2011 Annual Meeting of the International Network on

Household Water Treatment and Safe Storage

Meeting Report

Chapel Hill, North Carolina, USA

3 October 2011

WHO/UNICEF International Network on Household Water Treatment and Safe Storage

organised in collaboration with

the Water Institute at the University of North Carolina

Table of contents 1.  Summary ............................................................................................................................ 1 

2.  Background and introduction ............................................................................................. 1 

3.  Objectives and meeting agenda ......................................................................................... 2 

4.  Presentations and discussions ........................................................................................... 3 

5.  Meeting outcomes .............................................................................................................. 8 

References .................................................................................................................................. 11 

Annex 1 – Final programme ........................................................................................................ 13 

Annex 2 – List of participants ...................................................................................................... 15 

Annex 3 – List of presentations ................................................................................................... 17 

Annex 4 – Work plan templates for Working Groups .................................................................. 18 

- 1 -

1. Summary

This report contains a summary of discussions and outcomes of the 2011 Annual Meeting of the International Network on Household Water Treatment and Safe Storage (the Network). The meeting was held in Chapel Hill, USA on 3 October 2011. Approximately 80 individuals gathered for the meeting, representing 55 different organisations. Proceedings included presentations, panel discussions and break-out sessions. At the meeting, major initiatives in household water treatment and safe storage (HWTS) were presented in a structured forum for discussing key challenges, successes and new opportunities and for scaling-up and sustaining HWTS. In addition, participants convened in the following re-constituted working groups: advocacy/policy, implementation/integration/scaling-up, monitoring & evaluation, and research/knowledge advancement. Key themes of discussion included the integration of household water treatment and safe storage into broader water and health programmes and the development of standardised tools in monitoring and evaluation of programmes and technology performance. The main outcomes of the meeting were the sharing of challenges, successes and lessons learned among Network participants and initial discussions on draft action plans among the four working groups for 2012.1 In addition, on days prior to and following the Network meeting the Network Advisory Group and the Network Public-Private Partnership Group met for the first time in Phase II (2011-2016) of the Network. These groups offer leadership and expert input regarding key initiatives, such as the proposed WHO-led international household water treatment evaluation scheme. The meeting was convened jointly by the World Health Organization (WHO), the United Nations Children’s Fund (UNICEF) and the Water Institute at the University of North Carolina at Chapel Hill (UNC). This meeting report was prepared by Mr Ryan Rowe, Communications Officer for the Network and based at the Water Institute, with input from UNICEF and WHO. Annexes to this report include the final programme (Annex 1), a list of participants (Annex 2), a list of presentations (Annex 3), work plan templates for the Working Groups (Annex 4), a Network activities update for the period January 2011-September 2011 (Annex 5). 2. Background and introduction

The large burden of diarrhoeal diseases continues to drain important resources from developing countries. Approximately 88% of diarrhoea cases worldwide are attributable to unsafe water, inadequate sanitation, or insufficient hygiene. These cases result in an estimated 1.9 million deaths each year, the majority of which are preventable, mostly among young children (WHO, 2004). After pneumonia, diarrhoea is the second leading cause of death among children under five (Black et al., 2010). Drinking water contaminated by bacterial, viral, or protozoan pathogens is one of the major transmission routes for diarrhoeal disease.

1 The working group action plans have since been completed and are available online at: http://waterinstitute.unc.edu/files/wg/NetworkWGPlan2012.pdf.

Low-cost interventions for household-based treatment of drinking-water and safe storage can significantly reduce the pathogen load in drinking-water and, thereby reduce the risk of diarrhoeal diseases. HWTS offers the greatest benefits to high-risk populations such as young children, people living with HIV and AIDS, the malnourished and the displaced. The 7-point strategy for comprehensive diarrhoea control, adopted by the United Nations Children’s Fund (UNICEF) and the World Health Organization (WHO) in 2009, includes household water treatment and safe storage (HWTS) as a key proven method of primary prevention that also increases effectiveness of other interventions specifically aimed at reducing child mortality (UNICEF & WHO, 2009). In regards to those with HIV/AIDS diarrhoea is one the leading causes of death (Tillekeratne et al., 2009; WHO, 2008) and has resulted in health gains in countries such as Uganda (Lule et al., 2005). The Network The purpose of the International Network on Household Water Treatment and Safe Storage ("the Network) is “to contribute to a significant reduction in water-borne and water-related vector-borne diseases, especially among vulnerable populations, by promoting household water treatment and safe storage as a key component of community-targeted environmental health programmes”. The Network, established in 2003 by the World Health Organization (WHO) and as of 2011 co-hosted by WHO and the United Nations Children Fund (UNICEF), includes those international, governmental and non-governmental organizations, private sector entities and academia that subscribe to the above mission. The main areas of Network activity are reflected in four working groups: policy/advocacy, research/knowledge management, implementation/scale-up and monitoring and evaluation. As detailed in the Phase I strategy, initial Network efforts focused on raising awareness about HWTS needs and technologies.2 Now in Phase II of activity, the Network is concentrating on effective implementation and achieving scale.3 3. Objectives and meeting agenda

The overall objective of the meeting was to provide an update on the Network strategy, identify challenges and opportunities moving forward and engage participants and attendees in dialogue and action. Specific objectives include:

1. Present and discuss major initiatives in HWTS

– National HWTS policies/strategies, integration and scaling up – Strengthening HWTS monitoring and evaluation – Evaluation of household water treatment options

2. Provide structured forum for discussing key challenges, successes and new opportunities

among Network participants and way forward for scaling and sustaining HWTS

2 Network Phase I Strategy (2003-2008). http://www.who.int/household_water/advocacy/en/Network_Strategic_Plan_Draft_11_July_04.pdf. 3 Network Phase II Strategy (2011-2016). http://www.who.int/entity/household_water/resources/NetworkStrategyMar2011.pdf.

3. Spark interest in working groups, gain input for future activities and formulate a 2012

work plan, including involvement of Network participants at the 6th World Water Forum in Marseille, France in March 2012

The meeting agenda is found in Annex 1. 4. Presentations and discussions

This section briefly summarises the presentations and discussions during the meeting. At the outset of each sub-section, a synopsis of the discussion is provided. Refer to Annex 3 for a list of presentations and a link to the slides online. (Note: Not all speakers used slides.) Session: National HWTS Policies, Integration, and Scaling-up The ultimate objective and benefit of HWTS is protection against pathogens that cause diarrhoeal disease. HWTS contributes to the Millennium Development Goals (MDGs) on the reduction of child mortality (Goal 4), improving maternal health (Goal 5) and combating HIV/AIDs, malaria and other diseases (Goal 6). This gives Network activities a much broader audience beyond the water and sanitation sector. While the lead ministry on HWTS varies by country (health, water, environment), increasing collaboration within government entities on the health benefits of HWTS as well as using an integrated approach with those implementing HWTS are likely to increase the scale and impact of HWTS. The integration of HWTS into broader water and health programmes is a Network priority. Integration offers the potential for improved health outcomes as well as economic benefits, and there is a growing body of literature documenting the benefits and possible delivery mechanisms of this approach (Adam et al., 2005; Lugada et al., 2010; Sheth et al., 2010; ACF et al., 2011). “The Network: An Update” Dr Maggie Montgomery, World Health Organization Dr Montgomery provided an update on the Network’s Phase II strategy and key activities during 2011 (refer to Annex 5), including its focus on vulnerable populations and integration of HWTS with other environmental health household interventions. She outlined the Network governance structure, including the newly appointed members of the Advisory Group and Public Private Partnership Group and the various mechanisms for gaining input from Network participants (i.e. working groups, webinars, review of key documents, etc.). She also mentioned that the HWTS target on national policies and associated session planned for the 6th World Water Forum in March 2012 in Marseille provides an opportunity for increasing the visibility of HWTS and identifying solutions to achieve scaling-up. The Network has also expanded communications with initiatives such as webinars, a monthly newsletter and a twitter feed.4 “Integrating Household Water Treatment and Storage into Health Services: Rationale, Examples from the Field, and Lessons Learned” Dr Rob Quick, US Centers for Disease Control and Prevention

4 The Network’s archive of monthly newsletters is available at http://waterinstitute.unc.edu/hwts. The twitter feed is available at http://twitter.com/houshold_water.

Dr Quick spoke about the rationale for integration of HWTS into other interventions and provided examples of programmes in areas such as social entrepreneurship, maternal and child health services, and HIV care and support services. He provided support for this by discussing CDC work on integration from Kenya, Malawi, Uganda and Zambia. Lessons learned included that integrating HWTS with health care services can increase adoption by capitalising on "teachable moments", equity of access and potential for scale of HWTS. For example, free distribution of basic care packages (water treatment system, filter cloth, condom, bed nets, cotrimoxazole and educational materials) can attract people to clinics for voluntary counselling and testing, and subsequently HIV care, if needed. Where basic care packages had policy support (i.e. PEPFAR – the US President’s Emergency Plan for AIDS Relief), scale is possible. HWTS integration can be achieved at modest cost in some settings such as clinics and schools which enable access to large groups and reduce overall programme delivery costs. Challenges include long-term behaviour change, personnel changes in clinics and schools, and need for donor support due to free distribution of product. “Benefits of Integration of HWTS into School, HIV/AIDS, WASH and Nutrition Programs” Dr Greg Allgood, Procter & Gamble Dr Allgood gave examples of the integration of P&G water purification packets in schools, HIV/AIDS, water/sanitation/hygiene (WASH) and nutrition programmes and highlighted a range of improved outcomes relating to health, development, education, and user experience. The product is primarily used in emergency settings or where people are consuming turbid water commonly found in surface sources such as lakes, ponds or rivers. HWTS products such as these have been recognised as an essential component of a basic care package for people living with HIV/AIDS. The cost of providing safe water is a fraction of the cost of care for a patient suffering from a chronic water-related disease. Ingestion of pathogens, such as cryptosporidium can be fatal in immuno-compromised individuals. Further, when HWTS is combined with nutrition products such as Plumpynut, it can reduce programme expenditure per person by increasing efficacy of nutrient absorption. Dr Allgood encouraged the audience to attend the HIV/AIDS-focused HWTS seminar taking place on 4 October 2011.5 “Integrated household water treatment efforts in Kenya and the East Africa Region” Dr John Kariuki, Ministry of Public Health & Sanitation - Kenya Dr Kariuki spoke of the Ministry’s work in developing a comprehensive approach to scaling up HWTS. It has formed a Technical Working Group to coordinate action by a range of actors. Dr Kariuki outlined the policy framework around HWTS and indicated that the Ministry supports an integrated programmatic approach. He cited several examples of the Ministry’s support for integration of HWTS into school WASH projects, hand-washing and community-led total sanitation campaigns, and demonstrations in community settings. Dr Kariuki also reported on the results of the regional workshop for selected East African countries in June 2011 where country teams from Ethiopia, Kenya, Rwanda, Tanzania and Uganda developed national action plans on HWTS and identified common challenges facing the region.6 He voiced support for the WHO recommendations on evaluating performance of household water treatment technologies, and suggested these could inform the development of national guidelines in the region. Dr Kariuki

5 Presentations from this seminar are available at: http://waterinstitute.unc.edu/hwts/newsletter/oct2011#hwtshiv. 6 Report and proceedings of this regional workshop are available at http://waterinstitute.unc.edu/hwts/events/entebbe2011.

also expressed interest in partnering with others in the Network on the development of monitoring & evaluation guidelines specific to the Kenyan context. Session: Strengthening HWTS monitoring evaluation and targeted interventions WHO and UNICEF are jointly developing an HWTS monitoring and evaluation toolkit to aid in monitoring program implementation and evaluating outputs and outcomes.7 By standardising indicators of HWTS implementation, implementers, donors and decision-makers will more easily be able to compare results and understand how to improve delivery mechanisms to reach those most in need and better support sustained use. The new working group on monitoring, mapping and evaluation will be invited to contribute to review and stakeholder input on the toolkit, as well as assisting in piloting and implementation. “The HWTS M&E Toolkit: Work-to-date and Way Forward” Dr Daniele Lantagne, Harvard University Dr Lantagne discussed the current status and next steps in the development of the Monitoring & Evaluation Toolkit for HWTS. The document was drafted and circulated by WHO in April 2011 and builds upon previous Network efforts to develop harmonised indicators of HWTS use and in-turn improve programme outcomes. Based on reviewer input and feedback from a webinar on the toolkit, the document is under revision. Dr Lantagne highlighted that currently there is a perception that health outcomes are the only valid and reliable measure of program success. However, she noted that health indicators are extremely difficult and costly to measure correctly and often better suited for use in research studies designed to address specific evidence gaps. For routine monitoring, government officials and implementers are encouraged to measure outcomes (e.g. improvement in water quality or consistent use of HWTS). If these are improved, it can be inferred that health gains will be realised. The toolkit will also include examples of surveys, reports, and water quality metrics appropriate and relevant for implementers, decision-makers and donors. The second round of revisions is being jointly coordinated by WHO and UNICEF. A second draft for comment is expected in early 2012 with finalization occurring later in the year. “The 2011 household- and community water treatment and safe storage yearbook” Mr Christian Vousvouras, 300in6 Mr Vousvouras provided an overview of the Yearbook project of 300in6 whose purpose is to fill a perceived gap in knowledge of point-of-use water treatment efforts globally. The scope of information will include national policy, technologies used, distribution channels, payment strategies, and sales volume. The objectives of the Yearbook are to share good practices, inform policy-making, and provide a useful tool for potential investors in the sector. The Yearbook is expected to launch at the 6th World Water Forum in March 2012 in Marseille. “Predicting the Health Impact of HWT” Dr Kara Nelson, University of California at Berkeley and Dr Joe Eisenberg, University of Michigan Dr Nelson and Dr Eisenberg are currently researching the effect of HWTS compliance on health benefits through multivariate modelling efforts. Their work has found that when compliance is

7 The initial draft HWTS Monitoring and Evaluation Toolkit was completed in April 2011, circulated widely for comment, discussed in a Network webinar in May 2011 and presented at the East Africa HWTS workshop in June 2011.

less than 100%, the reduction in diarrhoea disease is greatly compromised. In other words, consumption of a small amount of untreated, contaminated drinking-water can completely offset the benefits of treating water in the first instance. In her presentation, Dr Nelson discussed issues such as a commonly understood definition of compliance, understanding what motivates greater compliance by users of HWTS, temporal and demographic variations in compliance, and pathogenic variation by source and seasonality. This can have policy implications and Dr Nelson challenged Network participants to consider how to better communicate the importance both measuring compliance and encouraging consistent and correct use. Roundtable discussion: Successes, failures, and the way forward Dr Jamie Bartram, Water Institute at the University of North Carolina (Moderator) Dr Bartram opened the session as moderator by providing some background on the history of the Network and achievements to date. He asked the audience and the panelists to think of one success, one failure, and one lesson learned to keep the discussion focused and specific. The panelists shared their perspectives and a lively discussion ensued. “Integrating and scaling up HWTS” Mr Navneet Garg, Vestergaard-Frandsen Mr Garg began by commenting that in every country he speaks to a different ministry about HWTS. He also suggested one failure inhibiting scale is the absence of a clear strategy linking HWTS and Millennium Development Goals, particularly MDGs 4, 5, and 6 so as to emphasise the need for a conversation about health impact. Greater alignment of stakeholder efforts, targets and goals is a key challenge facing the Network. He referred to two recent World Health Assembly resolutions passed earlier in 2011 that draw attention to the importance of HWTS in preventing disease and improving health (WHO, 2011a; WHO, 2011b) and the WHO HWT performance recommendations (WHO, 2011c) as important political and technical tools. He also noted that those involved in HWTS should learn from other public health scale-up success stories, such as insecticide treated bed nets and vaccination campaigns. “Market approach to HWTS” Mr Glenn Austin, PATH Mr Austin said that one of the greatest challenges is the failure to reach the poorest of the poor. He noted that those implementing HWTS continue to depend on commercial models rather than accepting that subsidised or free approaches are likely to be quicker and more effective ways of reaching the most vulnerable. Too often, there is a focus on products, technologies and methods – if a product has the desired impact on water quality, then what is acceptable in context and creates the desired behaviour change should become the driving factors. Private sector business models show that the issue of compliance fades away as we develop products that are tailored to user needs and preferences but a key learning is that we cannot keep hoping for a “silver bullet”. However, the public sector has the responsibility to fill the gap in the market which the private sector cannot meet. “Challenges in sustaining HWTS use” Dr Hans-Joachim Mosler, Eawag Dr Mosler agreed that a user-centred approach is important. He mentioned that a key failure is that our understanding of behaviour change remains limited. Continuing to hope for scalable

solutions ignores the importance of considering social norms, individual ability, or self-regulation. He cited the challenge to find ways of measuring and documenting compliance and behavioural determinants so that we learn what techniques work. “HWTS as a component of comprehensive WASH” Dr Rochelle Rainey, US Agency for International Development Dr Rainey cited the Hygiene Improvement Framework as a success. Developed by UNICEF, USAID, World Bank and the Water Supply and Sanitation Collaborative Council, it set out a clear strategy for the sector and brings three critical factors together: access to water and sanitation “hardware”, hygiene promotion for behaviour change, and the need to strengthen the “enabling environment” (UNICEF et al., 2004). She said all three must be addressed to effectively scale up HWTS and deliver sustained health benefits. The framework emphasises the integration of HWTS into the broader WASH and health context. She said that an important failure is a clear understanding of what leads to sustained use of HWTS but that a lesson learned is that channels at numerous levels in a community (faith-based organisations, access to credit, education, and media) must be activated to help spur the process along. In the ensuing discussion with the audience, several more ideas emerged: – Television ads and celebrity endorsements could be effective ways of promoting HWTS. – Position HWTS as a health intervention and integrate with other health programmes. – Network institutional memory can help the HWTS community be more effective at sharing

of successes and failures and moving forward. – Knowledge is not enough for behaviour change and more focus should be on the

physiological factors that influence adoption and ongoing use. – We must improve coordination of action by NGOs, the private sector, and government. Session: HWTS evaluation criteria and international/national schemes In July 2011, WHO published global criteria for evaluating household water treatment options in terms of their potential to reduce microbial pathogens and protect health (WHO, 2011c). The document, “Evaluating household water treatment options: Health based targets and microbiological performance specifications” sets out a range of risk-based water quality targets to assist policy-makers and practitioners in selecting options suited to local conditions. The Network Secretariat is now considering various efforts to aid in the implementation of the WHO criteria. "Health-based targets and guiding principles" Dr Mark Sobsey, University of North Carolina at Chapel Hill Dr Joe Brown, London School of Hygiene & Tropical Medicine Dr Sobsey and Dr Brown gave an overview of the WHO document "Evaluating household water treatment: health based targets and microbiological performance specifications" which was published in July 2011. The document, co-authored by Dr Sobsey and Dr Brown, provides risk-based criteria for evaluating household water treatment options in terms of their potential to reduce microbial pathogens and protect health. The document recommends three levels of performance (highly protective, protective, and interim) for the reduction of bacteria, viruses and protozoa. The document fills an important normative role in setting, for the first time ever, global minimum performance requirements for HWT. As the document is disseminated to national

authorities for implementation, it will require a strong regulatory structure and local laboratory capacity for testing. Capacity building will be necessary. Dr Sobsey and Dr Brown also stressed the importance of correct and consistent use of HWTS in order to realise the health benefits of devices that meet one of the three levels of performance. Breakout session: Formation of working groups and work plan discussions Dr Maggie Montgomery and Mr Michael Forson gave an introduction to the working group structure and invited participants to join discussions of one of four working groups: 1) Knowledge advancement, 2) Implementation, integration, and scaling-up, 3) Policy, advocacy, and communications, and 4) Monitoring, mapping & evaluation. Each group nominated at least one person to lead the group in developing draft action plan and report back to the plenary (refer to Annex 4 for work plan template). The knowledge advancement group, represented by Dr Rick Johnston (Eawag) and Dr Kara Nelson (University of California at Berkeley) listed two areas of priority: updating the research agenda, including a greater focus on behaviour change; creation of an online resource for researchers to provide brief updates on field work to better coordinate and collaborate on key research needs. Ms Sanne Fournier-Wendes (Vestergaard-Frandsen) of the integration, implementation and scaling-up group listed three areas of priority: assistance to developing countries with funding proposals for reaching vulnerable populations; identification of key bottlenecks in scaling up; utilisation of innovative financing mechanisms including market-based approaches. These issues will be addressed by three-sub working groups. Dr Greg Allgood (Procter & Gamble) from the policy and advocacy and communications group listed four areas of priority: mobilising resources for continuing national and regional meetings; the production of brief fact sheets on good practices and important policy developments; agreement on simple and effective messages and sound bites; presence of the Network at leading health and WASH meetings including the upcoming 6th World Water Forum in March 2012. Mr Paul Osborn (300in6) from the monitoring, mapping and evaluation group listed two areas of priority: understanding trends in both technology development and use and contributing to tools to inform implementation and evaluation such as the HWTS monitoring & evaluation toolkit. The working groups agreed to further refine their work plans and share activities and outputs with the Network on a regular basis. 5. Meeting outcomes

The main outcomes of the meeting were the sharing of perspectives by Network participants and development of draft work plans by each of the working groups.8 In conjunction with the Network Annual meeting, separate meetings of the Advisory and Public Private Partnership Groups allowed for gaining input on key Network items and initiatives. 1) Sharing of Network perspectives

80 individuals from over 50 different organisations shared perspectives and experiences either as presenters or during Q&A sessions. These discussions are detailed above in Section 4. Key 8 The working group actions plans have since been completed and are available online at: http://waterinstitute.unc.edu/files/wg/NetworkWGPlan2012.pdf.

themes of discussion included:

– Successes, failures, and ideas on the way forward; – Integrating HWTS into broader water and health programmes; – Framing HWTS from the health perspective; – Focusing on vulnerable populations; – Contribution of HWTS to MDGs 4, 5, and 6; and – Development of standardised tools in monitoring and evaluation of programmes and

technology performance.

2) Working groups The purpose of the working groups is to carry out activities in line with the Network strategy and offer opportunities for Network participants to contribute in a collaborative and coherent manner. The working groups aim to produce tangible outputs that contribute to the Network mission, objectives and targets and provide regular updates to the broader Network on their activities. Each group is co-convened by one or more participants of the Network who have expressed an interest in leading these activities. The working groups will focus on four broad thematic areas: - Knowledge advancement: This group will focus on developing a research agenda and will be convened by Dr Rick Johnston (Eawag, Switzerland) and Dr Joe Brown (London School of Hygiene and Tropical Medicine, United Kingdom) with lead facilitation from WHO. - Implementation, integration and scaling up: This group has set out three specific work streams of interest to contribute to the objective of scaling up integrated approaches to HWTS in combination with other water and health programmes. The group will be convened by Ms Sanne Fournier-Wendes (Vestergaard-Frandsen, Switzerland) and Mr Sjef Ernes (Aqua for All, Netherlands) with lead facilitation from UNICEF. - Policy, advocacy and communications: This group will focus on informing policy development, coordination of advocacy initiatives and sharing of expertise on effective communications tactics for global health issues. The group will be convened by Dr Greg Allgood (Procter & Gamble, USA) and Ms Katharine McHugh (Population Services International, USA) with lead facilitation from WHO. - Monitoring, mapping and evaluation: This group will focus on monitoring global progress on HWTS, mapping country-level implementation and feeding into the evaluation of the Network’s progress on key targets outlined in the Network Revised Strategy (March 2011). The group will be convened by Dr Khin Thet Wai (Department of Medical Research, Lower Myanmar), Mr Paul Osborn (300in6, Netherlands), and Mr Samuel Gitahi (UNICEF, Kenya) with lead facilitation from UNICEF.

3) Advisory Group In accordance with the Network Strategy, an Advisory Group (AG) has been formed to provide input and guidance to the Network Secretariat on strategic issues. The following individuals have confirmed their commitment to the AG: Dr Daniel Mäusezahl (Swiss Tropical and Public Health Institute, Switzerland), Dr John Kariuki (Ministry of Public Health and Sanitation, Kenya), Dr Leo Heller (Universidade Federal de Minas Gerais, Brazil), Dr Rochelle Rainey (US Agency for International Development, USA), Dr Rob Quick (Centers for Disease Control, USA), Dr Suree Wongpiyachon (Ministry of Public Health, Thailand), Dr Tom Clasen (London School of Hygiene & Tropical Medicine, United Kingdom), and Ms Alix Zwane (Bill & Melinda Gates Foundation, USA). The inaugural meeting of the Phase II AG was held on 2 October and the minutes have been published online.9 4) Public-Private Partnership Group In order to better utilise lessons learned from private public partnerships and to ensure the neutrality of the Advisory Group, a distinct Public-Private Partnership group was created. The PPG aims to facilitate learning from the private sector in areas such as distribution strategies, advocacy efforts, role/impact of subsidies, and tracking of consumer use of products. The members of this group include: Mr Navneet Garg (Vestergaard- Frandsen, Switzerland), Dr Greg Allgood (Procter & Gamble, USA), Mr Deepak Saksena (Hindustan Unilever, India), Mr Geoff Revell (WaterSHED Asia, Cambodia), Mr Kevin O'Callaghan (Medentech, Ireland), Dr John Kariuki (Ministry of Public Health and Sanitation, Kenya), and Dr Suree Wongpiyachon (Ministry of Public Health, Thailand). The inaugural meeting of the PPG was held on 4 October 2011 and the minutes have been published online.10

9 Network Advisory Group, Meeting Minutes, October 2 2011. http://waterinstitute.unc.edu/files/other/AG_Minutes2Oct2011.pdf. 10 Network Public-Private Partnership Group, Meeting Minutes, October 4 2011. http://waterinstitute.unc.edu/files/other/PPG_Minutes4Oct2011.pdf.

References

ACF, Action for Global Health, End Water Poverty, PATH, Tearfund & WaterAid. (2011). Join up, scale up. How integration can defeat disease and poverty. Available at: http://www.defeatdd.org/sites/default/files/nodeimages/WaterAid_20pp_Integration_Report_pages.pdf.

Adam, T., Manzi, F., Schellenberg, J.A., Mgalula, L., de Savigny, D. & Evans, D.B. (2005). Does the

Integrated approach to Management of Childhood Illness cost more than routine care? Results from the United Republic of Tanzania. Bulletin of the World Health Organization, 83: 369-377. Available at: http://www.who.int/bulletin/volumes/83/5/369.pdf

Black, R.E., Cousens, S., Johnson, H.L., Lawn, J.E., Rudan, I., Bassani, D.G., Jha, P., Campbell, H.,

Walker, C.F., Cibulskis, R., Eisele, T., Liu, L., Mathers, C., & Child Health Epidemiology Reference Group of WHO and UNICEF. (2010). Global, regional, and national causes of child mortality in 2008: a systematic analysis. The Lancet, (5)375:1969-1987. Available at: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)60549-1/abstract.

Lugada, E., Millar, D., Haskew, J., Grabowsky, M., Garg, N., Vestergaard, M., Kahn, J., Muraguri, N.

& Mermin, J. (2010). Rapid implementation of an integrated large-scale HIV counseling and testing, malaria and diarrhea prevention campaign in rural Kenya. PLoS ONE, 5(8), e12435.

Lule, J.R., Mermin, J., Ekwaru, J.P., Malamba, S., Downing, R., Ransom, R., Nakanjako, D., Wafula,

W., Hughes, P., Bunnell, R., Kaharuza, F., Coutinho, A., Kigozi, A., & Quick, R. (2005). Effect of home-based water chlorination and safe storage on diarrhea among persons with human immunodeficiency virus in Uganda. American Journal of Tropical Medicine and Hygiene, 73:5, 926-933.

Sheth, A.N., Russo, E.T., Menon, M., Wannemuehler, K., Weinger, M., Kudzala, A.C., Tauzie, B.,

Masuku, H.D., Msowoya, T.E. & Quick, R. (2010). Impact of Integration of Water Treatment and Handwashing Incentives with Antenatal Services in Hygiene Practices of Pregnant Women in Malawi. American Journal of Hygiene and Tropical Medicine, 83(6), 1315-1321.

Tillekeratne, L.G., Thielman, N.M., Kiwera, R.A., Chu, H.Y., Kaale, L., Morpeth, S.C., Ostermann, J.,

Mtweve, S.P., Shao, J.F., Bartlett, J.A. & Crump, J.A. (2009). Morbidity and mortality among a cohort of HIV-infected adults in a programme for community home-based care, in the Kilimanjaro Region of Tanzania (2003–2005). Annals of Tropical Medicine & Parasitology, 103 (3): 263–273.

UNICEF& WHO. (2009). Diarrhoea: Why children are still dying and what can be done. Available at:

http://www.who.int/child_adolescent_health/documents/9789241598415/en/index.html. UNICEF, USAID, World Bank & Water Supply and Sanitation Collaborative Council. (2004). Hygiene

Improvement Framework: A Comprehensive Approach for Preventing Childhood Diarrhea. Available at: http://www.ehproject.org/PDF/Joint_Publications/JP008-HIF.pdf.

WHO. (2004). Global estimates of environmental burden of disease - 2004 data. Available at:

http://www.who.int/quantifying_ehimpacts/global/envrf2004/en/index.html.

WHO. (2008). Essential prevention and care interventions for adults and adolescents living with HIV in resource-limited settings. Geneva, Switzerland. Available at: http://www.who.int/hiv/pub/guidelines/EP/en/index.html.

WHO. (2011a). World Health Assembly Resolution 64.15. Chlora: mechanism for control and

prevention. Available at: http://apps.who.int/gb/ebwha/pdf_files/WHA64/A64_R15-en.pdf. WHO. (2011b). World Health Assembly Resolution 64.24. Drinking-water, sanitation and health.

Available at: http://apps.who.int/gb/ebwha/pdf_files/WHA64/A64_R24-en.pdf. WHO. (2011c). Evaluating household water treatment options: Health based targets and

microbiological performance specifications. Geneva, Switzerland. Available at: http://www.who.int/water_sanitation_health/publications/2011/evaluating_water_treatment.pdf.

Annex 1 – Final programme

Annual Meeting of the

International Network on Household Water Treatment and Safe Storage

3 October 2011 University of North Carolina, USA

Revised Agenda

Schedule

9:00-9:05 Opening Remarks UNICEF/WHO

9:05-9:30 Meeting overview and Network update M Forson, UNICEF M Montgomery, WHO

R Rowe, UNC 9:30-10:30 National HWTS Policies, Integration and Scaling Up Moderator: Maggie Montgomery, WHO

Update from East Africa regional workshop J Kariuki, MoPH&S Kenya

Integrating HWTS with other health interventions R Quick, CDC

Benefits of integration-examples from around the globe G Allgood, P&G

Presentations followed by discussion led by moderator on key issues presented. 10:30-10:45 Coffee Break 10:45-12:15 Strengthening HWTS monitoring and evaluation and targeted interventions Moderator: Michael Forson, UNICEF

UNICEF/WHO HWTS M&E Toolkit D Lantagne, Harvard University HWTS Yearbook C Vousvouras, 300in6 Predicting impact of HWTS K Nelson, UC Berkeley

Presentations followed by discussion led by moderator on key M&E issues.

12:15-13:15 Lunch 13:15-14:15 HWTS: Successes, failures and the way forward-Roundtable discussion Moderator: Jamie Bartram, UNC

Integrating and scaling up HWTS N Garg, Vestergaard-Frandsen

Market approach to HWTS G Austin, PATH

Challenges in sustaining HWTS use H-J Mosler, Eawag

HWTS as a component of comprehensive WASH R Rainey, USAID

Each participant will speak for 5 minutes, followed by a discussion led by the moderator.

14:15-15:45 Reconstituted working groups and break-out sessions Evidence base strengthened/knowledge advancement WHO National policies developed/ policy and advocacy WHO Tangible results in scaling up/capacity building UNICEF Best practices evaluated and disseminated/monitoring UNICEF

WHO and UNICEF will introduce working groups and co-conveners (where appropriate) followed by break-out sessions. Working groups will be given template and asked to draft 2011/2012 workplan.

15:15-15:45 Coffee Break (working break, take coffee as needed) 15:45-16:30 HWTS Evaluation criteria and international/national schemes Moderator: Maggie Montgomery, WHO

Health-based targets and guiding principles M Sobsey, UNC

J Brown, LSHTM Next steps and implementation Discussion, All

16:30-17:00 Recap and looking ahead

Presentation of 2011/2012 workplan Working group co-conveners Closing remarks M Forson, UNICEF

M Montgomery, WHO 18:00-19:00 Happy Hour Back Bar, Top of the Hill

(downtown Chapel Hill)

Annex 2 – List of participants

Name Organisation

1 Henk Holtslag 300in6 2 Christian Vousvouras 300in6 3 Paul Osborn 300in6 4 Sjef Ernes Aqua for All 5 Michael Gately Aquatabs 6 Laura McLaughlin Cascade Designs 7 Chris Schulz CDM 8 Laura Schuelert Centre for Affordable Water & Sanitation Technology 9 Michael Ritter Deep Springs International

10 Valerie Cavin Eawag 11 Hans Mosler Eawag 12 Samina Panwhar Emory University 13 Camille Saade FHI 360 14 Ansley Lemons FHI 360 15 John G. Kariuki Government of Kenya 16 Michael Opere GTZ 17 Jeff Williams HaloSource 18 Daniele Lantagne Harvard University 19 Shaila Arman International Centre for Diarrhoeal Disease Research, Bangladesh 20 Tom Clasen London School of Hygiene & Tropical Medicine 21 Rebecca Psutka London School of Hygiene & Tropical Medicine 22 Sarah Singer Matrix Solutions 23 Candice Young-Rojanschi McGill University 24 Kyle Enger Michigan State 25 Erick Toledo Millennium Water Alliance 26 Ishwar Devkota North Carolina Dept. of Health and Human Services 27 Nikki Beetsch NSF International 28 Tom Mahin Oxfam America 29 Glenn Austin PATH 30 Pat Lennon PATH 31 Lorelei Goodyear PATH 32 Muleegata Plan USA 33 Katharine McHugh Population Services International 34 Reynaldo Diaz Potters for Peace 35 Peter Chartman Potters for Peace 36 Michael Robeson ProCleanse 37 Steve Ade ProCleanse 38 Greg Allgood Procter & Gamble 39 David Wilcox ReachScale 40 Regu P. Regunathan Regunathan & Associates 41 Carolina Avendano Rice University

42 Tracy Hawkins Safe Water NOW 43 Reid Harvey Silver Ceramic Systems 44 Fang Xu SJTU China 45 Jessica Husson Solar Solutions 46 Frank Husson Solar Solutions 47 Mark Vann TrueWater International 48 Deepak Saksena Unilever 49 Michael Forson United Nations Children's Fund 50 Rochelle Rainey United States Agency for International Development 51 John Dracup University of California, Berkeley 52 Ben Mann University of Maryland 53 Joe Eisenberg University of Michigan 54 Jamie Bartram University of North Carolina at Chapel Hill 55 Ryan Rowe University of North Carolina at Chapel Hill 56 Edema Ojomo University of North Carolina at Chapel Hill 57 Georgia Kayser University of North Carolina at Chapel Hill 58 Katie Camille Friedman University of North Carolina at Chapel Hill 59 Mark Elliott University of North Carolina at Chapel Hill 60 Maura Allaire University of North Carolina at Chapel Hill 61 Meghan Arnold University of Utah 62 Natasha Potgieter University of Venda, South Africa 63 Rob Quick US Centers for Disease Control 64 Nathan Hernandez US Department of State 65 Navneet Garg Vestergaard-Frandsen 66 Peter Bernstorff Vestergaard-Frandsen 67 Sanne Fournier-Wendes Vestergaard-Frandsen 68 Mark Toy Washington Department of Health 69 Ron Denham Water and Sanitation Rotarian Action Group 70 Nancy Gilbert Water and Sanitation Rotarian Action Group 71 Diana Reimers WaterLives 72 Geoff Revell WaterSHED 73 Kaida Liang WaterSHED 74 Daniel Powell WaterSHED 75 Maggie Montgomery World Health Organization 76 Sean Kerrigan World Vision 77 Laura Sima Yale University 78 Jim McGill 79 Asaduz Zaman

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

Annex 3 – List of presentations

Network Update, by Maggie Montgomery – WHO

Predicting the Health Impact of HWT, by Kara Nelson – University of California, Berkeley

Integrating Household Water Treatment and Storage into Health Services: Rationale, Examples from the Field, and Lessons Learned, by Rob Quick – CDC

Benefits of Integration of HWTS into School, HIV/AIDS, WASH and Nutrition Programs, by Greg Allgood – Procter & Gamble

Integrated household water treatment efforts in Kenya and the East Africa Region, by John Kariuki – Ministry of Public Health & Sanitation Kenya

The HWTS M&E Toolkit: Work-to-date and Way Forward, by Daniele Lantagne

The 2011 household- and community water treatment and safe storage yearbook, by Christian Vousvouras – 300in6

These presentations are available by download from the Network’s event website at: http://waterinstitute.unc.edu/hwts.

Annex 4 – Work plan templates for Working Groups

The International Network on Household Water Treatment and Safe Storage

2011/2012 Work plan

Working group__________________

Name and Organization___________________________

Instructions

Please use this time to brainstorm and strategize within your working group the key activities and outputs for 2011/2012. The co-conveners of your group will present this at the conclusion of the meeting today.

Background

The International Network on Household Water Treatment and Safe Storage (the Network)'s mission of “contribute to a significant reduction in water-borne and water-related vector-borne diseases, especially among vulnerable populations, by promoting household water treatment and safe storage as a key component of community-targeted environmental health programmes” is supported by activities carried out by the four, reconstituted working groups (1) knowledge advancement, (2) policy and advocacy, (3) capacity building and (4) monitoring. Each working group will develop a workplan with input and guidance from the Network Secretariat.

Key needs working group will address: Realistic actions working group will undertake to address needs:

- 19 -

Specific Work plan

Activity Who (person/organization) Output When Reporting and accessing progress

International Network on Household Water Treatment and Safe Storage

January – September 2011 Update Page 20

International Network on Household Water Treatment and Safe StorageSummary of Progress January 2011-September 201111

Overview

The purpose of the International Network on Household Water Treatment and Safe Storage ("the Network) as described in its Phase II (2011-2016) strategy is to contribute to a significant reduction in water-borne and water-related vector-borne diseases, especially among vulnerable populations, by promoting household water treatment and safe storage as a key component of community-targeted environmental health programmes. The Network includes those international, governmental and non-governmental organizations, private sector entities and academia that subscribe to the above mission. The four main areas of Network activity are: research, implementation and scaling up, creating an enabling environment, and monitoring and evaluation. The expectation and roles of the Network co-hosts, the World Health Organization and the United Nations Children Fund, participating organizations, and the University of North Carolina which manages external communications, are clearly defined in the Phase II Strategy.12

Snapshot of activities and progress

The major activities of the initial period of Phase II (January 2011-September 2011) are summarized in the table on the following page. In addition, the table includes proposed activities for the coming year. These will be further updated and refined with input from the Advisory Group, Public-Private Partnership Group and Working Groups.

The major highlights of the initial period of Phase II of the Network include:

Strengthening of governance structure, including finalizing co-hosting arrangements between WHO and UNICEF and establishing the Advisory Group and Public-Private Partnership Group;

Convening East Africa regional workshop on national strategies and integrating HWTS into environmental health interventions;

Expanded communication portals and regular newsletter, listserve exchange and webinars; Publication of various reports, technical documents and information sheets (refer to pg. 3).

Challenges Ahead

The Network has now matured beyond Phase I, which devoted considerable effort to raising awareness about the need for HWTS and various HWTS methods. Phase II requires that Network participating organizations think and act more strategically about effective implementation and achieving scale. Possible avenues to achieve this scale include integration within public health campaigns, more systematic consideration in drinking-water quality improvement activities and through commercial or semi-commercial ventures. In order to meet these future challenges, the Network will require additional funding, meaningful contributions from Network participating organizations in-line with the Phase II Strategy, and continued efforts to improve the sharing of information, resources, and learning among all Network stakeholders.

11 In February 2011, the Network released a full year update, available at: http://waterinstitute.unc.edu/files/other.NetworkProgressReport2011.pdf. 12 See publication list for full reference and link to Phase II Network Strategy.

International Network on Household Water Treatment and Safe Storage

January – September 2011 Update Page 21

Area of Work Objectives Completed Activities (Jan-Sept 2011)

Outputs/Results Proposed Activities (Sept 2011- Sept 2012)

Coordination (Secretariat)

-Provide leadership in addressing objectives outlined in Phase II Strategy

-Convene and facilitate stakeholder discussions and action on HWTS

-Sought participant feedback on Phase II Strategy -Formalized co-hosting arrangements between WHO and UNICEF -Strengthened governance of Network

-Revised Phase II Strategy -Convened East Africa workshop on integrated interventions and national HWTS strategies -Establishment of Advisory Group, Public/Private Partnership Group and Working Groups -Annual Network meeting

-Network Annual Report with inputs from participating organizations -Ongoing support to East Africa action plans -Regional workshops (e.g. West Africa) -Working group work-plan implementation -Annual Network meeting (place, TBD) -Development of funding strategy

Communication -Effectively disseminate information regarding the Network and HWTS related activities -Provide interactive exchange and learning among participants

-Establishment and/or strengthening of communication (EZCollab, Newsletters, Listserv, update of websites, webinars) -Survey of current participating organizations

-Doubled listserv subscribers, increased Network geographic reach -Produced two meeting reports & eight newsletters -Coordinated two webinars -Established comms portal -Collected data on participants -94 members on EZCollab

-Online posting of newsletters (see publications) -Summary of participating organizations -Establishment of Network logo, brand and external website -Create listserv archive

Advocacy and Policy

-Raise awareness within the WASH, public health, and development sectors regarding HWTS -Generate support for HWTS activities

-Coordination of East Africa workshop (see above) -Inclusion of Network policy targets in World Water Forum (WWF) 2012 -Inclusion of HWTS in World Health Assembly Resolutions

-HWTS national action plans (Ethiopia, Kenya, Rwanda, Tanzania, Uganda) -East Africa workhop report (see publications)

-Development of advocacy sheets (e.g. integration of HWTS, HWTS and HIVAIDS, HWTS best practices in the field) -Global survey of HWTS policies -Participating organization contribute to WWF 2012 HWTS "solutions"

Guidance and Tools

-Provide evidence-based recommendations and tools for HWTS and public health stakeholders

-Additional review and revisions to evaluating HWT document -Review of best practices for monitoring and evaluation

-Published document (see publications) -Draft monitoring and evaluation HWTS toolkit; in revision (see publications)

-Workshop on implementation of criteria in Lao (and others as identified) -Explore possibilities of international evaluation scheme

Learning and Research

-Share best practices among Network participants and support active learning

-Webinars (Evidence to action, Monitoring and evaluation) -Support to HWTS protocols in Nepal and Afghanistan

-Enhanced understanding on webinar topics gained through global exchange -Webinar summary (see publications)

-Webinars (e.g. best practices in sustaining HWTS, behaviour change) -Disseminate national protocol results -Compile/disseminate "best practices" in implementing/sustaining HWTS

International Network on Household Water Treatment and Safe Storage

January – September 2011 Update Page 22

Recent publications and reports Water Institute at the University of North Carolina at Chapel Hill, WHO, & UNICEF, 2011. East Africa Regional workshop report (Final draft in progress, 2011). Water Institute at the University of North Carolina at Chapel Hill, 2011. General Meeting of the International Network for Household Water Treatment and Safe Storage: Summary Report. January, 2011. Chapel Hill, USA. Water Institute at the University of North Carolina at Chapel Hill, 2011. Evaluating household water treatment: from evidence to action - Summary Report. April, 2011. Chapel Hill, USA. International Network on Household Water Treatment and Safe Storage Newsletter Archives http://waterinstitute.unc.edu/hwts/newsletter WHO, 2011. Combined household water treatment and indoor air pollution projects in urban Mambanda, Cameroon and rural, Nyanza, Kenya. February 2011. Geneva, Switzerland. http://www.who.int/household_water/resources/HWTSIndoorAirV3.pdf WHO, 2011. Draft monitoring and evaluation for household water treatment and safe storage programs, toolkit and recommendations. April, 2011. Geneva, Switzerland. (Currently under revision in collaboration with UNICEF; joint publication for release in 2012). WHO, 2011. Evaluating household water treatment options: Health based targets and microbiological performance specifications. June 2011. Geneva, Switzerland. http://www.who.int/water_sanitation_health/publications/2011/household_water/en/index.html WHO, 2011. Information sheet for government and policy-makers on evaluation household water treatment options. July 2011. Geneva, Switzerland. http://www.who.int/household_water/resources/EvaluatingHWT_forGovt.pdf WHO, 2011. Strategic consultation on household water treatment and safe storage. June 2011. Geneva, Switzerland. WHO/HSE/WSH/11.06. http://www.who.int/household_water/resources/consultreportV4.pdf WHO & UNICEF. International Network on Household Water Treatment and Safe Storage, Strategy. Revised March 2011, Geneva, Switzerland. http://www.who.int/household_water/resources/NetworkStrategyMar2011.pdf Lantagne, D. & Clasen, T. (2010). Project Report: Assessing the Sustained Uptake Of Selected Point-of-Use Water Treatment Methods In Emergency Setting. London School of Hygiene and Tropical Medicine. London, UK. (Commissioned by UNICEF) Lantagne, D. & Clasen, T. (2011). Project Report: Assessing the Implementation of selected household water treatment and safe storage (HWTS) methods in emergency settings. London School of Hygiene and Tropical Medicine, London, UK (Commissioned by UNICEF and OXFAM GB)