unclear.

Training for staff of EEAA, water authorities and NOPW ASD was said to be largely
provided 'in house'. According to Mitwally (1991) for the staff of the water treatment
plants, academically or vocationally trained personnel represented less than 20 per
cent of the total.

235
 Under the joint UNDP/UNICEF /WHO Drinking Water Supply and Sanitation Sector
Support Programme. an HRD core group was established in ORDEV as a 'permanent
focal point for training of water supply and sanitation sector personnel in co-
ordination with NOPW'ASD and Ministry of Health' (Mullick 1991). Under the
associated training scheme 18 chemists and 20 sanitarians were trained, each on two
occasions. Nevertheless. during visits to sector institutions and interviews with senior
sector staff, no reference to this was made and these activities had been concluded.

Training of staff involved in water quality monitoring was identified as a priority by

both the national water supply and sanitation sector profile (Anon, 1987) and in the
report of the national seminar on water quality (Commins 1987).

236
 Annex 2: Nepal

Monitoring in an NGO Rural

Water Supply Project
in Rural Nepal

A2.1 Introduction

A major non-governmental programme of water supply construction which had been

ongoing for several years was to receive increased resourcing to enable an increased
rate of activity. The inclusion of a monitoring and follow-up element was initially
insisted upon by the external support agency and was subsequently accepted by the
NGO itself.

Support was provided to develop a monitoring function as part of the programme by a

team of experts. Support included training of staff; development , field testing and
refining of materials; and repeat visits to assess progress. The programme included
attempts to incorporate operation and maintenance activities in the work of the
'monitors' and linking the monitoring programme to a hygiene education campaign.

In light of the findings of the assessment various changes to standard designs and
construction practice were discussed and implemented.

The following case study is based upon four reports concerning the programme
(Robens Institute 1990a, 1990b, 1991 and 1992), observations made during field work
with the project monitors; and discussions held with staff of other external agencies .

237
A2.2 Area and Population

The rural population of Nepal was estimated at 16 million in l 990.

The Himalayan region is subject to interacting natural and anthropogenic influences

which threaten the lives of its inhabitants and those living in the plains below.
Particular problems relate to increasing population, destruction of forest cover and soil
erosion , aggra vated by natural weathering processes in one of the world's unstable
mountain ranges, leading to river siltation and disruption to watersheds.

The monsoon season lasts from mid-June to mid-September during which 120 - 240
cm of rain falls upon the southern Himalayas depending on altitude.

Geographically Nepal is divided into the low lying and flat Terai to the south and the
Himalayan mountain ranges. The terai has a high population density and a high rate
of population growth.

High rates of population growth in the terai and elsewhere lead to pressure to occupy
marginal land and 1115th of the population of the country seeks a living in localities
with a slope of greater than 30 degrees.

Administratively, Nepal had been divided into five regions, each sub-divided into two
or three zones which were in turn subdivided into districts and then into Panchayats
and Wards. At the time of the described intervention, this system was under review
and the Panchayats had been dissolved.

A2.3 Institutional Context

The NGO was set up in 1962 and had a Community Aid Section which undertook
diverse projects such as agricultural aid, bridge construction and water supply
projects, with resourcing from diverse donors. The scale of activity in water supply
construction was significant with 29 schemes approved for the year 1990-1 for
example. At the time of the intervention a major ESA was to provide additional
resourcing to increase this rate of construction.

Rural water supplies constructed by the NGO were initiated by a request from a
community member who acted as 'sponsor' for the village. The responsibilities of a
sponsor included requesting a project, acting as local contact point and supervising the
work.

Nationally, there was no system for water analysis throughout the country, although a
number of laboratories offered water testing services for persons bringing samples
(Robens Institute 1990).

238
A2.4 Water Supply Context

His Majesty's Nepalese Government had a five year plan for water supply which
stressed surveillance and monitoring. Little had been done to this end by either
national or external agencies or the Government (Robens Institute , 1990).

Improved rural water supply was principally through gravity fed piped supply from
surface waters or (generally unprotected) spring sources. Most supply systems
comprised intake, conduction line (including pressure break tanks and washout
valves), distribution system (including valve boxes and pressure break tanks) and
public tapstands (although some open systems existed). Water was collected and
stored in 'gagris' whether collected from standposts or unimproved sources. Personal
washing and laundry was often conducted at standposts. Excess water, especially from
open systems was often utilised for watering household vegetable plots

Numerous agencies are active in rural water supply in Nepal and the result is a
diversity of approaches and the not infrequent finding of multiple supply systems to a
single village.

Extension of population to higher ground was forcing tree-felling and human , animal
and agricultural pollution nearer to the sources of drinking water.

A2.5 External Support and Interventions

Two programmes of external support were being implemented in parallel: increased

resourcing for the construction of gravity fed piped rural water supply systems; and a
monitoring scheme for these systems. The second of these is the topic of this case
study and had as its objective to gain a high degree of protection of water quality in
the design and construction as well as to maintain the integrity of systems for the
benefit of the health and welfare of the recipients (Robens Institute, 1990).

It was initially proposed that two monitors be recruited, to be responsible to keep

inventories of population served by new supplies and volume supplied per capita;
ensure that a sanitary risk assessment of source and distribution systems was carried
out on completion of each water project; note and changes or illegal connections;
classify the quality of water supplied by each system as soon as training for water
testing had been established; co-ordinate remedial action as necessary, promote and
support local people undertaking remedial action within their capabilities; and assess
hygiene education support and latrine coverage.

Sanitary inspection forms were developed, translated, field tested and revised, and
included illustration to ensure their applicability to the region and ready interpretation.
These initial forms were exclusively concerned with water quality aspects and
addressed both sanitary inspection and water quality analysis. They were further
revised after pilot testing to include estimates of coverage, continuity, cost and
quantity also.
239
Training was provided for the (water supply) project managers, the monitors noted
above and two health assistants. in approaches to monitoring, sanitary inspection and
water quality analysis and included field work. It was immediately followed by field
training of the monitoring staff.

Convergence of criteria in data collection was tested by dividing trainees into two
groups and to undertake separate assessments of the same system and then comparing
the findings. Some divergence was found after working in one village and excellent
convergence of responses was found after working in a second village.

Water quality analysis was to be undertaken on site using 'DelAgua' equipment in

light of transport limitations and the non-availability of alternative analytical facilities.
Trainees received initial orientation in its use, a demonstration and were then overseen
undertaking analysis of simulated samples. Despite occasional errors in procedure,
good agreement was noted in the results obtained.

Proficiency in both sanitary inspection and water quality analysis was confirmed
during subsequent field work

Sanitary defects noted in November 1990 lead to recommendations to alter standard

designs for storage tank lids, pressure break tanks and collection tanks in March 1991.

It should be noted that travel times were extremely delayed in the region concerned.
In the western region eight treks totalling 112 days of field work were required to visit
25 water supplies; whilst in the eastern region where 119 days of field work were
required to visit 20 communities. Despite use of field testing equipment with
rechargeable batteries, the need to return to a source of electricity in order to recharge
equipment after five incubation cycles was a limiting factor.

It should be noted that from early stages the monitoring activity was paralleled by a
hygiene education activity, which included hygiene surveys run parallel to the water
supply services.

Following project initiation, it was decided that monitors should not restrict their
activities to the collection of information, but make a positive contribution to the
maintenance of supplies. In light of the extended travel times it was considered
important to increase the proportion of productive time by increasing time spent in
each community . It was envisaged that:
• Certain repairs (such as repair and replacement of taps and repair of leaking pipes)
should be undertaken by the communities themselves and that the monitors could
train community members to undertake such repairs and assist them in these tasks.
The parts necessary for such repairs would therefore have to be carried by the
monitors in the field. It was further agreed that the costs of materials for such
minor repairs would be borne by the ESA.
• Where deterioration of older systems was such that rehabilitation was warranted
monitors were to encourage sponsors to approach authorities to seek assistance.
240
In March 1991 it was noted that the recommendation to alter design of lids and tanks
was being acted upon and further recommendations were made concerning spring
source protection and treatment of water from surface sources.

Monitoring was successfully implemented, although the rate of implementation was

constrained by loss of staff.

By January 1992 the concept of including repair in the programme had expanded
significantly and it was proposed (by the local agency) to recruit repairers to assist
communities in which more substantial repairs were needed. At the same time the
issue of recontamination of water between collection and use was confirmed and the
strategy of incorporating hygiene education in the overall strategy endorsed, with the
additional proposal that the hygiene educators should travel with the monitors and
work in parallel.

A2.6 Methodological Development

The overall strategy adopted included development of an inventory of systems and

visits to communities selected on the basis of management demands. The procedure
adopted for monitoring in each community was as follow:
• water quality analysis at source, reservoir (if present), a minimum fthree tapstands
and a minimum of one household gagri, plus one sterile sample for self-
monitoring of analytical performance;
• inspection of the water supply, to define water supply quality by means of the
indicators coverage, continuity, quantity, cost and quality, the latter by sanitary
inspection;
• report and make recommendations to the community regarding the repairs and
improvements which should be made. These include improving drainage around
tapstands, digging-in of exposed pipelines, fencing and hedging around tapstands,
and construction of surface water diversion ditches around sources;
• supervising and assisting the community in undertaking repairs which can be
undertaken with such assistance. These included, for example, repair of pipelines
and of taps (washer repair and re-bedding) and tap replacement; and
• if rehabilitation or extensive repairs beyond the capacity of the monitor and
community to undertake were required then the monitor, during discussion would
recommend that the sponsor approach the NGO for assistance
• report to ESA authorities. This should include a copy of the field report form,
additional comments, recommendations of the monitor concerning support for
rehabilitation and a summary of (a) support provided and (b) recommendations
made, including whether the community was recommended to approach the NGO
for support with rehabilitation (Robens Institute, Jan 1992).

241
A2.7 Data Handling and Analysis

The Government with UNDP through a programme of Management Information and

Technical Support to Water Sector Agencies had developed a data base in which they
were placing information on all rural water supply projects (both governmental and
non-governmental). Nevertheless in practice little systematic information on the level
of water supply service was available in Nepal although major investments to increase
overage had been made during the Water Decade .

A2.8 Reporting and Facilitation of Remedial Actions

On recognition of the construction problems the NGO concerned both altered standard
designs for spring source protection, constructed a demonstration spring near to its
logistical base and provided training to its construction supervisors in improved
source protection.

A2.9 Training and Human Resource Development

The Ministry of Health centrally in Kathmandu was responsible for the training of
sanitary technicians (who work in the urban sector) but very few had been trained
(Robens Institute, 1990).

242
 Annex 3: Pakistan I

An NGO Rural Water Supply

Project in Pakistan

A3.1 Introduction

This case study relates to the progressive development of the activities of a major
international NGO involved in rural water supply in the mountainous northern areas
of Pakistan. The NGO had been working for many years in the northern areas through
a number of sub-programmes including 'health' and 'construction'.

This case study looks at the approaches adopted by the two sub-programmes 'health'
and 'construction', especially the way in which monitoring and assessment activities
were planned, implemented and used to develop and orientate approaches to problem-
solving.

243
The principal steps which are further described below were as follows:

Construction sub-programme Health sub-programme

October 1990 technical seminar to assess problems of
drinking water quality and water
treatment in the project area
1991 - 1994 Planned period for water and sanitation
study by health sub-programme
May 1991 National Consultants report on five
experimental water filtration units
Aug- Five additional treatment units added to Author contracted by international
Sept/Oct 1991 already-constructed water treatment headquarters to lead a team for
systems technical review, proposal development
and recruitment of a project director for
a water and sanitation studies project of
the health sub-programme
Nov 1991 Director of water and sanitation studies
project appointed
Nov 91 - Nov 92 Intermittent sampling programme for
water quality analysis by construction
agency
Expanded programme of monitoring
November 1992 Author contracted by international No significant progress in either
headquarters and construction sub- development of a general survey of
programme to undertake field visits to water supply provision or assessment of
treatment systems, prepare a report and water treatment options
recommend future strategy
July 1993 Author contracted by international
headquarters and construction sub-
programme to undertake a second
series of field visits to treatment
systems, prepare a report and
recommend future strategy

A3.2 Area and Population

The region encompassed by the work of the NGO in the mountainous north of
Pakistan comprised the Chitral District of the North-west Frontier Province and the
Gilgit and Baltistan Districts of the Northern Areas. The region shares borders with
Afghanistan, China and India and is extremely mountainous, including peaks in
excess of 8,000m. Geographically, most of the land surface is permanently covered
with ice or snow.

The inhabited range is from 1,500 to 3,500m and total population around 1 million.
Ninety five per cent of the population is rural and a large proportion of the population
inhabits valleys which are inaccessible for much of the year. Because of this isolation,
social and cultural conditions vary significantly between even geographically-close
groups in adjacent valleys.

244
Infant mortality, especially related to diarrhoeal disease was described as 'high' .

Temperatures range from 40C in low areas in the summer to less than -20C in
highland areas in winter .

Most of the population lived in clusters of dwellings which may be crudely classified
as 'tight' or 'loose'. In loose clusters there was a private yard associated with each
house. In tight clusters dwellings were more closely arranged and private yards were
uncommon.

The unusual nature and specific challenges which development of water supply in
such an environment would represent were well-recognised by the NGO concerned
which appreciated that many 'standard solutions' were not applicable to the peculiar
conditions of a high-altitude mountainous environment.

A3.3 Institutional Context

The NGO concerned had been working in the study area since 1964 and both health
and construction sub-programmes had a long track-record of activity there.
Management of the two sub-programmes differed substantially. Whilst management
of the health sub-programme was decentralised and substantially undertaken within
the project area, that of the construction sub-programme was based outside the
programme area (remotely , in Karachi).

The health sub-programme had been a major area of activity for many years,
especially in providing health care services through a primary health care network.
Follo\\ing a major evaluation programme extension and expansion was planned for
the period 1991 - 4 of which one area of activity was watersupply and sanitation. It
was anticipated that a major 'study' would be required to orientate and better-inform
activities in water supply and sanitation. It was envisaged that implementation of the
planned intervention would not be undertaken by the health sub-programme which
was to develop the study. The brief of the water and sanitation study included
assessment of two of the then ongoing initiatives of the construction sub-programme :
village water treatment installations (ie connected to a piped water supply) and a
' filter bag' being promoted for household use. It also included 'to develop.field test
and document ... standard designs for ... community water filters' and it was
anticipated that the results of 'research on water contamination (would) be used to
help evaluate the problems of silting from suspended solids'.

The construction sub-programme had also been active in the project area for many
years, principally in the provision of basic physical infrastructure and in particular
schools, health centres, housing, irrigation and water supply. At around the same time
that the decision was made to extend and expand the health sub-programmes activities
in water and sanitation, the construction sub-programme also re-evaluated its activities
in the field. They identified that water quality would become an important issue as
water supply coverage increased, and having detected demand for water quality
245
improvement amongst communities in the region, initiated a programme of
experimentation in village-level water treatment systems to complement an
established initiative in household water treatment and storage. For both of these
initiatives the declared objective was to contribute to the reduction of infectious
water-borne disease. The five interventions which were the topic of the construction
programme's programme of experimentation were undertaken with community
participation, in an approach tested and proven in the area and which had received
significant international recognition .

As a result of the above a tension was established between the health and construction
sub-programmes. It was the former who were to 'establish the brief and assess the
efficacy of the possible solutions'; whilst the co-ordination of the design of the
anticipated implementation activities would be carried out by an agency with 'more
relevant expertise ' which might have been the construction sub-programme. Under
these circumstances it is likely that the construction agency had not only a perceived
need to demonstrate its competence in delivery, but also to establish its credentials as
a leader and in providing sector orientation ..

A3.4 Water Supply Context

Estimates of water supply coverage in the region were varied and included 7 - 9 per
cent of the rural population and 15 per cent of the total population. Systems to supply
water to more than 20 per cent of the total population had been constructed by diverse
agencies but much of this infrastructure was already non-operational and in need of
rehabilitation. At the time of the work undertaken by the author, aggressive plans
were being developed to increase coverage to 70 per cent by the year 2000 .

Piped drinking water was derived from rivers, springs, wells, irrigation canals or snow
melt. In practice most was derived from irrigation canals receiving water from snow
or glacier melt.

The soils of the area are unconsolidated and vegetative cover sparse. Most soils
comprise loose conglomerates of sand, silt and/or schists. As a result surface waters
are often highly turbid. Furthermore, the irrigation channels flow through areas of
inhabitation, irrigated agriculture and animal husbandry and may be contaminated
from these sources. Flow in all surface waters varied with season. In winter melt
waters decrease as does demand for irrigation water. Some irrigation canals are
subject to freezing (which often damages them) and are drained or only filled
intermittently at this time. During summer, flows of melt water increase dramatically
and many surface waters become highly turbid.

Water treatment in the region is typically and 'add on' to water supply and rarely
planned as part of a water supply intervention from the outset.

In villages without piped water supply, it was common to find 'wells' built alongside
irrigation canals and these represented the source of drinking water for a significant
246
proportion of the population. These were not wells as such, but pits which were filled
directly with canal water by diverting the surface flow into them. The pits were
covered once full and left for eight to 12 hours (typically overnight) to settle and the
supernatant then collected by bucket for household use

A3.4.1 Construction sub-programme's programme of experimentation

The construction sub-programme· s experimentation began in 1990 with the design
and construction of five water treatment systems . The locations for these systems
were selected to represent the diverse conditions in different valleys in the region.
The outline scheme for treatment was proposed by an external, non-national
consultant and developed and applied by national experts foreign to the project area.
It was based upon the approach adopted by UNICEF in Vietnam.

Following their construction, a simple water quality monitoring scheme was initiated .

The monitoring undertaken by the construction sub-programme reported the effluent

water to be 'bacteria free' in all but one case although despite this apparently
encouraging result. plans were already in place to undertake ·minor modifications ' in
April 1992 to 'further improve efficiency·. Even a cursory review of documents and
communications from around this time indicates that the construction sub-programme
was sensitive to possible failure and \.\'illing to act on the findings of its own
monitoring.

Notwithstanding the above, the construction sub-programme contracted a recognised

national expert to review the experience obtained with the systems including the
results of monitoring and recommend further actions in May 1991. As a result of this
assessment five additional water treatment units were designed and constructed in
August - October 1991 to amplify the already-existing sedimentation-filtration
systems. These new units utilised a novel and un-proven treatment technology
developed and promoted by the national expert.

Following construction of these additional units, further monitoring was undertaken

and the author requested to review the experience and make recommendations.

Whilst the nature of the novel treatment process is largely irrelevant for the purposes
of this thesis, a brief description is of interest. The technology promoted is described
as a 'reverse flow channel'. The concept, as described to the author, may be
summarised as a parabolic section channel (either straight serpentine in plan) of
considerable length (120 feet was typical of the units constructed) through which the
water flows after grit removal. The bed of the channel slopes towards the channel
inlet (ie the depth of the water in the channel decreases towards the outlet). The
' reverse gradient' of the bed of the channel was claimed to induce movement of
accumulated sediment against the flow of the water, thereby allowing sediment to
accumulate near to the inlet. No technical critique of the technology is included here.

247
A3.5 External Support and Interventions

T\vo parallel and overlapping processes occurred: the initiation of the study by the
health sub-programme and the programme of experimentation by the construction
sub-programme. They are described separately below

A3.5.1 Construction sub-programme

As noted above, following construction of the additional water treatment units, further
monitoring was undertaken and the author requested to review the overall experience.

The author's report called into question a number of assumptions underpinning the
approach adopted but recommended continuation of a revised programme of
experimentation. The construction sub-programme responded formally and
defensively to the report. Nevertheless it subsequently requested that the author make
a further visit in a contrasting season to re-consider some aspects of the report and
propose a programme of work. The second assessment was made with no significant
changes when compared to the first, the report was accepted and the proposed
programme of work adopted.

A3.5.2 Health sub-programme

In mid-1991 the author was contacted by the NGO's international headquarters to lead
a team for technical review, proposal development and recruitment of the Director for
the Water and Sanitation Studies Project of the health sub-programme.

There are a number of features of the technical review and proposal development
undertaken which are relevant to the topic of this work and will be noted here:
• it was recommended that monitoring and assessment of water supply and quality
be undertaken using a limited number of critical parameters of water quality which
should be analysed with high frequency;
• it was further recommended that sanitary inspection be used as a vital complement
to water quality analysis in investigating hygienic status and be based upon simple
observations that could be readily standardised;
• the author also proposed that - given the high number of communities and
available information concerning inter-valley differences- a structured sample
based approach rather than full-coverage monitoring should be adopted;
• the need to take full advantage of community-based knowledge to improve the
quality of data/information collected and therefore to involve community members
in, for example, source survey and sanitary inspection procedures;
• the absence of substantial published material on water supply and treatment in
high mountainous environments was noted and it was recommended links be
established with persons with expertise in this field and with roughing pre-
filtration and gravel bed filters in particular; and
• (without prior knowledge of the activities of the construction sub-programme in its
programme of experimentation in village water treatment) it was suggested that
water treatment research be separated as a 'more rigorous development and
evaluation schedule would be required' and be of more than two years duration.

248
With regard to the final point it should be noted that the original project brief for the
water and sanitation study envisaged very extensive use of external expertise. Despite
direct relevance of technical expertise in specific areas it was conspicuous that it was
proposed to use consultants with little or no experience of high mountainous
environments (despite noting their particular problems) and no consultants were
planned from other countries with high mountainous environments of their own.

A3.6 Methodological Development

From the viewpoint of water quality monitoring a series of short phases, each
including lessons learned and leading logically to the next may be identified as
follows in the work of the construction sub-programme:

Phase 1 • Need for assessment identified, external analytical facilities

used
• Doubt about quality of analytical service partially perceived
• Recognition of need to generate increased volumes of data
• Recognition of logistical problems with sample transport
Phase 2 • Purchase of portable water testing equipment to overcome
the above
• Realisation of extent of the staff commitment required to
drive a monitoring programme in this challenging
environment
• Recognition of need to ensure trained staff if analytical
quality to be assured
Phase 3 • Training provided
• Recognition of need to use indicators of process efficiency
in addition to input/output measures of microbiological
quality
Phase 4 • Adoption of increased analytical range
• Trainee increasingly recognises limitations to analytical
results alone through field experience and exposure to
critical point rapid assessment/inspection
• Monitor ' s reports increasingly describe specific problems as
well as report water quality results

The basic method adopted was:

• programmed schedule of visits so community know when to expect monitors;
• visual inspection , interview with community members and authorities, water
quality analysis ;
• field worker , direct liaison with community;
• field worker monthly reports to remote national office.

249
A3. 7 Reporting and Facilitation of Remedial Actions

Following the initial defensive reaction to the findings of monitoring a decision was
made to halt construction of new treatment systems and to continue monitoring for a
further 12 months to confirm the initial findings.

Fallowing a further 12 month period of monitoring the findings of the initial

assessment were confirmed and the construction agency:
• sought external advice from an institution with relevant experience in furthering
their programme;
• decided to rehabilitate the plants progressively and to use this as the basis of a
process of real-scale experimentation and research; and
• made a policy change with respect to treatment plant construction in withholding
further activity in new water treatment construction pending findings.

250
 Annex 4: Pakistan II

Status Assessment for Pakistan

A4.1 Introduction

In 1993 a series of national status assessments of drinking water quality monitoring in

Egypt, Pakistan and Yemen were prepared on behalf of the East Mediterranean
Regional Office of the World Health Organization (Bartram, 1993a; Bartram, 1993b;
Bartram 1993c; Bartram, 1993d). This activity involved observation of current
practice through interviews with national, regional and local level staff, field visits
and visits to laboratories and offices of environmental inspection agencies and training
agencies.

The aspects relevant to rural water supply monitoring from the three studies are
presented as separate annexes here and provide insights into the organisation and
practice of drinking water supply monitoring in the three States concerned.

A4.2 Area and Population

Pakistan was the ninth most populous country in the world and was estimated to have
been home to more than 120 million inhabitants or about 2 per cent of the global
population (Government of Pakistan, 1993). Population growth was estimated to be
2.2 per cent per annum in 1989 (WHO, 1989).

The process of urbanisation was significant (Anon 1985 and Government of Pakistan
1993), more than 33 per cent of the population was estimated to live in cities (ie
communities greater than 5,000 inhabitants compared to 29 per cent in 1985.

251
The country has an area of about 800,000 square kilometres of which a quarter to a
third is arable (most of it in the Indus plains); the reminder is largely desert and
mountain. Apart from the semi-tropical coast and delta areas. the fertile Indus plains
in the centre of the country are flanked by arid deserts both east and west. To the
north the land rises sharply and despite extensive glacial and snow cover remains
largely arid.

Overall it was estimated that 60 per cent of the land in Pakistan had been or was likely
to be affected by desertification; forest loss was estimated at one per cent per annum;
soil erosion had affected 1.2 million hectares; salt-affected lands were estimated at 2
million hectares and 2 million hectares were waterlogged (Government of Pakistan,
1993).

The provinces of Punjab and Sindh are densely populated and contrast with the rest of
the country. In Baluchistan, desert areas separate settlements while in the north of the
country travel is constrained by the mountainous topography. These factors inevitably
affected any attempt to implement water quality monitoring in smaller communities.

A4.3 Institutional Context

Pakistan had three levels of administration: federal Government , provincial

Government and ·local bodies' (this latter being represented by Metropolitan
Corporations, Municipalities, Union Councils and District Councils).

The country was divided into three Provinces: Punjab; Sindh; North-west Frontier
Province (NWFP); and Baluchistan. The Federal Government administered the
Federal Capital Territory, the Federally-administered Tribal Areas (FATA), the
Northern Areas; and Az.ad Jammu and Kashmir.

A4.4 Water Supply Context

Estimates (Government of Pakistan 1993) indicate that 61.5 per cent of the total
population had access to safe drinking water (85 and 47 per cent of the urban and rural
areas respectively).

In the rural areas drinking water was obtained variously from piped supplies and from
handpumps (both household and community) as well as traditional sources such as
ponds, dug wells and karezes (underground channels). Rural piped supplies were
generally untreated.

It had been estimated that there were more than 13,000 public tube wells and 260,000
private tubewells in Pakistan in addition to open dug wells and karezes serving both
for consumption and irrigation (Government of Pakistan, 1993).

252
The then current national eight year plan contemplated large scale investment in rural
water supply with the target of raising coverage with improved water in the rural areas
to 70.5 per cent and also raising the coverage of the urban population from 85 to 95
per cent by 1998. This represented supply to an additional 27 and 11.9 million
persons in the rural and urban areas respectively.

A4.5 Water Quality Issues

Few reliable data were available on drinking water quality. Those that were available
indicated that faecal contamination was a major problem, being both widespread and
severe in both urban and rural areas. Furthermore there was good reason to believe
that this had a major public health impact. Gastrointestinal diseases account for 25 -
30 per cent of all hospital cases and it is estimated that 60 per cent of infant deaths
were due to infectious and parasitic diseases, most of them potentially water-borne
(Government of Pakistan, 1993). Feacal contamination of water sources was a major
problem. Available data suggested that surface water sources were universally
contaminated and that water from wells was commonly contaminated in both urban
and rural areas.

PCSIR studies had demonstrated higher levels of faecal contamination in households

than in the piped distribution network (apparently in the network mains) in the federal
capital. The study concluded that this was often due to contamination in distribution
and of ground-level tanks. Ground-level tanks were common, in part due to problems
of rationing of supply by rotation between districts. This form of rationing was a
significant cause of contamination of water in distribution due to seepage between
leaky sewage pipes and water supply pipes and storage tanks at zero pressure
(Mahmood and Tahmir 1988).

Similar findings of a high rate of occurrence and of degree of faecal contamination

had been reported for rural areas by the Pakistan Medical Research Council, NIH and
PCRWR (for references see for example Government of Pakistan, 1993, Beg and
Mahmood, 1991).

There was a high degree of awareness amongst relevant authorities nationally of the
overwhelming importance of faecal contamination of water supplies for health.

Other pollutants affecting health were of local importance and included heavy metals
for instance in Kasure, near Lahore (due to the 152 small tanneries there); Karachi
(lead, apparently derived from plumbing and storage tanks); nitrate (locally, due to
groundwater contamination from agricultural sources); and fluoride in a few areas
such as Bahanlpur and Tharparkar (Beg and Mahmood, 1991) from geological
formations, apparently leading to dental but not skeletal fluorosis.

Guinea worm had been reported from Bannu and Thatta (Beg and Mahmood 1991).
Goitre was endemic in large tracts of the Northern Areas and iodine concentrations
were often very low in samples from here.
253
A4.6 National Policy and Strategy

Environment sector policy and strategy was in a process of change at the time of the
study. This was due to the establishment of the (federal) Pakistan Environment
Protection Agency (PEPA) and provincial environmental protection agencies (EPAs).
preparation of a full draft Environmental Protection Act (to supersede the
environmental protection ordinance of 1983) and the preparation of an Environmental
Health Action plan by the Ministry of Health. Other agencies, notably PCSIR, were
also active in this field.

Due to the rapid rate of change in the sector and uncertain position of drinking water
within the environment sector in general, it was difficult to foresee the situation that
would exist even in the short to medium term. Nevertheless it appeared likely that the
PEP A and EP As would assume an environment sector-wide co-ordinating role that
would include drinking water quality, although accepting the special role and
responsibility of the health sector for drinking water.

A4.6.1 Nationally
The federal Government was responsible for overall development planning and
national development plans were prepared by the Planning Commission in
consultation with the Provinces. The (federal) Environment and Urban Affairs
Division of the Ministry of Housing and Works was responsible for environmental
programmes in general (including water supply). PEPA was a dependency of this
Division.

The Pakistan Environmental Protection Ordinance included amongst the functions of

the PEPA to: 'prepare national environmental policy' and to 'co-ordinate
environmental policies and programmes nationally and internationally'.

The proposed Environmental Health Action Plan assigned responsibility for inter-
Ministerial co-ordination, preparation of national environmental policy and for setting
of environmental standards to the Ministry of Housing and Works, Environment and
Urban Affairs Division.

A4.6.2 Provincially
The national 'Sector Profile for Pakistan' (Anon, 1986) cites 'the lack of effective
provincial mechanisms for policy and programme development' and 'the need for
stronger participation of public health priorities ... in ... monitoring drinking water
quality' as major issues requiring corrective action. ' It goes on to recommend that:

'Each Province should establish a specific mechanism to bring together officials of

sector agencies on a regular basis. The technical directors of executing and support
agencies, including PHED, LGRD, Health, Finance and PPH should meet monthly,
or at other appropriate intervals as a "Provincial Water and Sanitation Committee" '

254
and that:

'The Provincial Water and Sanitation Committees should give first attention to the
systematic collection of data on sub-sector installations. coverage, past investment
and operating costs. manpower needs, etc, and the preparation of comprehensive
provincial sector studies. The committees should agree on provincial policies
concerning levels of service, criteria for priority projects. financial arrangements, etc.
Finally the Committees should prepare provincial Sector plans as guidelines to sector
activities '

The formation of provincial EPAs may have provided a suitable focus for the
establishment of sector policy and co-ordination along the above lines. Nevertheless -
and regardless of the lead agency for the proposed Committees - these observations
and recommendations made in 1986 remained valid in 1994.

A4.6.3 Pakistan Environmental Protection Ordinance

The Pakistan Environmental Protection Ordinance. 1983 specifies that the
establishment of comprehensive national environmental policy is a function of the
PEPC and that PEP A should prepare national environmental policy and revise
national environmental quality standards for approval by the Council. However it
makes no reference to the provincial EPAs whatsoever and does not specify whether
drinking water quality is considered a part of the general PEPC and/or PEPA remit for
environmental protection.

A4.6.4 Proposed Pakistan Environmental Health Action Plan

During 1993 an ·Environmental Health Action Plan' was formulated by the Ministry
of Health, in part in response to the UN CED Agenda 21 resolution regarding
environmental health. As this potentially represents a major step for the field of
environmental health (including drinking water quality monitoring) in Pakistan it is
outlined here and referred to throughout this section of the thesis.

The Plan emphasises five areas: water supply and freshwater management; sanitation;
solid waste management; food safety; and urban air quality control. For each area
strategies for human resource and institutional development are proposed, including
an environmental health information network, technology promotion, strengthening of
laboratories and research institutions; awareness raising; community participation; and
integration of environmental concerns into health programmes.

The Plan recommends the establishment of an 'Environmental Health Cell' in the

federal Ministry of Health and similar establishments in the provincial Health
Departments. The Plan also recommends strengthening of the National Institute of
Health (NIH), PCSIR and other laboratories throughout the country.

It was proposed that the plan be implemented in three phases and that water quality,
sanitation and water resources management all be targeted under Phase 1.
Furthermore, water supply and management was identified as the first of the major
programmes. The Water Supply and Management programme identified water as
255
being the binding constraint on agricultural development and increasing population. It
goes on to note that almost all national water resources were already being extensively
used, for instance through the 57.000 Km of irrigation canal system associated with
the Indus and that environmental impacts, such as salinisation of the aquifer beneath
this area were recognised.

Measures identified in the Water Supply and Management Programme (of relevance
to the theme of this thesis) included:
• addressing water quality deterioration/source pollution;
• ensuring water source quality through waste disposal control;
• rehabilitation of water supply systems;
• adoption of environmental quality standards and regulations;
• human resource development, emphasising water quality
• institutional strengthening;
• establishing a nation-wide laboratory network (in collaboration with EPAs) with
the objective of establishing a laboratory in each population centre of more than
100,000 inhabitants and reference laboratories in the provincial headquarters all
under the direction of NIH);
• mass awareness-raising on safe drinking water and national water quality
database .

Whilst the EHAP was a major step forward, it left unclear a number of issues of
importance. These included:
• who was to be responsible for execution of environmental health monitoring;
• further clarification was needed regarding the relationship between the Ministry of
Health (at both federal and provincial levels) and the PEPA/Provincial EPAs with
regard to - for example - leadership and participation in policy development,
standards , inter-agency coodination, preparation of legislation and overseeing
enforcement, and management and interpretation of drinking water supply quality
data.

A4.7 Institutions with a Role in Water Supply Monitoring

Delineation of the boundaries for institutional responsibilities, inter-programme

linkages and to a lesser extent lines of responsibility and accountability varied
throughout Pakistan as did the titles of the (Provincial) Government Agencies.
Furthermore, institutional arrangements are structured differently at federal and
provincial levels and a number of significant developments were either ongoing or
mooted (as noted in preceding sections). Arrangements were therefore complex and
the outline below represents a summary of the typical aspects of the situation that
existed at the time of the study.

A4.7.1 Federal agencies

the following quote from the proposed Environmental Health Action Plan
(Government of Pakistan, 1993) is self-explanatory:

256
Insofar as Environmental Health responsibilities at federal level are concerned, there
exists no specific agency to deal lrith this subject. This fact is contradictory to the to
the vital roles of the environment and health in securing a healthy society.
Consequently neither the Ministry of Health, nor Environment Ministry perform any
monitoring services to assess the condition of air, water and food in the country·

Water supply agencies

The provision of water supply outside metropolitan areas was primarily a provincial
responsibility. Technical planning and design of projects was the responsibility of the
provincial Public Health Engineering Departments (PHEDs), except in Baluchistan,
where these are undertaken by the Irrigation and Power Department.

Water supply projects were intended to be handed over (usually after two years) to
Local Bodies (Municipalities, Union Councils and District Councils) which should
then have been responsible for operation and maintenance. At provincial level, Local
Bodies were responsible to the secretary for Local Government.

After hand-over to Local Bodies, it would appear that these agencies were responsible
to control the quality of the water they supplied. During the study no examples were
found of Municipalities, Union Councils or District Councils adopting this role and
there was no system of support to assist them in this.

In practice the system of hand-over from PHEDs to Local Bodies often failed and in
recent years PHEDs had increasingly assumed the role of supply agencies. At the
time of the study there appeared to be a desire on behalf of the PHEDs and federal
planners to reverse this trend. Nevertheless, a large proportion of the annual budgets
of the PHEDs was expended on operation, maintenance and rehabilitation of supplies.
Thus for example in Peshawar these elements account for 60 per cent of budget and
the remaining 40 per cent is expended on capital projects).

As the design and construction agency, the PHEDs should have undertaken testing
when abstracting from a new source or constructing a new supply. The actual extent
of water quality testing and monitoring undertaken by the PHEDs was unclear. In the
case of the Lahore laboratory all new sources were tested and some follow-up visits
and sampling were made; in this case monitoring was combined with hygiene
education.

Independent 'surveillance' function

The general mandates of both the Ministry of Health and PEP A would appear to have
justified their adopting the role of independent surveillance agency.

In general terms the involvement of the health authorities in environmental health

issues and specifically drinking water quality surveillance had been low, largely due
to financial constraints. Nevertheless, some sampling and testing was undertaken by
the health sector, for instance at NIH , Islamabad and the College of Community
Medicine at Lahore.

257
General
At the time of the study there appeared to be no independent authority responsible to
approve water sources as suitable for drinking purposes.

At Provincial level there was confusion regarding the role of the provincial EP As in
drinking water quality monitoring. In Lahore for example. the EPA laboratory had
been established by separating the air, solid waste and wastewater laboratories of the
PHED, leaving the PHED with the drinking water quality laboratory. In this case
therefore, the EPA had no drinking water testing facility. Furthermore, since it shared
accommodation, facilities and local-level management with the PHED, whose
activities it should have been monitoring , it would be unable to adopt an independent
surveillance role. In Baluchistan, as part of a laudable initiative not to unnecessarily
duplicate laboratory facilities, the EPA utilised the local laboratory facilities of other
agencies.

Other agencies which undertake occasional drinking water quality monitoring include
Universities (notably the Institute for Public Health Engineering and Research), the
various laboratory complexes and centres of PC SIR across the country, the College of
Community Medicine at Lahore, and the PCRWR.

A4.8 Sector Co-ordination

Sector co-ordination was unclear in theory and weak in practice, for example:
• The Ministry of Planning and development co-ordinated development activities in
general and specifically the institutions involved in the water supply sector at
federal level and its equivalent adopted the same role at provincial level. However
the Pakistan Environmental Protection Ordinance made provision for
environment-wide sector co-ordination by PEPA at national level, but not for the
provincial level
whilst
• the proposed EHAP assigned responsibility for co-ordination between Ministries
involved in different aspects of environment, monitoring and enforcement to the
Ministry of Housing and Works, Environment and Urban Affairs Division;
and
• there was no federal or other authority which co-ordinated amongst the 13 urban
water supply authorities

This should be contrasted with the importance of establishing such co-ordination,

particularly at provincial level. The national 'Sector Profile for Pakistan' (Anon,
1986) made a number of recommendations regarding sector co-ordination and policy
development which are cited above and which remained as valid in 1993. The
proposed Pakistan National Environment and Health Action Plan recommended a
single comprehensive law governing environmental control and protection.

Notwithstanding the above, bilateral co-ordination between some agencies appeared to

be good. For example communication between PCSIR and PEPAIPEPC appeared to
258
exist although PCSIR (for example) were largely unaware of Ministry of Health plans
and activities.

Sector co-ordination at provincial level was complicated because the three agencies
involved (W ASA. Local Bodies and PHED) may have had distinct lines of
accountability. Thus whilst the Local Bodies were responsible to the Secretary for
Local Government, PHEDs may be responsible to the Secretary for Housing, whilst
the DAs (and therefore WASAs) were variously treated as special cases or were
accountable to the Secretary for Housing and Town planning (or its equivalent).

The Pakistan Environmental Health Action Plan noted that in Pakistan there was
inadequate communication between scientific institutes, universities and policy
making agencies. It goes on to suggest that a permanent mechanism be established to
facilitate communication between these groups and that the Environment Division
(Ministry of Housing and Works) play a critical role in setting up such a group
(Government of Pakistan 1993).

A4.9 Laws, Regulations and Standards

At the time of the study there were no Pakistani Drinking-water Quality Standards or
supporting legislation or equivalent and in their absence reference was made to WHO
Guideline Values. This was despite the recommendation of the national conference
on water supply and sanitation (November 1991) that national standards and
legislation should be introduced.

The proposed Environmental Health Action Plan noted the need for clear-cut
legislation for requirements for clean drinking water (Government of Pakistan, 1993).

The Plan assigned responsibility for setting of environmental of environmental

standards to the Ministry of Housing and Works, Environment and Urban Affairs
Division (in collaboration with the Ministry of Health) whilst the Pakistan
Environment Protection Ordinance defined the establishment and revision of
environmental quality standards as a function of the PEP A and their approval the
PEPC .

Despite the above, various agencies, including PEPA, PCSIR, PCRWR and the
Ministry of Health had all at one time or another produced or contributed to proposed
drinking water quality standards at national and/or provincial levels.

There were no national plumbing standards or codes of good practice although local
systems for certification of plumbers exist, at least in some areas (such as Karachi). In
contrast there was a national system of this type for sanitary technicians. It appeared
that problems concerned with basic construction and plumbing practice at household
level (such as construction of ground-level storage tanks) were significant causes of
water quality problems.

259
A4.10 Information Management

The national 'Sector Profile for Pakistan' (Anon, 1986) cited 'the need/or improved
... information/data systems in both national and provincial agencies' as a major
issue requiring corrective action and went on to recommend that:

'Tofacilitate the recording of sector information and ... , to provide systematically the
data needed for sector planning each province should be equipped with electronic
data processing equipment. This equipment might be operated by the provincial
Departments of Planning and Development and be linked with similar equipment in
the Ministry of Health '

No systematic recording of drinking water supply or drinking water quality data was
found in any of the agencies visited during the study and none of the persons
interviewed was aware of such an initiative or activity.

A4.11 Laboratory Infrastructure

Nationally, there was a significant. although inadequate, quantity of laboratory

infrastructure for water quality monitoring. However any interpretation of the
situation was complicated by the lack of clarity regarding the roles and responsibilities
of the agencies concerned . For example:
• the network of PCSIR laboratories nationally represented a major analytical
resource strongly focused upon research;
• within the health sector the NIH laboratory, Islamabad, played a lead role, but
because of the relatively low level of activity by the health sector in drinking
water quality surveillance, this role was not optimised and the laboratory was not
adequately equipped to perform a reference role; other laboratory facilities within
the health sector also undertook significant numbers of analyses of drinking water;
• the role of EPA laboratories continued to evolve. The PEP A laboratory in
Islamabad was under construction and was being equipped to a level which would
enable it to perform a major role, particularly in pollution control; the role of the
separate provincial EPA laboratories was less clear, not least because there was a
strong rationale for them not to further duplicate existing laboratory facilities, but
to establish effective collaboration in monitoring
• PHED laboratory infrastructure was poorly developed and this situation was
aggravated by poor clarification of the role the PHEDs should play in testing and
monitoring and their evolving role in construction versus operation and
maintenance
• the level of laboratory infrastructure in the various WASAs and Local Bodies
varied extremely widely from non-existent in the smaller authorities to adequate
and well-used in the case of KWSBof Karachi Metropolitan Council.

Nevertheless in some cases this infrastructure was not optimally used and was not
well-focused upon public health or operational priorities. Furthermore there was little
260
or no effective co-ordination between laboratories and analytical quality control was
not practised or was rudimentary

It was conspicuous that the infrastructure to undertake basic hygiene-related analysis

was particularly poorly developed. Existing laboratories focused their activity on
comprehensive chemical analysis.

The principal factors limiting the effectiveness of laboratories undertaking water

quality analysis were assessed as inadequate equipment and inadequate quantity of
staff and of staff training (see section on training).

Whilst several of the laboratories that were visited cited their desire to establish
sophisticated analyses, such as for heavy metals by atomic absorption
spectrophotometry or organics in water by gas chromatography at a national level, this
was considered a research and not routine monitoring activity. In the short term this
could have been reasonably serviced by the then-existing facilities in PCSIR and in
the longer term this analytical capacity should have been established at NIH using
existing equipment.

The proposed EHAP referred to the need to establish a network of laboratories and
cited the need for analytical quality control. It also noted that many laboratories were
involved in environmental monitoring and that these needed to ensure that the data
they produced was reliable. It also cited inadequate equipment and staffing, deficient
quality control and a lack of inter-laboratory calibration.

A4.12 Actual Level of Monitoring Activity

The actual level of drinking water quality monitoring of all types - whether quality
control by the major supply agencies or independent surveillance by the Ministry of
Health was typically low, although exceptions to this existed.

Of particular note were the failure of even major supply agencies to adequately link
results of monitoring to programmes of maintenance and repair and the almost
complete lack of use of sanitary inspection as a component of quality control and
surveillance.

A4.13 Staffing and Training for Water Quality Monitoring

Because of the low level of routine water quality control and surveillance
implementation nationally, total staff involved in this activity were relatively few.
Whilst training opportunities were correspondingly few, those that existed were not,
in general, over-subscribed due to low demand. The author was unable to visit more
than a representative sample of training institutions and made the following
assessment based upon this:

261
A4.13. l Post-graduate training
There were two courses orientated towards engineers in the environment field in
Pakistan:
• the Institute of Public Health Engineering and Research of the University of
Engineering and Technology at Lahore offered an MSc in Public Health
Engineering:
• the Institute of Environmental Engineering and Research at the NED University,
Karachi. offered an MSc in Environmental Engineering. although the drinking
water component of this course is small. The course was only available on a part
time basis.

Between them these two courses produced about 35 engineers qualified to post-
graduate level per annum. Neither course was over-subscribed and it was judged
unlikely that this figure would increase beyond 40 in the foreseeable future unless a
major change in demand for this type of qualification occured.

There was only one institution offering post-graduate qualifications to doctors in the
field of environmental or public health - the College of Community Medicine at
Lahore. The College offered the following courses:
• a diploma in public health (DPH) which was awarded, on average, to 30 students
each year. most of whom were senior medical officers \\ith significant experience
and who 'Wished to progress to become District Health Officers. The course
therefore included elements of management. Environmental health, including
water supply, comprised a significant component of the course.
• An MPhil in Community medicine for which a student must have studied
Community Medicine as a major subject and two minor subjects from a list of 15,
one of which was Environmental Health Sciences.
• Fellowship and Membership of the College of Physicians and Surgeons of
Pakistan in Community Medicine. This qualification was principally for those
who intended to teach in the field.

These were full-time courses. The MPhil and Fellowship courses were higher levels
of award. Both were awarded to few students and were of two years duration.

The Department of Environmental Planning and Management of Peshawar University

was said to have recently started work on a course in environmental health planning.

There was a proposal to establish a national University of Science and Technology to

include a large Department of Environmental Science and Technology. The proposed
University would be located on a new campus site, but be based on the existing
(army) National College of Science and Technology and was intended to be a joint
venture between the military, public and private sectors.

A4.13.2 Technician training

The national sector profile (Anon, 1986) mentioned 'the lack of general programmes
of technical training for the sector' as an issue.

262
The only public institution nationally offering technician-level training relevant to the
subject of the report was the College of Community Medicine, Lahore. Two 'para-
medial' courses were offered:
• certificate for sanitary inspectors which was followed by a total of about 100
students annually. On qualification students received a recognised qualification
(Sanitary Inspectors Certificate) and entered various fields of environmental
health, mostly employed by Municipalities, Health Departments and W ASAs.
Themes covered included general hygiene, rural hygiene, and minor sanitary
engineering; all of which included a significant drinking water component. The
course included substantial field training.
• Certificate for Laboratory Technicians which was followed by about 30 students
per year and was of 1.5 years duration. Although the course touched upon
environmental health it had a medical emphasis and most students were employed
in the medical field.

In response to pressure from external funding agencies, several WASAs had instigated
reforms (in fields such as financial management) and had organised in-house training
for both technical and senior staff. This was the case in Karachi, Lahore, Faisalabad,
Peshawar and Quetta for example. However there is no federal or other authority
which co-ordinated amongst the various WASAs for training.

A4.13.3 Training of trainers

The proposed EHAP noted the need to create a core of trained staff to act as trainers to
conduct local training courses. No progress seemed to have been made in this regard,
although with updating, staff of NIH, the College of Community Medicine and the
Institute for Public Health Engineering and research could have played this role.

A4.13.4 Refresher courses and specific training on drinking water quality

No public institutions were offering this type of training in this field as a mater of
course, although several were capable of doing so (as noted above) and would
probably have done so were there sufficient demand. WHO had organised some
courses for laboratory staff

263
 Annex 5: Peru I

A Governmental Programme for

Monitoring and Improvement
of Rural Water Supplies
in Peru

This case study concerns the implementation of a large-scale rural water supply
monitoring programme by the Ministry of Health (which was also involved in water
supply construction). This work included the development of the Peruvian National
Plan for Water Supply Surveillance (Gobiemo del Peru, 1988).

A detailed description of the programme has been published as ' Surveillance and
Improvement of Peruvian Drinking-water Supplies (Lloyd et al 1991).

A5.1 Introduction

The Peruvian Water Supply Surveillance Programme represented a comprehensive

effort to establish routine assessment procedures for water supply services in both
rural and urban sectors in Peru. The Programme differed from previously attempted
quality control programmes in less-developed countries in two significant ways:
firstly a major objective included the development of strategies for linking the outputs
of monitoring to prioritised remedial measures where problems were identified.
Secondly, the separate but complementary roles of water supply agency and health
authority were accepted and intensive effort devoted to developing these roles in order
to maximise the benefits of water supply surveillance.

264
AS.2 Area and population

The surveillance agency and rural construction agency at national level (DITESA and
DISABAR respectively) agreed on the choice of the Central Region of Peru (then
Health Region XIII of Junin - Huancavelica) as the pilot project area. This region had
previously served as the pilot area of the National Plan for Basic Rural Sanitation and
therefore contained considerable and varied rural water supply infrastructure (Comite
Nacional de Coordinacon de Saneamiento Basico, 1986). In addition it varied both in
geography and population, including highlands, high plains, high and low jungle, rich
valleys dedicated to agriculture and areas of intensive mining and smelting. The area
included three Departments, two typical of the country and the third , Huancavelica,
being the least developed of all. It had a total surface area of 70,487Krn2. Most of
the population of the pilot project area lived in the fertile Mantaro Valley in the Seirra,
3000 - 4000 metres above sea level.

AS.3 Institutional Context

Institutional arrangements both at national and regional levels suffered a series of

fundamental changes during the period of the project described here. Until 1985 the
health administration of Peru was divided into health regions divided into hospital
areas. In 1986 the 16 Health Regions of Peru were replaced by 56 health areas,
closely corresponding to the previous hospital areas (ie sub-areas of the health
regions). In 1987 the hospital areas were superseded by Health Departments .

In parallel with these changes, at central level in the Ministry of Health , DIGEMA
(the General Directorate for the Environment) was divided into the DISABAR
(Directorate for Basic Rural Sanitation) and DIGEMA's technical functions which
gave rise to DITESA (the Technical Directorate for Environmental Health . Whilst
these changes separated conceptually the surveillance and construction functions, at
operational level the two converged and the engineer responsible for rural water
supply construction at regional level was also the head of environmental health,
responsible for motoring his own undertaking. Finally, the diverse agencies
concerned with both urban and rural aspects of basic sanitation were co-ordinated
through CONCOSAB: the National Committee for the Co-ordination of Basic
Sanitation.

Because of the rapid and frequent changes little meaningful institutional analysis of
this case study is possible. Local surveillance teams based in provincial hospitals were
chosen to incorporate environmental health technicians and in some cases laboratory
staff, a total of 3 5 staff in nine locations comprised the teams. The surveillance teams
included an area co-ordinator.

265
AS.4 Water Supply Context

Water supply to highland rural communities in Peru was principally through piped
supplies. Rainfall was highly seasonal and where surface water was available it was
used for irrigated agriculture and irrigation canals are widespread. Small springs
typically yielding water of high quality were relatively common and the predominant
means of supply was through gravity-fed systems from protected spring sources.

AS.5 Training and Human Resource Development

Vocational training for environmental health technicians in Peru was reduced in the
1980s from two years to six months. Additional training for surveillance was therefore
provided for staff involved in the Programme. Training was both through intensive
courses and field supervision. Topics covered during initial training included: water
supply and treatment; critical parameter water quality analysis; sanitary inspection;
surveillance planning; and interacting with community members. Supervision was
used especially to provide follow-up training concerning sanitary inspection, on site
water quality testing and interaction with communities.

A total of eight training courses for environmental health technicians were run during
the course of the Programme. The content and duration of the courses were tailored to
meet requirements; for example, rural and urban methodologies were distinct and new
training requirements were identified as the Programme evolved. Training courses
were evaluated and the experiences integrated into a standard two week training
module for environmental health technicians comprising formal lectures,
demonstrations, group-work and laboratory and field practicals.

Further training was provided by accompanying technicians during fieldwork in 1986.

This undoubtedly contributed to the success of training at this time. During 1987, the
author was sometimes accompanied by DITESA personnel on these supervisory visits
but it rapidly became evident that this high input from professional staff would not be
sustained, nor would this be a cost-effective means of providing decentralised
supervision for a national programme. An intermediate supervisory tier of
Programme staff was therefore created and given additional responsibility for
reporting at regional level, field training and supervision of technicians.

With subsequent Programme expansion and institutional development activities a

further educational package was required: for high-level surveillance managers
(national and regional directors) and for mid-level managers in the health and water
supply sectors e.g. Programme co-ordinators and regional supervisors. This module
was designed to promote awareness of Programme objectives and outputs. It was
therefore a mechanism for increasing understanding of the Programme by directors
and managers of health and water supply sectors in order to enhance the adoption of
appropriate remedial strategies. Staff at this level were unable to dedicate protracted
periods exclusively to the Programme and due to the continual relocation of staff it
was necessary to provide a summary of the programme on each occasion that a
266
meeting was held. This module was therefore designed as a half-day workshop
divided into three sessions . The first sessions comprised a summary of the National
Surveillance Plan, and covered the importance of water supply for health, the
definition of surveillance and how it contributes to health improvement, and the
objectives and strategy for development of surveillance in Peru. This was followed by
a one-hour discussion of surveillance findings regionally or nationally (depending on
the area(s) ofresponsibility of those attending the meeting). The final session of one
hour was then dedicated to discussing the findings , their health implications and
remedial strategies.

A5.6 Methodological Development

A systematic approach to the identification of deficiencies in water supply services

was adopted which has been reported previously (Bartram 1990; Lloyd and Bartram
1990).

Three particular methodological elements merit specific note:

• the development of a water supply surveillance scheme which was based upon five
indicators of service quality: quality. quantity, coverage, cost and continuity;
• the development of a risk assessment procedure based on systematic sanitary
inspection and analysis; and
• the field testing of portable equipment for water quality analysis.

The surveillance teams included an area co-ordinator and were responsible initially for
gathering basic data in order to prepare inventories of their area. The teams:
• recorded the population in each community and town;
• summarised the known existing water supply systems from the water supply
agency archives; and
• identified water supply systems not registered by the supply agencies (for instance
those constructed by the community itself or with support ofNGOs)

AS.6.1 Developing report forms

Sanitary survey forms were designed for each type of supply system (gravity fed
without treatment, gravity fed with treatment and pumped without treatment). The
objective was to establish a standardised inspection and reporting system which could
be rapidly but accurately completed on-site at the same time that sampling and water
quality analysis were carried out. The report forms were intended to serve several
purposes:
• identify potential sources of contamination of the supply;
• standardise the work and responses of the sanitary technicians to enable data
analysis to be undertaken;
• quantify the susceptibility to contamination of each facility; and
• provide a record for the local surveillance supervisor , as to the remedial action
which was required.

267
The surveillance methods initially employed in the rural sector were based on the
WHO Guidelines for Drinking Water Quality Volume 3 ( 1984). These were found to
be of limited applicability in Peru. The model report forms were too Jong, poorly
structured, and open to varied interpretation by technicians in the field. They also
gave insufficient emphasis to the water supply sef\"ice indicators of quantity,
continuity. coverage and cost. Revised field methods and report forms were devised
in 1986 and field tested during 1987.

Each form was developed during workshop sessions with field staff, field tested,
reviewed and used at a large scale with intensive supervision. After one full annual
cycle, further workshop-based revision was carried out.

AS.6.2 Initial community visits

On-site, the environmental health technicians first contacted the community
authorities and then completed the checklist on the report form with the assistance of
the operator or community representative.

The visits began in the community itself with a group of questions to the community
authorities to ascertain details of coverage and also of the administration, operation
and maintenance of the system. Household visits enabled both on-site analysis of
water quality in the distribution network as well as interviews to investigate coverage,
continuity of supply and water use habits within the household. The visit then
proceeded to include a systematic inspection of identified points of risk of the entire
supply system including source, conduction lines and reservoir using the field report
forms.

On-site testing using portable test kits based on standard methods has been described
elsewhere (Lloyd, Pardon and Bartram, 1987). The importance of quantitative
analysis of faecal indicator bacteria e.g. thermotolerant (faecal) coliforms to enable
prioritisation on the basis of health risk was considered high and under-pinned the
analytical approach adopted . Experience demonstrated that sanitary technicians could
be readily trained to undertake thermotolerantr coliform analysis in the field using the
field testing equipment employed in this programme.

AS. 7 Data Handling and Analysis

An information management and reporting system was developed. This was based on
the 3-tier concept proposed by WHO (1984) for water quality data but modified to
incorporate two important additional reporting levels: on-the-spot reporting to the
community water committees (both of sanitary inspection and water quality results)
and overview reporting to the agency responsible for determining priorities for
investment in the water supply sector. In Peru this was the inter-ministry National
Committee for the Co-ordination of Basic Sanitation (CONCOSAB). At local level,
especially in the rural sector, use of portable testing equipment enabled on-the-spot
reporting to both community water committees and the community authorities. This

268
was especially important in areas where results could not effectively be sent on and
had to be delivered by hand.

Requirements for data management at national level were distinct from those at local
and regional levels. Local and regional levels prioritised activities by system or
community. National level data management had to orientate policy and investment.
It was therefore necessary to analyse trends by region. supply type and population
size. Due to the volume of data involved, computerisation was required. A
preliminary database was designed in 1987 and used for analysis of the data from the
central region. The database underwent revision during 1988 and 1989. The database
incorporated a total of 12 reporting options. It also incorporated a number of features
useful to the regional offices such as the facility to produce reports for local supply
agencies.

The majority of rural supplies in Peru were unchlorinated and it was therefore likely
that they would contain large numbers bacteria with limited faecal significance
(including, for example, total coliforms). A bacteriological classification scheme was
developed which was based on increasing degrees of thermotolerant coliform
contamination.

The most important outcome of the risk assessment approach was the ranking of risk
for a collection of sources and systems. This contributed to the assessment of degree
of urgency for preventive and remedial action.

The procedures described here were applied in pilot projects in Peru for the first time
in the period 1985/1988. Systems were classified into levels of action to form the
basis of a rational strategy for prioritising remedial action:
• Very high risk and hence urgent remedial action
• Intermediate to high risk requiring action as soon as resources permit.
• Low risk; low priority for action.
• No risk; no action.

The information generated was also consolidated and details added to an inventory of
supply systems. Data which was available through the inventory included the
parameters of coverage, quality, quantity, continuity and cost. In addition,
information regarding administration and operation and maintenance was included.
Where appropriate, these were supplemented with details of collection and transport,
household treatment and storage .

A5.8 Reporting and Facilitation of Remedial Actions

In the rural sector, the variable institutional arrangements complicated reporting. A

community drinking water committee was generally responsible for an individual
supply. These committees were often established by DISABAR with the main
objectives of promoting community participation during the construction stage, partial
cost recovery and subsequent administrative responsibility for the service. They
269
received little training and supervision and their capacity for direct involvement in
improvement was limited. Reporting the results of surveillance directly to the
community authorities was carried out.

Rehabilitation and improvement of supplies was undertaken by various construction

agencies, most importantly DISABAR and NGOs such as CARE, to whom
surveillance results were also reported. Reporting to these agencies was also
orientated towards prioritisation of communities for intervention and therefore based
on yearly overviews which summarised the five water supply service indicators for
each community.

Severe problems with rural water treatment were identified through pilot scale
monitoring and assessment. A series of pilot demonstration plants incorporating a
pre-treatment technology new to the country were constructed. There was
considerable initial resistance to this work by the governmental construction agency
and it is likely that the continuation of the work at this stage was related to pressure
from a major international agency . defended by the findings of the initial study. As a
result much activity was undertaken without involvement of that agency by external
consultants and an NGO.

The NGO linkage is significant in that they were uninvolved in the generation of the
initial data from monitoring and assessment but were prepared to act on its general
conclusions and also initiated a local survey using similar methods in their area of
activity.

The second phase of monitoring quantified the extent of the problem and reinforced
the conclusions of the initial study regarding rural water treatment. Results were
disseminated with the involvement of the Minsitry of Health. The governmental
construction agency (DISABAR, also part of the Ministry of Health) subsequently:
• paralysed construction of all rural water treatment plants;
• provided training for its regional engineers in an appropriate technology; and
• subsequently reinitiated rural water treatment plant construction .

Furthermore, certain regional engineers adopted rehabilitation of existing water

treatment systems using the new technology

A5.9 Laws, Regulations and Standards

Under Peruvian Law there were provisions for the protection of drinking water
sources, the treatment of drinking water and the surveillance of drinking water quality
(Ley de Aguas 13997; Codigo Sanitario 17405 and Codigo Sanitario de Alimentos DL
102/03)

270
AS.10 Indicators of Sustainability

This case study is of some value in that a predetermined approach to the

progressive /incremental increase in surveillance coverage was developed and applied.
Whilst described here it is impossible to analyse the experience in terms of
sustainability since programme management was disrupted in the years following
conclusion of external support.

The approach adopted was to commence with a preliminary survey of a limited

number of systems. Following evaluation and revision of methods this was expanded
into a pilot project also followed by evaluation. Subsequently expansion and
replication throughout a Department or Region was undertaken and finally national
replication was planned.

The frequency of surveillance visits was similarly to be gradually increased during

phased implementation. A baseline of one visit per system per year was selected in
order to enable the preparation of yearly summary reports. While this frequency was
thought to be suitable for sanitary inspection of small water supply systems, it was
considered inadequate in the long term.

The experience gained in preliminary phases was consolidated into a draft

surveillance procedures manual in October 1988. Following substantial revision, this
was printed in limited quantities and distributed for field evaluation. Final revision
was undertaken in April 1990, resulting in a three Volume manual organised into nine
modules covering surveillance theory, planning, information gathering and
management, data processing and quality assurance, water quality standards, and
sampling and analytical methods (Gobiemo del Peru, 1990a; Gobiemo del Peru,
1990b; Gobiemo del Peru, 1990c).

271
 Annex 6: Peru II

Water Supply Assessment by a

Self-help Development
Association in
Rural Peru

A6.1 Introduction

A self-help development association of jungle Indian communities had initiated

various activities in water supply and sanitation. A team of staff had been designated
as 'monitors' for these activities but had no materials or strategies with which to
approach their work. The principal external support agency operating with the
association had no clear policy or strategy for this field but recognised its importance.
A month of direct field work was undertaken to make an assessment of the work
undertaken and to assist the development of materials and approaches for the
monitors. Monitoring and assessment work was carried out with and through the team
of 'monitors' who were responsible for environmental health monitoring and follow-up
in the region.

A description of this work has been published previously (Bartram and Johns 1988).

272
A6.2 Area and Population

The jurisdiction of the Consejo Aguaruna y Huambisa (CAH) covers an area of

around 22,000 Km2 in the north eastern jungle of Peru. The population of around
35,000 is of the 'Jivaro' ethno-linguistic group (approximately 28,000 Aguaruna and
7,000 Huambisa) which is dispersed in northern Peru and southern Ecuador. The
population traditionally lived in dispersed extended family groups which relocated
relatively frequently. In recent years the population had tended to nuclearise and form
more stable settlements of 100 - 1,000 persons along the banks of the five principal
rivers (the Maranon and its tributaries the Chiriaco, Nieva, Cenepa and Santiago).
Travel and transport is by river and on foot. Consequences of the increased
nuclearisation include competition and over-use of environmental resources around
the settlements (especially game and soil) and increasing problems of environmental
sanitation in and around the settlements.

Despite the presence of a dedicated health programme (see below), information on

health status is extremely scarce. Based upon a brief review of available information
it was concluded that:
• the most important health concerns were related to gastrointestinal and respiratory
disease (infections); and
• the health programme had made no fundamental change in the health status of the
population.

A6.3 Institutional Context

The CAH was formed in 1977 and operated through a series of programmes, including
one on health. The CAH and its health programme in particular had benefited from
international support from a range of charities since their formation.

The CAH health programme was unusual in that it had received the recognition of the
national Ministry of Health and had effectively inverted the traditional hierarchy: the
highest authority of the programme is the Assembly of' Sanitarios' (literally
' sanitarians', the local voluntary primary health care worker based in their own
communities). The health programme was staffed by 119 sanitarios (70 in health
posts, the remainder operating without), five health centres (one on each of the five
rivers, each with a supervisor and laboratory worker) and an elected programme
director.

The post of laboratory worker had been relatively recently established and included
responsibility for an (at that time) as yet undefined drinking water programme.

The sanitarios were responsible for all aspects of the programme in their community,
including diagnosis and treatment, education on nutrition and preventive aspects,
vaccination campaigns, environmental sanitation and were, in some cases, active in
other areas such as organising fish farming and chicken rearing.

273
At the time of the authors contact with the programme. it also benefited from a Jong
term (three year) presence of two doctors and one laboratory worker sponsored by an
outside charity.

A6.4 Water Supply Context

Interest in establishing a water component to the health programme had begun with
mothers in 1985. Women were responsible for (drinking) water management,
including collection, transport, storage and, when practised, household treatment.

Little was known about the provision of drinking water in the zone except anecdotal
evidence that only one piped supply existed. Most of the population collected water
from springs, 'quebradas' (strictly a rocky steep upland stream, but used in the zone
to mean any course of water except the principal rivers) and rivers; that protected
sources were rare.

A6.5 External Support and Interventions

During 1987 the CAH requested assistance with the assessment of the environmental
sanitation situation in their area and advice on remedial measures, Drinking water
was a highly perceived need and formed an important component of the work.

A series of preliminary meetings and discussions outside the area (which is difficult to
access) was held over the course of a year and these resulted in some preparatory
activities. In October/November 1987 local staff were assisted in the development
and implementation of a rapid assessment using monitoring methods and around two
months of direct supervision and field work in the area were undertaken to assist this.
Contact with the CAH was maintained for more than one year after this and limited
training support provided on request in spring protection. The continued contact
allowed an assessment of the impact of the work and its results on activities.

A6.6 Methodological Development

The principal objective of the work was to define priorities at regional level and based
upon these to propose objectives and activities to improve the situation.

The work was undertaken in close co-operation with four of the ('laboratory')
technicians of the health centres and the CAH laboratory supervisor. It addressed
aspects of drinking water, excreta disposal and household hygiene. Only the first of
these is discussed here.

Relatively little was known about the state of water supply except that little
infrastructure was thought to exist. The approach adopted therefore focused upon
defining actual and potential means of provision of drinking water. Water quality
274
analysis was planned and inspection of any protected sources was undertaken on an ad
hoc basis when encountered.

The sanitary inspection forms used in other parts of Peru were discussed with local
staff and a draft suitable for use in the zone prepared, expanding elements related to
reviewing existing sources and reducing those related to the evaluation of existing
infrastructure. This built also upon experience from elsewhere in Peru and therefore
incorporated many of the concepts described under ·Peru r . One community was
visited with this form and informal visits to water sources and households made. On
the basis of this limited field testing the form was revised and then used for the
remainder of the assessment.

For water quality analysis portable water testing equipment was employed. The
technicians had received some training in the use of the kit prior to the visit from the
external laboratory advisor. On-the-spot evaluation of the technicians competence in
the use of the testing equipment on arrival in the zone revealed deficiencies and half a
day was spent in providing practical demonstrations and hands-on experience.
Analysis during the remainder of the period was undertaken by the technicians and
observed and by the end of the period of supervision all were competent in the
procedures required.

The programme of visits was planned as far as was possible under prevailing transport
conditions. Sanitarios were warned some time in advance of the visit without specific
timings and, in most cases, had discussed it with community leaders.

A total of 39 of the 119 principal communities in the area was visited. In two no
inspection or analysis were performed because all members of the community were
absent (tending remote chacras). Community selection was not random but dictated
by travel constraints and demand from the Programme's managers. In particular one
section of the Nieva sector could not be visited due to problems of water level.

In each community visited contact was made with the community authority and with
the sanitario. With the sanitario visits were made to a sample of households and to a
selection of water sources. Selection of households was not random, in part because
no practical means to achieve this in the available time was identified and in part
because pressures from within the community prevented such a rigid approach.
Inspection of both water sources and households was by direct observation.

The four technicians worked together to complete the sanitary inspection form and
undertake water quality analysis. The author observed both inspections and water
quality analysis and discussed errors and inconsistencies with the technicians between
household/ community visits.

The results of both sanitary inspection recorded and presented in subsequent sections
of this thesis represent the consensus view of the technicians. The quality of the water
quality data was considered poor in substantial proportion and for this reason was not
used in further analysis.
275
The results of the assessment were presented by the technicians at the Assembly of
Sanitarios, following which they requested the Health Programme Director to seek
external support for expanded work in this area. The report (Bartram, 1987) was
submitted to the external support agency supporting the programme and well received.

During subsequent months, a request for training support in the protection of spring
sources was received by and responded to and a formal request made by the Health
Programme to recruit a water specialist to support the programme. Follo\\'ing the
practical training in spring protection a model spring protection was constructed by
the group of technicians in the central community for the programme for
demonstration purposes and that further springs were protected by each of the
technicians. The response for external support lead to recruitment of a water specialist
who began work on the programme in late 1988.

276
 Annex 7: Romania

A Governmental Assessment
of Rural Water Supply
in Romania

A 7.1 Introduction

This case study concerns a public sector assessment approach to rural water supply. It
began in 1994 as part of an integrated programme on environment and health . The
main aim of the programme was to foster dialogue between the Romanian Ministry of
Health and the Romanian Ministry of Water, Forestry and Environmental Protection.

A7.2 Area and Population

The population living in rural areas represents 46.8 per cent of the total population of
Romania

A7.3 Water Supply Context

Drinking water supply to rural areas was principally through shallow wells of five to
20 metres depth. Previous studies had indicated that levels of nitrates, organochlorine
pesticides and total coliforms higher than the maximum admissible concentrations
(according to State Standard 1342/1991, which coincided with WHO Guideline
Values for drinking water quality as published in the first edition , WHO, 1985).

277
Nitrate contamination of household wells in rural areas was a well-recognised
problem. Two thousand case s of methaemoglobinaemia including 62 deaths were
reported between 1985 and I 99 I. In 3 89 of these the source of water used was
investigated and in 66 per cent of these well water had both a high nitrate content and
poor microbiological quality.

A 7.4 External Support and Intenrentions

External support was limited to initial orientation through discussion and provision of
limited equipment and consumables. One national workshop was held to discuss the
national situation with regard to drinking water supply and quality and this included a
review of the experience with the pilot study.

A 7.5 Methodological Development

This study is unusual in that the method adopted an assessment approach. Three
phases were proposed as follows:

Action Output
Preparatory Phase
• collect data regarding the number of wells and • stratified sample of wells for investigation
population in all villages • characterisation of wells in terms of sanitary
• collect data at national level about wells and status and water quality
their hygienic status • overview of national situation
Pilot study (one village)
• sanitary inspect ion of wells • validation of methodolog y
• measurement of well water quality • guidelines for implementing case studies
• data collection n selected health indicators
Case Studies
detailed sanitary inspection of wells description of health risks
analysis of well water quality analysis of technical alternatives
collection of health indicators

It was envisaged at the time of commencement that the timetable for completion of the
study would be of the order of six months for pilot testing and 12 months for the
national study and case studies in parallel, thus enabling a full annual cycle of
monitoring in selected locations in order to investigate the impact of seasonality.

The sanitary inspection procedure used was modified from that previously employed
in the former administration. Training was provided to those undertaking the sanitary
inspection and the forms designed to minimise interpretation bias between
respondents. The form required both interviewing and direct observation.

Water quality samples were taken only once. For the purposes of the pilot study, all
samples were transported to the national laboratory and analysed there on receipt .

278
 Annex 8: Yemen

Status Assessment for Yemen

In 1993 a series of national status assessments of drinking water quality monitoring in

Egypt, Pakistan and Yemen were prepared on behalf of the East Mediterranean
Regional Office of the World Health Organization (Bartram, 1993a; Bartram, 1993b;
Bartram 1993c; Bartram , 1993d). This activity involved observation of current
practice through interviews with national, regional and local level staff, field visits
and visits to laboratories and offices of environmental inspection agencies and training
agencies.

The aspects relevant to rural water supply monitoring from the three studies are
presented as separate annexes here and provide insights into the organisation and
practice of drinking water supply monitoring in the three States concerned .

A8.1 Introduction

The Republic of Yemen was formed on 22 May 1990 from the merger of the former
Yemen Arab Republic ('North Yemen') and the Peoples Democratic Republic of
Yemen ('South Yemen'). Elections had been held in April 1993 and the
administration and state organisation were still in the process of development. In part
because of this there were conspicuous gaps in basic infrastructure of some
institutions outside the capital or the North.

The young country was classified as one of the least developed globally (the World
Bank estimated GNP per capita as US$540 in 1991) and this situation was
exacerbated by the reaction of the Arab States and the West during and following the
Gulf crisis. The lack of remittances from ex-patriate labour had had an effect and the
279
country relied heavily on external assistance in some fields - notably health, water
supply and sanitation; similarly an influx of Somali refugees was judged to have been
likely to have had a detrimental effect.

A8.2 A_reaand Population

There was a great discrepancy in population figures quoted for the Yemen. This was
in part due to lack of data, particularly from the south following unification but also
due to confusion with earlier statistics regarding the status of the ex patriate workforce
and more recently due to the influx of refugees from Somalia. A total population for
the country of the order of 13-14 millions was estimated, with up to 1.2 million
living in the capital Sana'a. Although the urban population was growing rapidly,
around 80 per cent of the population was considered rural.

The land area of the Republic of Yemen was approximately 555,000 square kilometers
and could be divided into the coastal flatlands (Tihama), mountainous areas and
desert. These three types of geography occupied 25, 60 and 15 per cent of the land
area respectively . The rugged topography, scattered settlement pattern and high rural
population make the provision of any services to the rural population difficult.

A8.3 Institutional Context

The country was divided administratively into Govemorates, the number of which
was quoted variously as 16 to 18. The Govemorates were in tum divided into
Municipalities

A8.4 Water Supply Context

Estimates of the population with safe drinking water were quoted at 85 to 90 per cent
for the urban sector and 30 to 50 per cent for the rural sector (see for example UNDP,
1993 and WHO, 1989) These 'coverage' figures were based on the population
intended to benefit from 'improved' water supplies. Although no reliable data were
available, it appeared likely that around 5,000 rural water supplies had been
constructed by the various agencies throughout the unified country and it was
estimated that there were of the order of25,000 wells in the former YAR ('North
Yemen'). Whether all of this infrastructure was operational was questionable and the
rural coverage figure especially was therefore considered likely to be an optimistic
estimate.

Much of the population, especially in rural areas relies on unimproved water sources,
some of which take non-conventional forms such as bunded wadis (kafirs) and
collection of rainwater from hard surfaces such as roofs (both especially in the south.

280
A8.5 Water Quality Context

Health statistics regarding water-related disease were not readily available but high
rates of diseases associated with inadequate water supply and quality were said to be
common. It appeared likely that faecally-contarninated drinking water was a
significant cause of disease . The only chemical contaminant having a health impact
nationally was fluoride. There was said to be a high incidence of dental fluorosis in
some areas and concentrations in drinking water in some sources considerably
exceeded the WHO Guideline Value.

In the great majority of institutions interviewed it was stated that water quality was a
priority and should receive increased attention

A8.6 National Policy and Strategy

There was no national policy or strategy document incorporating drinking water in

general or drinking water quality in particular . A National Environmental Action Plan
was being developed, although it was unclear whether this would include drinking
water supply and quality.

A8.7 Institutions with a Role in Water Quality Monitoring

A limited number of key institutions could be readily identified in Yemen as follows:

• one agency with overall responsibility for policy planning and co-ordination for
environmental matters with direct accountability to the Council of Ministers - the
Environment Protection Council (EPC);
• one urban water supply agency - the National Water and Sanitation Authority
(NWSA);
• an agency responsible for design and construction of rural water supplies - the
general Authority for Rural Electricity and Water (GAREW). After construction,
systems were handed over to the community for subsequent operation and
maintenance and GAREW was not therefore a supply agency per se although it
did have some responsibility for monitoring rural water supplies;
• an agency with responsibility for environmental control (surveillance) - the
general Directorate of Environmental health (GDEH) of the Ministry of Housing
and Urban Planning) which was the line Ministry associated with the
Govemorates and Municipalities; and
• three principal training institutions: the Health Manpower Institutes in Sana'a and
Aden and the faculties of Engineering and Medicine at the University of Sana'a.

The Ministry of Public Health played no role in environmental health, although the
Central Health Laboratory undertook limited water analysis in co-ordination with
GDEH.

281
One source of information noted that 23 per cent of the basic health units were active
in water control although none of those interviewed were aware of this and the
statistic was open to question. According to senior sources interviewed, these PHC
Units undertook no activities in the field of water or environmental health.

A8.8 Sector Co-ordination

Inter-institutional co-ordination was poor and ad hoc when it occurred. There was no
agency or mechanism to support it.

The Ministry of Public Health was generally uninvolved in water quality issues and
specifically policy and standard development and investigation of environmental
health aspects of disease outbreaks.

There was a general lack of systematic data collection from rural areas and under-
served segments of the rural population . According to the EPC (Government of
Yemen, 1993):

'it has been observed that so many authorities carry out the analysis of water without
co-ordination between them since they do that according to the demand of some
individuals and authorities ·

A8.9 Laws, Regulations and Standards

As of 1992, Yemen was one of the areas where only traditional water regulations
governed water management (Caponera, 1992).

Two draft laws to regulate water resource usage had been prepared, one by the
Ministry of Agriculture and Water Resources and the other by the High Water
Council. Neither had been approved . As far as it was possible to discern, there were
no current laws and regulations governing water supply or codes of practice for
construction .

Draft drinking water quality standards had recently been prepared by the EPC in
consultation with other sector institutions. The EPC report which presents the water
and wastewater quality guidelines (Government of Yemen, 1993) included the
following recommendations:

'Recommendations
I. The Environment protection law should be issued soon since it is the only
environmental legislation that regulates the environmental activities. According
to this law other environmental related legislation specially those related to water
can be issued
2. preparation of the water and sewage system law

282
3. L'isueof the different laws and legislations that ensure the application of the
environment standards
4. Support NWSA labs. And pro vide the equipments needed to ensure complete
water analysis including the physical analysis. The needfor training the nationals
at all levels in this field
5. Co-ordination between the concerned authorities and the preparation of common
references to undertake the analysis at the required.frequency
6. the analysis should include the private and public wells the rural areas and sub-
cities
7. Issue the standards related to the methods of physical, chemical and microbial
analysis
8.. The need for a hydrochemical map of the Ro Y
9. the need of training programmes for laboratory staff (sic)

The standards themselves (Government of Yemen 1993b) include not only

concentrations not to be exceeded but also sampling methods and sample storage
needs, requirements for disinfection (chlorination), special considerations for
emergency situations; frequency and nwnbers of samples to be taken; approved
analytical methods; and reporting formats.

The document should be viewed as provisional and as setting initial guidelines for
activities. There was insufficient experience in water quality monitoring (except by
the supply agency in the urban area) on which to base achievable monitoring or water
quality targets. Furthermore, one of the institutions which should have had a key role
in the development of drinking water quality standards - the Ministry of Public Health
- did not participate because of lack of expertise .

AS.to Actual Level of Monitoring Activity

Water quality monitoring was very poorly developed. While NWSA undertook
quality control of its water - at least in the capital and to some extent elsewhere - no
other agency was involved in routine monitoring whatsoever and no agency
considered its monitoring remit to include deterioration of quality in households

A8.11 Staffing and Training for Water Quality Monitoring

Because of the underdevelopment of the sector it is difficult to estimate hwnan

resource requirements both by type and quantity for the short-mediwn term.

Training of relevant staff was as follows:

• Health inspectors (sanitarians) 30 - 40 per annum. The course was in general very
good although the curriculwn had not been revised for some years, no feedback
was received from employers and the water quality component appeared
inadequate.
• Assistant health inspectors: occasional courses only.
283
• Sanitary Engineers: undergraduate and post-graduate training was coming on-
stream with significant water quality components.
• Medical Students: the intention was to integrate environmental issues into the
curriculum.
• At the level of the trainers themselves there were few with recent, post-graduate
training in any field of the environment and none with specific post-graduate
training in water quality.

284
 Annex 9: Colombia

Environmental Monitoring and

Institutional Roles in Post-
Disaster Development
in Colombia

285
Environmental monitoring and institutional roles in
post-disaster development

J. BARTRAM, BSc,AIMLS,University of Stlrrey, M. SUAREZ, Edificio

de Gobernacion, Ibague, Tolima, Colombia, and E. QUIRcx;A, BEng,
and G. GALVIS, BEng, MSc,Universidad del Valle, Colombia

SYNOPSIS An environmentalsurveillancepropammewas developedin

Colombiafollowing a majordisaster. Theprogrammef!Ovideds=.Jo
of problemsand
the local Health Service andenabledidentification s
in the water supply and sanitation sector. These were used to develop a
strategy for prioritising remedial actions according ID public health criteria.
The programme is now an ongoing activity of the local Health Service.
Disaster relief may weaken local institutions and it is therefore crucial that
these fulfil their roles in post-disaster development aid. Non-involvement of
such agencies may affect the viability of investment in infrastructure.
Similarly, individual and community attitudes may be created which
influence the success of post-disaster development initiatives.
BACKGROUND
1. On the 13th of November, 1985, the glacier-covered volcano 'Nevado
Del Ruiz' in central Colombia erupted. Part of the avalanche produced by the
melting of the glacier cover flowed down the valley of the river Lagunilla
and swept away the city of Armero. In total about 22,000 died and more
than 5,000 were made homeless.
2. Following the disaster, national and international agenciesinvolved in
disaster relief provided substantial suppon for resettlement and improvement
of living conditions, including improvementof basic ICIVicel.
3. Investment in sanitary infrastructure included the construction of two
wutewater treatment lagoons for the towns of Lerida and Ouayabal and
improvement of water. treatment and distribution.
4. Following immediate disaster relief and expansion of basic sanitary infra-
structure, the British Red Cross identified the needU> consolidate the invest-
ments made and ensure their long-term contribution to public health (ref 1).
METHODS·
5. A team of HealthPromoterswas trainedin buic Uf.C:Cts
of public health,
water supplyand saniaationand watersupplysurveillance. Teamswere
based in the four Regional capitalsandprovidedwithbuic equipmentin-
cluding portablewater testingkits.
6. Basic information regarding the state of sanitary infrastruc~ was not
available. Further, the Promoters had little experience of sanitary inspection
or systematic data collection. A preliminary studyof a sample of urban and
rural communities was therefore undertaken.
7. The local Health Service was supponcd to undertake inspection and
sampling of water supplies and investigate excreta and waste disposal
facilities. Preliminary contacts were made with local institutions involved in
~~ ~t for mm..... Thom11Telford,London,1991
WATER. SANITATION AND FOOD WORKSHOP
water supply and sanitation. Furthermore, a survey of public attitudes to
water supply and sanitation following the disaster was undertaken. The
approach to systematic data collection has been described previously(ref 2).
RESULTS
8. A number of imponant findings were derived from the preliminarystudy
(ref 3):
Sa.No water treatment plant was in operation. This included those
constructed in the wake of the disaster. Funhcnnorc, most systems supplird
grossly contaminated water and water supply services were gene'"
deficient as shown in Table1.

Table 1: Qulity ol Water Supply Services iD a Sample of Communities, Tolima,

Cololllbla,1919
Population Sysaan Number~ Quality Conrinuity
Type Type visited (faecal of service
coliforms/100ml) hours/day

Urban surface water 4 83-96% 3 with >SO 1 with 1-10

sourcewith 2 with 11-23
treatment 1 wilh 11-50 t with 24

Rural surface water I 96% >50 24

sourcewith
trcatrncnt

surface water 7 65-96% 3 with >50 l with 1-10

source,no 3 wilh 11-50 6 with 11-24
treatment 1 with 1-10

Sb. Although water quality was generally very poor, considerable

infrastructure existed for water treatment and little additional investment
would be required to enable operation of existing water treatmentplants, see
Table 2.
8c. Public percepriqnof the imponance of water quality was high and many
households claimed to regularly treat drinking water at home, buy bottled
water or collect treated water from nearby indusaial premises.
8d. Considerable investment had been made in wastewater treatment by
lagooning,_a technology which is generally considered low-costand requires
little operarion andmaintenance, but the Municipalities who 'inherited' this
infrasauctureshowed little interest in iL
Se. Despite tariff levels below the minimum necessary for operation and
maintenance, public attitudes to tariffs varied widely. In one district, users
refused to pay any tariff because the water supply system bad been given to
them as disaster survivors by an international aid agency.
9. In light of these findings, a series of activities were initiated to promote
the undenaking of remedial actions. These included training in urban water
supply administration,organisation and tariff structuring; fosteringof a link
between the local University and the Municipalities for monitoring and
optimisation of the wastewater treatment lagoons; rehabilitation of a pilot
rural water treatment plant; and promotion of infonnation dissemination to
promote awareness both amongstthe general publicand local authorities.
10. These were undenaken not by direct intervention by outside agencies,
 BARTRAM ET AL.

but by promoting remedial actions to be taken by the appropriate local

agency. These activities were largely targeted through the local Health
Service at the Service itself and the Municipalities.

Table 2: Actions Needed to Enable Functioningof Water Treatment Infrastructure

Town Acwal Actionsneeded

Status

Armero- Consauction • eliminate IOilet sited on clear warertank;

Guayabal swted 1987, • repair coagulant mixing and dosing
still non- equipment;
opcnlional • finishconsauctioa of second saorage tank
and fillcr-saora,e umkin&u~on;
• purchase cblmne cylinders;
• operatorll'aining;
• complete lab equipment and ll'ain user.
Lerida Consttuction • repair pumping equipment and prevent
started 1987, repeator flooding;
commissioned • operator training;
but nownon- • complete lab equipment and train users;
operational • purchase chlorine dosing equipment
Mariquita Functioning • repair coagulant mixing and dosing
since 1986, equipment;
coagulantand • initiate lime dosing to counter acidity
chlorine dosing or sourcewater;
practised • complete rehabililation works
irregularly; (expansionor sedimentationand
rehabilitation filtrationcapacity);
begun in 1988 • initiate chlorine dosing;
now paralysed. • operator training.

Foocnote:All planrs comprised coagulmt dosing,flocculation,sedimentation and rapid sand

fdtration. Most also had chlorine dosingequipnenL

DISCUSSION
11. The exercise outlined above can be analysed as a success. Problems
were identified and solutions applied. These included aspects of institutional
development of local institutions andthe perspectives for long-term benefit
are good. Funhcrmore, the project attracted national attention and the
National Director of Environmental Sanitation is now seeking means to
replicate the experience nationally.
12. It is imponant to distinguish between disaster relief and post-disaster
development. During disaster relief the need for action, for instance to save
lives, is immediate and urgent. However, once immediate relief has been
successful, actions should be governed by developmental criteria. There arc
a number of aspects of this project which merit analysis in this context.
13. Aid itself may influence local institutions which may be by-passed,
especially during disaster relief and short-term aid, although it is these
agencies which will be expected to operate and maintain any infrastructure
developed.
WATER, SANITATION AND FOOD WORKSHOP

13a. The funding received in an area following a disaster may be much

greater than the budgets of the local agencies. Funhennore, much disaster
relief is administered by external agencies with considerable independence,
often without reference to local agencies or procedures and with specially
contracted staff. In these conditions, local agencies may appear impotent
when external support is withdrawn, along with budget and 'experts'.
Positive action should be taken to mitigate this. In this project local staff
were supponed to manage the project themselves; workgroups included
appropriate local institutions and established procedures (for example for
water quality monitoring) were respected (ref 4).
13b. The failute to involve local institutions in the initial phases of projects
may also lead towards problems. In this case, the initial disinterest of the
Municipalities in the wastewater treatment lagoons and the non-functioning
of much water trcauncnt plant appear to be related to some extent to the non-
involvementof these agencies.
14. Disaster relief may also affect community and individual attitudes.
14a. Cases of •divided' communities where the new residents attained a
higher standard of living (thanks to aid) than the original residents occurred.
Contrasting attitudes were seen in some such communities. In the settlement
of Lerida, the population refused to pay even the low local tariff for water;
during interviews, inhabitants commented that they should not pay at all as
the system had been donated to them and rather, the other users of the system
should be grateful to be able to use the system. Also here, the original
residents were resistant to the idea that the water sources (which their
families had used for generations) were contaminated; while new residents
were far more ready to accept and act on this idea.
15b. Attitudes createJ in response to the disaster relief and subsequent
development aid also affected the project which was managed by the local
Health Service itself. Health Promoters were initially reluctant to become
involved because they were to receive or,ly Ministry of Health travelling
allowances, rather than the enhanced rates known to be paid by most
international agencies active in the area.
16. Perhapsthe bestexampleof the success of the strategy of involving
local staff and agencies in order to cnsur~ project acceptance and transfer of
ideas is thatthe Departmental Governor and the local Health Service decided
during the final phase of external support to fund the rehabilitation of a
demonstration rural water treatment plant, incorporating technologies new to
the area, from their own resources.

REFERENCES
1. Lloyd, B.J. The Development and Control of Hygiene, Health and
Sanitation Services in the Municipalities of Lcrida, Guayabal and Mariquita.
Consultancy Repon to the British Red Cross Society, September 1987.
2. Uoyd, B.J. and Bartram, J.B. Surveillance Solutions to Microbiological
Problems in Water Quality Control in Developing Countries (in press) in:
Proceedings of Symposium on Health-Related Water Microbiology,
IAWPRC, Tubingen, April 1990.
3. Anon. Proyecto Sobre Vigilancia y Mejoramicnto de Sistemas de
Abastecimiento y Remoci6n de Agua en la Regional de Armcro dcl Servicio
Scccional de Salud del Tolima, CINARA-SSS-Tol-Robens Institute,
December, 1989.
4. Anon. Disposiciones Sanitarias Sobrc Aguas, Dccreto2105, Ministerio de