Water safety Water safety frameworks in frameworks in

developing developing countries: countries:

science-policy science-policy linkageslinkagesDr Guy Howard, DFIDDr Guy Howard, DFID

Policy and sciencePolicy and science

Policy requires evidence – the role of Policy requires evidence – the role of sciencescience

BUT BUT other factors – social, ethical, other factors – social, ethical, political also importantpolitical also important

SO SO policy often policy often evidence-informed evidence-informed rather than rather than evidence-basedevidence-based

Policy works through formal and Policy works through formal and informal processes informal processes don’t get fixated on policy documentsdon’t get fixated on policy documents

Policy and science – fraught Policy and science – fraught with mis-understandingwith mis-understanding

Scientists think policy-makers do not Scientists think policy-makers do not follow evidencefollow evidence

Policy-makers think scientists Policy-makers think scientists narrow techniciansnarrow technicians

Further complicated when science isFurther complicated when science is Limited in its development in-countryLimited in its development in-country Small number of ‘voices’ dominateSmall number of ‘voices’ dominate Limited operational research of policy Limited operational research of policy

relevancerelevance

Water safety framework – Water safety framework – science and policy in actionscience and policy in actionWater safety framework comprises Water safety framework comprises

(WHO 2004):(WHO 2004): Health-based targetsHealth-based targets Water safety plansWater safety plans SurveillanceSurveillance

Driven by improving public healthDriven by improving public health Also Also allows transparent trade-offs allows transparent trade-offs Applied in BangladeshApplied in Bangladesh

Health-based Health-based targets and targets and

quantitative risk quantitative risk assessmentassessment

Bangladesh contextBangladesh context

In early 1990s reached 97% coverage In early 1990s reached 97% coverage in rural areas (WHO & Unicef 2000) – in rural areas (WHO & Unicef 2000) – contribution to reduced diarrhoeacontribution to reduced diarrhoea

1993 arsenic first detected1993 arsenic first detected Survey (1999-2000) indicates 27% Survey (1999-2000) indicates 27%

tubewells >50tubewells >50µg/l and 46% >10 µg/l µg/l and 46% >10 µg/l (BGS& DPHE 2001)(BGS& DPHE 2001)

Blanket testing shows 29% > Blanket testing shows 29% > 5050µg/l µg/l (about 20% of country total)(about 20% of country total)

Policy contextPolicy context

Technologies identified for use in Technologies identified for use in mitigation mitigation Dug wells Dug wells Rainwater harvesters Rainwater harvesters Pond sand filters Pond sand filters Deep tubewells Deep tubewells Arsenic-removal technologiesArsenic-removal technologies

Surface water use prioritisedSurface water use prioritised Priority given to 1Priority given to 1stst 3 technologies 3 technologies

Others only to be used when these failedOthers only to be used when these failed

Risk substitutionRisk substitution

These policy choices equate to ‘Specified These policy choices equate to ‘Specified technology Health-based targets’technology Health-based targets’

BUTBUT no consideration given to risk no consideration given to risk substitutionsubstitution PathogensPathogens Cynaobacterial toxinsCynaobacterial toxins Other chemicals (natural or anthropogenic)Other chemicals (natural or anthropogenic)

QHRA undertaken to estimate impact QHRA undertaken to estimate impact of these risks and benefits of policy of these risks and benefits of policy choiceschoices

RAAMO method RAAMO method (abbreviated)(abbreviated)

Representative set of main technologies tested Representative set of main technologies tested monsoon & dry season using cluster samplingmonsoon & dry season using cluster sampling

Model developed with output in DALYs for Model developed with output in DALYs for microbial & arsenic risksmicrobial & arsenic risks

3 ‘reference’ pathogens 3 ‘reference’ pathogens Composite model bacteria, cryptosporidium and Composite model bacteria, cryptosporidium and

rotavirusrotavirus Input data from indicator organisms - derived Input data from indicator organisms - derived

relationships to pathogensrelationships to pathogens Arsenic disease burden input data direct Arsenic disease burden input data direct

arsenic measurement and focus on main arsenic measurement and focus on main health outcomeshealth outcomes

Infection withRotavirus, Shigella,

Cryptosporidium

Volume ofwater consumedunboiled locally

[Pathogen] in sewage

Dose of pathogens

[E. coli] in sewage

Ratio[pathogen]:[E. coli]

Ratio[TTC]:[E. coli]

Measured[Arsenic]for option

Measured[TTC]

for option

Predicted[E. coli]

for option

Predicted[pathogen]for option

Cancer of lung, bladder and skin

Measured[TTC]locally

Measured[E. coli]locally

Disease Burden for option

Inputs to or outputs from

the model

Model process steps

Model architecture (Howard et al Model architecture (Howard et al 2007)2007)

Results: Microbial DALYsResults: Microbial DALYs

TechnologyTechnology Dry seasonDry season Monsoon Monsoon seasonseason

Dug wellDug well 1.111.11-2-2 1.341.34-2-2

Deep Deep tubewelltubewell

6.986.98-5-5 1.261.26-3-3

Pond sand Pond sand filterfilter

1.071.07-2-2 1.31.3-2-2

Rainwater Rainwater harvesterharvester

6.486.48-3-3 3.733.73-3-3

0.01

0.1

1

10

100

1000

10000D

W(d

)

DW

(w)

DTW

(d)

DTW

(w)

PS

F(d)

PS

F(w

)

RW

HS

(d)

RW

HS

(w)

STW

Arsenic Mitigation Options

Ars

enic

DA

LY

, 1

0^-6

LCL Median UCL

Results: arsenic DALYsResults: arsenic DALYs

WHO reference level of WHO reference level of riskrisk

GDWQ suggests reference levels of GDWQ suggests reference levels of risk can be used in setting health-risk can be used in setting health-based targetsbased targets

Suggested 10Suggested 10-6-6 DALYs – broadly DALYs – broadly equivalent to 10equivalent to 10-5-5 lifetime cancer risk lifetime cancer risk used in chemical guideline derivationused in chemical guideline derivation

Conceptually elegant, but poses Conceptually elegant, but poses practical problems practical problems E.g real-life considerations of impact of E.g real-life considerations of impact of

diarrhoea & cancerdiarrhoea & cancer

RAAMO findings RAAMO findings reference riskreference risk

Microbial contaminants Microbial contaminants Reference risk not achievable for any Reference risk not achievable for any

technologies year-roundtechnologies year-round Arsenic standard already much higher Arsenic standard already much higher

DALY score than WHO reference riskDALY score than WHO reference risk Not clear how useful the concept of Not clear how useful the concept of

‘reference risk’ is in such ‘reference risk’ is in such circumstancescircumstances

Better to use comparative measures & Better to use comparative measures & aim for best achievable resultaim for best achievable result

Changes in practice & Changes in practice & policypolicy

Chlorination on dug wells and PSFs Chlorination on dug wells and PSFs increasingly standard – overcame previous increasingly standard – overcame previous resistanceresistance

Led to re-emphasis by implementing Led to re-emphasis by implementing agencies on technologies with lower health agencies on technologies with lower health riskrisk

Review of National Policy and Review of National Policy and Implementation Plan now initiatedImplementation Plan now initiated

Water safety Water safety plans and plans and

surveillancesurveillance

Water safety plansWater safety plans

Identified as critical to improving Identified as critical to improving water safety from RAAMOwater safety from RAAMO

O&M failures particularly highlighted O&M failures particularly highlighted in relation to microbial qualityin relation to microbial quality

In principle agreement by all major In principle agreement by all major players that should be followedplayers that should be followed

BUT needed locally relevant WSPs with BUT needed locally relevant WSPs with evidence in-country of their evidence in-country of their effectivenesseffectiveness

The process that was The process that was followedfollowed

National conference on water quality National conference on water quality Government, donors & NGOs agree need Government, donors & NGOs agree need

for pilot projects for pilot projects Workshop to develop a set of draft Workshop to develop a set of draft

WSPs for rural technologiesWSPs for rural technologies Govt, donors, NGOs involvedGovt, donors, NGOs involved

Pilot projects to apply WSPs Pilot projects to apply WSPs Consolidation of experience and Consolidation of experience and

revision of WSPsrevision of WSPs

Developing the WSPsDeveloping the WSPs

Generic WSPs Generic WSPs developeddeveloped Cover all water Cover all water

supplies with supplies with particular particular technologytechnology

Developed using Developed using proformas & proformas & existing knowledge existing knowledge and experienceand experience

Systematic Systematic assessment of: assessment of: hazards, hazards, degree of risk, degree of risk, control measures, control measures, monitoring, monitoring, validation and validation and verificationverification

Actions plans Actions plans developeddeveloped

Technologies consideredTechnologies considered

Protected dug Protected dug wellswells

Pond sand filtersPond sand filters Rainwater Rainwater

harvestersharvesters Deep tubewellsDeep tubewells Shallow Shallow

tubewellstubewells

Piped systemsPiped systems From tubewellFrom tubewell From surface From surface

water after multi-water after multi-stage filtrationstage filtration

Gravity-fed Gravity-fed (minor)(minor)

LaterLater Arsenic removal Arsenic removal

systemssystems

Pilot projectsPilot projects

3 NGOs covering 82 communities 3 NGOs covering 82 communities across Bangladesh (also Unicef/GoB)across Bangladesh (also Unicef/GoB)

Every major technology addressedEvery major technology addressed Baseline, intermediate and final Baseline, intermediate and final

water quality assessments water quality assessments undertakenundertaken

Community caretakers supported Community caretakers supported with pictorial monitoring toolswith pictorial monitoring tools

Key findingsKey findings

Reductions in sanitary risks for all Reductions in sanitary risks for all technologiestechnologies

Microbial quality improvedMicrobial quality improved Water handling hygiene practices Water handling hygiene practices

improved improved 12% reduction in diarrhoeal disease 12% reduction in diarrhoeal disease

in one pilot projectin one pilot project Greater caretaker accountabilityGreater caretaker accountability Pictorial tools found usefulPictorial tools found useful

0

10

20

30

40

50

60

70

80

90

Baseline Final

Sanitary risk category (%)

Low

Medium

High

Water quality risk grading Water quality risk grading schemescheme

Count per Count per 100ml100ml

CategoryCategory CommentsComments

00 AA Very low riskVery low risk

1-101-10 BB Low riskLow risk

11-10011-100 CC Intermediate riskIntermediate risk

101-1000101-1000 DD High riskHigh risk

>1000>1000 EE Very high riskVery high risk

0

5

10

15

20

25

30

35

40

45

50

Baseline Final

Dug wells: water quality

Low & v.low

Medium

High & v.high

0

10

20

30

40

50

60

70

80

90

100

Covered & elevevated Covered

Water handling hygiene

Baseline

Final

Evidence to practiceEvidence to practice

All major water rural programmes All major water rural programmes committed to WSPscommitted to WSPs

Moved into 2Moved into 2ndnd edition – regular edition – regular interactionsinteractions

Capacity support offered via ITN-Capacity support offered via ITN-BUET (training, consultancy)BUET (training, consultancy)

See See www.buet.ac.bd/itnwww.buet.ac.bd/itn

Key lessonsKey lessons

Bangladesh showed possible to get Bangladesh showed possible to get wide stakeholder buy-inwide stakeholder buy-in

Important to get all major players Important to get all major players agreed on single set of products and agreed on single set of products and approachesapproaches

Need to develop more standardised Need to develop more standardised approachesapproaches More cost-effectiveMore cost-effective Consistency and coherenceConsistency and coherence

SurveillanceSurveillance

Surveillance protocol developed and Surveillance protocol developed and approved by GoBapproved by GoB

Limited but practicalLimited but practical Emphasis on cost-effective survey Emphasis on cost-effective survey

methodsmethods Very difficult to implementVery difficult to implement

Funding for monitoring scarce and Funding for monitoring scarce and veryvery limitedlimited

Implications and Implications and conclusionsconclusions

ImplicationsImplications

RAAMO & WSPs showed could get RAAMO & WSPs showed could get change in policy and practicechange in policy and practice

BUTBUT also highlighted informal as also highlighted informal as well as formal policy processeswell as formal policy processes Formal policies relative recent so no Formal policies relative recent so no

immediate change likelyimmediate change likely Water & Sanitation Program now Water & Sanitation Program now

leading process of formal policy leading process of formal policy reviewreview

Future challengesFuture challenges

Climate change and impacts on Climate change and impacts on water supply and sanitationwater supply and sanitation

DFID/WHO funding joint work DFID/WHO funding joint work Decadal forecasting to 2020 and 2030Decadal forecasting to 2020 and 2030 Assessment of technology susceptibilityAssessment of technology susceptibility

Focus on ‘hotpsots’ and longer-term Focus on ‘hotpsots’ and longer-term policy implicationspolicy implications

ConclusionsConclusions

Bangladesh water safety frameworkBangladesh water safety framework Good illustration of policy-science Good illustration of policy-science

interactionsinteractions Uncertainty could be managed provided Uncertainty could be managed provided

transparent and quantifiedtransparent and quantified Evidence based practice importantEvidence based practice important Highlighted value of informal as well as Highlighted value of informal as well as

formal policy processesformal policy processes This type of approach needs wider This type of approach needs wider

replicationsreplications