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    IPA Kenya Maseno Conference IPA Kenya Maseno Conference Presentation Transcript

    • School-Based Public HealthInterventions and Educational Outcomes Wilson Odero MD, PhDSchool of Public Health & Community Development IPAK-Maseno University Policy Workshop July 14, 2011 Kisumu Hotel
    • OutlineReview of conceptsRelationship between health and academic performanceEvidence from literatureExamples of public health interventionsConclusions
    • What is Health?• A state of complete physical, social and mental well-being, and not merely the absence of disease or infirmity (WHO) • Health is regarded as a fundamental human right and all people should have access to basic health care (Ch 4;sec 43(1) Constitution of Kenya)
    • Public Health• Public health - is a scientific, social and political concept aimed at improving health, prolonging life and improving the quality of life through health promotion, disease prevention and other forms of health intervention: • is concerned with the overall health of a community • Focuses on prevention rather than treatment of diseases
    • Quality of Life• Quality of life is a multidimensional concept which encompasses 5 dimensions: • physical wellbeing • social wellbeing • emotional wellbeing • material wellbeing • development and activity
    • Health Promotion and School Health • Health promotion is the process of enabling people to increase control over, and to improve, their health. • Health promotion is not just the responsibility of the health sector, but involves all sectors that contribute to human development, especially the education sector. • School health programs comprise all activities in the school environment aimed at promoting and maintaining the health and development of students • Schools provide a unique opportunity to influence students’ health and their educational achievement
    • Health and Academic performance• Health and learning are interdependent: • Children who are malnourished, sick and tired tend to have trouble in learning and performing well in class; • Conversely, cognition, concentration and cooperation are enhanced when students are healthier • children who do poorly in school may have more health risks, which adversely affect their learning.• Academic performance of children impacts on their future health, educational attainment, career choices, income, social status and quality of life
    • Education and Health“Good education predicts good health.” • More formal education is associated with lower death rates. • The less schooling people have, the higher their levels of risky behaviours such as smoking, alcohol abuse, being overweight, or having a low level of physical activity. • School completion rate can be a useful measure of educational attainment • Interventions that reduce school dropouts by improving the health of students can improve educational attainment Molla M. et al., 2004; Lantz PM. et al., 1998.
    • Specific public health interventionsand resources can positively affect both student health and academic achievement.
    • Public Health Interventions Public health measures administered at various stages ofhuman development improve school attendance, enhance childhood learning and contribute to improved academic performance
    • Examples of public health interventions1. Prenatal period – to prevent infections and improve fetal development  ANC services  Vaccinations – tetanus toxoid  Prophylactic treatment – IPT for placental malaria (using SP), ARVs (Nevirapine) for HIV  Iron/ folate supplementation - to prevent anaemia; Vitamin A – to prevent eye infections  Prevention of infections – ITNs to prevent malaria2. Early childhood (under 5s)  Vaccinations – BCG, measles, polio, HBV, etc.  Nutrition – exclusive breastfeeding for 6 months  Prevention of infections – use of ITNs
    • 3. Late childhood: School-based health  Personal hygiene: promote and support hand washing and general cleanliness  Sanitation – use of toilets, provision of sanitary towels  Diet/food practices – nutritional services, school feeding program, milk, fruits, etc  Prophylactic treatment – periodic deworming,
    •  Physical activity – increased PE classes and extracurricular physical activities Psychological support - counseling to reduce delinquent behaviour, tobacco, alcohol and drug use Health education and hygiene – part of the curriculum Road safety education – part of the school curriculum Health care services – early diagnosis and treatment
    • Some evidence on the positiverelationship between school-based health programs and academic performance
    • Some evidence --- from LiteratureA. Diet and Nutrition  undernourished children have decreased school attendance, less attention, and lower academic performance, and also experience more health problems compared to well- nourished children Taras H. 2005; Galal & Hulett, 2003; Kretchmer et al., 1996; Meyers et al., 1991
    • B. Sexual behaviours:  students who do not engage in sexual risk behaviors receive higher grades than their classmates who do engage in sexual risk behaviors.  students with higher grades are less likely to engage in sexual risk behaviors than their classmates with lower grades, CDC (2010). Sexual Risk Behaviors and Academic Achievement.
    • C. Physical activity:  In addition to the known positive health impacts, there is evidence that physical activity in schools may help improve academic performance CDC (2010). The association between school based physical activity, including physical education, and academic performance.
    • D. Water and Sanitation • In schools with access to water and sanitation facilities, teachers engage pupils frequently on discussions about health; this promotes teaching and learning thus increasing student’s chances of excelling in their academics. • Pupils who study in schools that provide water and soap are more likely to wash hands than those in schools that do not have the facilities. • Healthy schools improve national academic performance. African Population and Health Research Center, 2011
    • Conclusions• Health and education are intricately linked.• Health risks can affect academic success.• Public health interventions can improve health, learning and academic performance.• Comprehensive and coordinated school health programs that address policy issues, curriculum content and implementation, and health services are needed to improve educational outcomes.
    • Some Questions• What are the limitations in the current knowledge and research on the association between public health measures and academic performance?• How can academicians be involved in translating the research findings on school health into policy?
    • Thanks
    • Worms at Work: Long-run Impacts of Child Health Gains July 14, 2011 Kisumu Hotel, Maseno University Presented by: Prof. Edward Miguel, Ph.D. University of California, Berkeley
    • The Impact of Public Health Investments• Advocates argue that child public health investments generate high returns through improved adult living standards.• Optimal subsidies for public health depend on both the direct and externality, or spillover, impacts.• But it is challenging to estimate causal impacts: – Some studies show that adult health affects productivity, but child health could also affect education, occupational choice. – Panel datasets that track children into adulthood are rare. – Isolating the impact of child health is difficult (confounding). – Few studies are set up to measure treatment externalities.Kisumu-7/2011 Worms at Work 23
    • The Case of Deworming• 1 in 4 people worldwide are infected by intestinal worms – hookworm, whipworm, roundworm, schistosomiasis – with high rates in Africa, especially among school-age children.• Worms cause anemia, stunting, lethargy.• Broader Impacts on immune system, malaria? – Kirwan et al (2010) on deworming in Nigeria.• Inexpensive, infrequent and safe treatment, but costly diagnosis  WHO support for mass school-based treatment in high prevalence regions, like most of Kenya.Kisumu-7/2011 Worms at Work 24
    • ICS Primary School Deworming Project• 75 rural primary schools in Busia, Kenya (30,000 children aged 6-18), with deworming treatment phased in over three years (25 schools at a time).• Over 90 percent worm infection rates at baseline (S. Brooker, A. Luoba, et al. 2000, East African Medical Journal).• List randomization of phase-in: Group 1 (starting in 1998), Group 2 (1999), Group 3 (2001). – Due to the design, on average the groups are similar in all ways but one: the intervention.• In 2001, cost-sharing in half of Group 1 and 2 schools. Take up 75% with free treatment free; 18% with cost-sharing.• The program ended in 2003.Kisumu-7/2011 Worms at Work 25
    • Kisumu-7/2011 Worms at Work 26
    • Short-Run Impacts of School Deworming• After one year of deworming, rates of serious worm infections were 25% in the treated schools versus 52% in untreated.• Significant gains in height, self-reported health.• School absence fell by one quarter (7 percentage points).• Reduced re-infection and school absence among other community members, including: – Untreated children in treatment schools; children in other schools within 6 km.• Accounting for spillovers, the cost per year of increased school participation was only US$3.50.Kisumu-7/2011 Worms at Work 27
    • Long-Run Impacts: Data and Measurement• Kenya Life Panel Survey, KLPS (1998-2009): a representative sample of 7,530 people from the deworming sample.• By the 2007-2009 survey round, most were 20-26 years old.• 85% effective tracking rate among those still alive.• Differences in deworming treatment: 2.5 years of additional child deworming in Groups 1 and 2, versus Group 3.Kisumu-7/2011 Worms at Work 28
    • Long-Run Impacts: Health and Education• Self-reported health status is significantly better (p<0.05); no significant change in height or body mass index (BMI).• On average, the total time enrolled in school between 1998 and 2008 rose by 0.3 years in the deworming treatment group (p<0.05), and test scores also improved by 0.1 s.d. (p<0.10).• More grade repetition, but not grade completion.Kisumu-7/2011 Worms at Work 29
    • Long-run Economic Impacts• As adults, individuals in the treatment group ate 0.1 more meals / day (p<0.01), and there are externalities: their neighbors also ate 0.08 more meals/day (p<0.01).• Deworming beneficiaries work longer hours: hours rose 12% (1.76 hours, p<0.10) in the full sample, and among both wage earners and the self-employed (p<0.05). -- In a decomposition, the effects are concentrated among those with positive hours (2.4 hours per week, p<0.05).Kisumu-7/2011 Worms at Work 30
    • Disaggregating the Economic Impacts• Examine effects among wage earners, self-employed, and farmers. There are no large shifts between these groups.• Strongest effects among wage earners: – Work hours rise 12%, or 5.2 more hours per week (p<0.10) – 0.5 fewer work days missed per month due to poor health (p<0.05). – Total earnings in the past month rose 29% (p<0.01). – Men triple employment in manufacturing (9 p.p., p<0.01). – Women: less casual labor, domestic work (17 p.p., p=0.11)Kisumu-7/2011 Worms at Work 31
    • Kisumu-7/2011 Worms at Work 32
    • Kisumu-7/2011 Worms at Work 33
    • Long-run Impacts among Self-Employed• Some positive effects among the self-employed: – Suggestive positive point estimates on self-reported and constructed profits, and total employees hired – Combining these variables, the mean effect size is 0.175 standard deviation units (p<0.05)• Few estimated impacts in agricultural production.• Challenging to measure productivity in this sector: • Measurement error? • Individual versus family production? • Differential impact across sectors?Kisumu-7/2011 Worms at Work 34
    • Evidence of Externalities• Positive, large and statistically significant local spillovers in terms of both meals eaten (0.080, p<0.01) and labor supply for those with positive hours (2.75 hours/week, p<0.05).• Deworming creates an estimated 20% increase in labor earnings for wage earners within 6 km of treatment schools (p=0.2).Kisumu-7/2011 Worms at Work 35
    • The Economic Returns to Deworming• Benefits: – Higher earnings in the treatment group, plus spillovers. – Gains for those not earning wages; other health benefits• Costs: – (i) deworming pills and delivery (plus deadweight loss of raising government revenue); – (ii) opportunity cost of time spent in school and not working• Depends on assumptions, but estimated social financial internal rate of return is 74.1% per year, treating the increased hours worked as a gain in endowment.• Externality benefits alone justify full subsidies for school- based deworming. E.g., 2009 Kenyan national program.Kisumu-7/2011 Worms at Work 36
    • Kisumu-7/2011 Worms at Work 37
    • Kenya’s National School-Based Deworming ProgrammeDr. Charles Mwandawiro Karen Levy Assistant Director, Regional Director, Deworm the World KEMRI Initiative
    • Background: The National School Health Policy and Guidelines• Signed and launched in May 2009• Policy developed by Ministry of Education, Ministry of Public Health and Sanitation, various partners and stakeholders.• The policy provides: – A legal framework – Clear cut leadership for ownership and sustainability – A guide to program implementation
    • National School Health PolicySchool-based mass deworming adopted as aneffective preventative and treatmentmeasure; policy instructs that:“Treatment shall be administered to allschool-age children, including those outof school, based on the prevalence andintensity of worms and bilharzias in thearea.” - GoK Nat’l School Health Policy, p. 32
    • Roles under the National School Health Policy Ministry of Education: main coordinating body; chairs National Inter-Agency Committee “Will coordinate all aspects of the implementation of all health related activities within schools” Ministry of Public Health: technical support; chairs National Technical Committee “Will provide integrated curative, preventive and promotive health services”
    • Geographic Targeting• Scientific basis for targeting mass treatment • Increases efficiency and effectiveness of program • Helps to explain resource allocation choices to local and national leaders and politicians
    • Worm Prevalence vs. Population Density(information from Dr. Simon Brooker, KEMRI-Wellcome Trust) Three areas of high prevalence: Coast; Western/Nyanza; parts of Eastern/Central 43
    • Map of Phase I Coverage
    • IPA’s Deworm the World Initiative Implementing School- Based Deworming in Kenya • Policy development • Operational support • Catalytic funding • PR and advocacy • Technical assistance (direct and indirect)
    • Using existing infrastructure and personnel 46
    • Training Roll-Out 47
    • Training Materials 48
    • Engaging Stakeholders
    • Engaging Stakeholders• Programme Launched at KEMRI• Press Conference attended by Ministers, Assistant Ministers, Permanent Secretaries of both ministries• Covered by print media, television, and numerous radio stations 50
    • Engaging Stakeholders:Deworming day press coverage 51
    • Technical Support: M&E 52
    • Partnership and Collaboration MoE Others MoPHSDtW, PCD, Deworming other Programme KEMRI- partners ESACIPAC JICA, World KEMRI- Bank, other Wellcome donors Trust
    • Achievements• Roll-out of Phase I successfully reached all 45 targeted districts• Over 1,000 district and division personnel trained (MoE, MoPHS, KEMRI)• Over 16,000 teachers trained Over 3.6 million children in over 8,200 schools were dewormed! 54
    • The National School-Based Deworming Programme: Improving the Health and Education of Kenya’s Children 55
    • Prof. JR Aluoch Professor of Medicine &Dean, School of Medicine Maseno University
    •  Around the World in 80 Days by Jules Verne According to the Guinness Book of Records, the longest time a human has survived without water is 18 days. In 1981 a series of prisoners in Northern Ireland went on hunger strike. They joined the protest in stages. Ten of them died. The numbers of days the ten who died lasted were ..... 46 59 60 61 61 61 62 66 71 73
    •  Less than 1% of the world’s water is accessible to direct human use (WHO) More than half the of the poor in the developing world are ill from causes related to hygiene, sanitation and water supply (Water Supply and Sanitation Collaborative Council [WSSCC], 2008) 37% of people in Sub-Saharan Africa do not use improved sources of drinking water (WHO and UNICEF 2010 Joint Monitoring Programme [JMP]) 3.575 million people die each year from water related diseases (WHO)
    •  Unsafe sanitation and drinking water account for at least 7% of the total global disease burden 43% of water related deaths are due to diarrhea (WHO 2008) 88% of cases of diarrhea worldwide are attributable to unsafe water, poor sanitation and insufficient hygiene (WSSCC, 2008) 98% of water-related deaths occur in the developing world (WHO, 2008)
    •  At any given time half of the world’s hospital beds are occupied by patients suffering from water- related preventable diseases (2006 UNHDR) Children in poor environments often carry 1,000 parasitic worms in their bodies at any time (water.org) About 4,500 children die each day from unsafe water and lack of basic sanitation facilities, countless others suffer from poor health, diminished productivity and missed opportunities for education (water.org)
    •  In 2006, only 57% of Kenyans had access to improved drinking water, and only 42% had access to improved sanitation facilities (USAID) Under age 5 mortality rate due to diarrheal disease (2000) was 16.5% (USAID) Over 50% of hospital visits in Kenya are for illnesses related to water, sanitation and hygiene (USAID) Ensuring access to clean water for human consumption and use is mandatory.
    • Innovation for Poverty Action (IPA) Conference: “Real World Impact of Applied Research: A Focus on New Approaches in Health Policy” Kisumu, July the 14th 2011 PROMOTER MONITORING AND INCENTIVES RESEARCH Celine GratadourTeam:Principal Investigators in the US: Amrita Ahuja, Vivian Hoffman, Michael KremerField Officers in Bungoma: Miriam Wekesa, Nettah Isavwa, Esther Avedi, Martha Mukwana,Valentine Bwire, James Mamadi, Ben Wekesa, Titian Korir, Benjamin Watako, Maureen Akinyi,Kevin Kayando, Norman Isavwa, Michael Omollo, Godwin Munialo, Stephen Okubo, BerylAchando, Sheila Libese, John Kudoyi.
    • Chlorine Dispenser SystemDispenser Hardware Bulk Chlorine Refills Local Promoter
    • Chlorine Dispenser SystemDispenser Hardware Local Promoter Bulk Chlorine Refills
    • Previous work on chlorine dispensers Adoption of Chlorination: Communities with Dispenser versus Control% of households with chlorinated water 3 weeks 6 mths 30 mths • Chlorine dispenser: a significant impact on chlorine adoption (8% in control villages versus 61% in villages with a dispenser); • This figure persists across time within communities; • But, there are significant variation across communities; the chlorine take-up rate varies from 30% to 90%; • Promoter and promoter-community relationship seems to be important;  Assumption: The way the promoter is selected, incentivized and monitored matters.
    • PMI Research Questions• If we focus on the Promoter, many questions need to be addressed as regards: – 1/Promoter`s selection: • Does the method of selection matter? • In particular, if hand vote or secret ballot is used for the selection, does it affect the type of promoter elected? – 2/Promoter`s Incentives: • How should Promoters be incentivized? • Monetary versus Non-Monetary payments? • Flat-fee versus Performance-based payment?
    • PMI Research Questions– 3/Announcement of Incentives before or after the selection: • If we announce the incentive before the selection, does it affect the number and type of candidates?– 4/Promoter`s Monitoring: • Does monitoring matter? • Who is the best person for monitoring the Promoter`s work? (Community members? Village elder?)
    • PMI Study Methodology• Randomized Control Trial: – 220 water sources randomly selected in Bungoma South and Bungoma East District; – 220 chlorine dispensers installed with some variations on Promoter`s selection, Incentives and Monitoring• Key outcomes: – Share of Households with chlorine in their water at surprise visit; – Share of Dispenser spot checks on which dispenser contains chlorine; – Household Knowledge as regards the chlorine dispenser; – Household Opinion as regards the work of the Promoter
    • PMI Timeline• July-August 2010 – Meeting with DC, DO, Chief, Assistant Chief – Identification of all villages in Bungoma East (445) and Bungoma South (272)• October-November 2010 – Random Selection of 40% of villages-Bungoma East (174) and Bungoma South (100); – Meeting with village elders and selection of the main water source used for collecting drinking water in each village;• December 2010 – Pilot of PMI survey instruments and interventions
    • PMI Timeline• January 2011: – Notification of assistant chiefs and village elders;• Mid February –Mid April 2011: – Organization of 220 community meetings (community members education, selection and training of the promoter)• Mid May –End June 2011: – 3 Months follow-up survey-20 Households surveyed + Promoter – Objective: to collect information on how many Households are using chlorine to treat their water? How many Households know the promoter? Is there chlorine in the dispenser?...• Mid July – End July 2011: – Promoter Appreciation Gift payment and Promoter Survey• Next August 2011: Monitoring by Phone• Next Fall 2011: 7 months Follow-up survey• Next February 2012: 12 Months Follow-up survey
    • PMI Preliminary Results• Promoter`s selection (hand vote versus secret ballot) – More often only one candidate when election by hand vote versus secret ballot; – More often, this “unique” candidate had, by the past, some people sick in his/her family (cholera, typhoid, …);• When the announcement of incentives is made before the selection: – … candidates who stand are older; – … more women stand and win the selection; – … more candidates who stand used chlorine by the past; – … candidates who win and become the promoter have a higher level of education;• When the incentives is based on performance: – … more women stand and win the election
    • PMI Challenges• 1/Difficult to get the right information on the water source  Is it the main water source in the village? How many households are using it?• 2/Difficult to mobilize community members for the meeting  Need to involve more people in the village as Community Health Workers, Teachers, …• 3/Introduction of Lifestraws by VF  2 new technologies whose objectives is for community members to get safe water  Confusion for community members … need to give more information• 4/Difficult to change behaviors  “I don`t like the taste of chlorine”, “My husband does not like the taste”, “My water is safe to drink, why should I use chlorine?” …  Need to give more messages / information? Target also the husband in the household?
    • Community-Financed Dispensers project (CFD)Vivian Hoffmann, Clair Null, Olga Rostapshova, Renaud Lapeyre Bumula district, Western Rachuonyo South district, Nyanza “Lipia Dawa kwa Maisha!”
    • Context• New paradigms emerge so as to promote participation, bottom-up and community-based approaches, incl. in the health and water sector• Over the past two decades, the GoK has pursued a policy of cost-sharing in the health sector• Some critics arose as the policy could have become a barrier to utilization and adoption by the poor and most vulnerable.Where do we stand now in terms of research evidence in order to advise policy makerswhether to promote or not cost-sharing in theprovision of local public goods, e.g. health and water services?
    • Research questions1) Is cost-sharing resulting in ownership effect?2) Is cost-sharing resulting in sunk-cost effect?3) Is cost-sharing resulting in selection effect?4) What are the factors that determine community capacity/willingness to raise money collectively?5) How can one foster community collection of money?
    • The project• The CFD project is installing chlorine dispensers at drinking water sources for use by the surrounding community (excl. privately used water points)• The community of users pays for the up- front payment of the dispenser device and in addition pays for the on-going cost of chlorine refills (both at subsidized prices)
    • The project pilot• 26 dispensers were to be installed in May-June 2010 (Bumula district): 4 for free, 12 proposed at a subsidized price• Upfront payment: 7 dispensers at 500Ksh and 5 dispensers at 30Ksh per each household• Payment for refills: Half sources were to organize an harambee every 3 months while half were to go and buy regularly at the nearby duka• Threat mechanism: 8 portable dispensers (rental agreement) versus 18 permanent dispensers (owned by the community)• Compliance mechanism: 5 dispensers were equipped with boards where were written names of contributors and non contributors• All communities elected a fund-raising community and were provided with a receipt book and a contributor signatures’ log book
    • Pilot preliminary resultsUP-FRONT PAYMENT OF THE DISPENSER• All free dispensers were installed while 11 out 12 subsidized dispensers were paid for by communities (92% success)• Average community contribution for subsidized dispensers was 1,180Ksh (1600Ksh with equal contribution)• Average number of contributors was 54 people per source
    • Pilot preliminary results (Cont.) ON-GOING PAYMENT FOR THE CHLORINE REFILLS • No harambee was ever organized, though chlorine was still bought • Names’ lists were rapidly abandoned • After 12 months: - 41% of permanent dispensers (11 out of 17) has no chlorine in the tank at spot check whereas only 12,5% of portable dispensers have no chlorine in the tank (1/8). - 21,4% of free dispensers have empty tanks while 45% of subsidized dispensers have no chlorine in the tank. • Overall, community contribution to chlorine refills has decreased since January: 88% had chlorine in the tank End of January, 84% End March and 60% End of May
    • Challenges• Accountability/transparency of money collection and use by fundraising members• Incentives for members in charge of money collection and of the smooth running of the project (fundraising committee + promoter)• Clear understanding by village members of the project and its rules (payment, threat)• High variation in the number of users between rainy and dry season (rain water catchment vs free-riders from neighbouring villages)• Complementarity/substitution issues with the distribution of LifeStraw Family filters in Western
    • The way forward• Main study in Rachuonyo South: 100 dispensers to be installed.• Test further the ownership effect (free vs subsidy) and the threat effect (portable dispenser)• Test the factors that determine willingness to contribute at the household level• Baseline and installation before End of the year, follow-up End 2012 THANK YOU!
    • Taking Chlorine Dispensers to Scale Eric Kouskalis104 14 July 2011
    • Diarrhoeal Disease in Western Kenya Diarrhoeal Disease by Province 30 25 20 2-week prevalence 15 10 5 0 Coast Western Nyanza North Rift Valley Eastern Central Nairobi Eastern• Diarrhoeal disease is the #1 cause of child deaths in Kenya, and the share of child deathscaused by diarrhoea increased from 2000 to 2008• Half of the child deaths in Kenya occur in Western and Nyanza Provinces 105
    • Combating Diarrhoeal DiseaseChlorinating drinking water reduces diarrhoea 41%However, less than 10% of rural households use chlorine treatment 106
    • Potential for Impact In Western and Nyanza, 7 million people could benefit Over 10 years: 32m diarrhoea cases averted 31,000 lives saved107
    • Scaling Up with PartnersFour types of partners have deployed ~790 chlorine dispensers to reach ~150,000 people MoE MoPHS Local Governments Water Services BoardPartners DEOs of Busia, DHMTs of Busia, Busia County LVNWSB Nambale, Butula, Namable, Council, Busia Mumias Kakamega Central, Municipal Council, East, South, and Mumias Municipal Vihiga CouncilOperational model 33 schools with 16 health facilities Circuit rider Promoters pick-up dispensers each managing and chlorine delivery to chlorine from local overseeing and supplying 10 water points chemists supplying satellite dispensers through dispensers at community health nearby community workers water points# of dispensers 227 160* 57 15Est. people served 60,000 24,000 9,500 2,000 108
    • Ministry of EducationThirty three schools have a school-based dispenser and dispensers at each communalwater point in their catchment areas• Student “Safe Water Champions” help local promoters ensure that dispensers are functioning• Schools support community outreach and education efforts through students, SMC• Chlorine is delivered in bulk to schools, where it is kept until needed in communities• Ensures students are drinking safe water at home and at school 109
    • Lake Victoria North Water Services BoardCommunities in the Busia, Butula and Funyula areas are served by LVNWSB dispensers• Dispensers become integrated into source improvement projects• Community Water Users Associations manage, refill, and maintain dispensers• A chlorine supply is made available via a local retail chemist 110
    • Local AuthoritiesThree local authorities offer chlorine dispenser services to their constituents• Busia Municipality, Mumias Municipality, Busia County• Installation and ongoing chlorine delivery are contracted out by the local authorities• Chlorine delivered directly to sites by “circuit riders” on motorcycles 111
    • International PilotsPilots have begun in other countries to test the viability of chlorine dispensers in newcontexts• Ethiopia - Relief Society of the Tigray (ReST)• Swaziland - Nazarene Compassionate Ministries (NCM)• Bangladesh - International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B)• India - International Development Enterprises (IDE)• Haiti - Deep Springs International (DSI) 112
    • Chlorine DispensersLinking Rural Water Safety toHealth Facilities in Busia District. Ambrose Fwamba District Public Health Officer Ministry of Public Health and Sanitation 14July 2011
    • Introduction• Partnership between MoPHS-Busia District and Innovations for Poverty Action (IPA) to provide community level drinking water treatment through CHW managed chlorine dispensers
    • Goal: Reduce Waterborne Illness• Waterborne illness is a major problem in Busia district• Diarrhea was the leading cause of sickness for children under five in Busia district in 2009, with 9,427 cases of diarrhea seen by health facilities• Busia is vulnerable to cholera outbreaks, with the most recent outbreak occurring in 2008
    • New Water Safety Plan:CHW Managed Chlorine Dispensers Integrate dispensers into community health system
    • Dispenser Program Overview Launched in September 2010 Five Facilities: Matayos Health Centre Busibwabo Dispensary Lupida Health Centre Madende Dispensary Khayo Dispensary 50 water sources 25% of dispenser appropriate communal water sources 10,000+ peopleFive dispenser clusters (facilities are yellow)
    • Implementation through CHWsCHW Dispenser Duties (1 hour/week):• Educate the community about child health, waterborne illnesses, and dispenser usage• Top up the chlorine tank monthly with bulk refills from health facility• Provide updates to CHEWs on household adoption, refill frequency, dispenser promotion activities, and hardware condition
    • Chlorine Distribution Through Health Facilities• Chlorine refills are delivered to the health facility in bulk• The CHEW distributes refills to the CHWs: – 1 Dispenser per CHW – 10 CHWs per facility• CHWs top up the dispenser tank at their home water source each month
    • Preliminary Evaluation Results • 481 respondents were randomly surveyed from 48 different water pointsChlorine with dispensersAdoption • ~45% of respondents’ stored drinking water tested positive for residual chlorine • Although the community education meetings were well attended several community members were not sensitized about the dispenserPromotion – ~35% of respondents attended the first meeting – ~30% of respondents did not attend the first meeting and no-one had spoken with them about the dispenser • In general the CHWs have been more active in encouraging dispenser usage than the PromotersCHWs and – ~70% of respondents report that the CHW spoke with them about thePromoters dispenser compared to ~25% for the Promoter – Although 40% said they speak with the CHW 1-2 time per month there is room for more outreach since ~30% of respondents said they have never spoken with the CHW
    • Chlorine dispensers haveimproved health in nearbycommunities, so my village isvery excited to get a dispenserat our water source. Thedispenser makes treatingwater convenient and helpseveryone remember to usechlorine.-Karoli Samuel Ekesa,Community Health WorkerKhayo Dispensary
    • Child diarrhea is one of the mostcommon illnesses this healthfacility handles. Preventingdiarrhea through chlorination atwater sources will give my staffmore time to focus on patientswith other illnesses such as HIVand malaria. It will also savemoney for the facility and thepatients, since prevention is muchcheaper than treatment.-Syphrine WaswaDivisional Public Health OfficerMatayos Health Centre
    • Thank youJames Simiyu, Busia District Ag. DPHO