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In recent years, much focus has been put on the sustainability of water and sanitation development projects. Experts in this field have found that many of the projects of the past have failed to achieve sustainability because of a lack of demand for water and sanitation interventions at a grassroots level. For years projects looked to create this demand through various subsidy schemes, with the "software" of behavior change and education taking a backseat to the "hardware" of infrastructure provision. Community-Led Total Sanitation (CLTS) is a fairly new way of looking at the issues of increasing basic sanitation coverage, promoting good hygiene practices, and facilitating the change in behaviors that is necessary for a level of basic sanitation coverage to be sustained for any significant length of time. CLTS looks to get people to come to the realization that open defecation is dangerous, and that they have to power to stop this practice. The purpose of this research study was to assess the water, sanitation, and hygiene situation on the ground in villages that through CLTS have achieved open defecation free (ODF) status in the Mopti region of Mali, West Africa. This assessment was done through a willingness-to-pay study, that showed how important sanitation infrastructure was in the daily lives of villagers in this region of Mali. This research study also examines any possible correlations between certain socioeconomic data and willingness-to-pay. A questionnaire was developed and completed with 95 household heads spread across 6 of the 21 ODF villages in the region. The results of this research study show that the behavior change brought about by CLTS was sustained. Every household in the study had at least one latrine (total latrines = 186), or had access to a neighbor's latrine because theirs had recently collapsed. Of these latrines 82.3% were reported as meeting the Malian nation government requirements of basic sanitation. 89.3% of the observed latrines were built by the participant families themselves using predominately materials that could be found in or harvested from the local environment (e.g., mud, rocks, sticks). Fifty-three percent of the latrines were built completely free of cost, and of the 88 latrines that were paid for in part or in whole the average cost was about US $13.00. The majority of the participants (64.2%) in the research study reported making improvements and maintaining their latrines, clearly showing the importance of sanitation infrastructure in the 6 study villages. The average cost of this maintenance was about US $1.50. Alongside of willingness-to-pay data, more qualitative data were collected on the relative importance of sanitation infrastructure in the daily lives of people in ODF villages in Mopti. This study found that on average throughout the 6 study villages, about 13% of discretionary funds are saved for or spent on maintenance and improvements to sanitation infrastructure on a monthly basis. When sanitation infrastructure investments were compared with other infrastructure and livelihood investments, on the average it was ranked 7th out of the possible 10. These data seem to indicate that future investment in sanitation infrastructure was not a high priority for the participants. This could be stem from the fact that many of the participants had not directly experienced the need for continued investments, because their original latrines were still functional. The willingness-to-pay regression analysis produced very few statistically valid results. Only a few of the correlations found between willingness-to-pay data and socioeconomic characteristics of the sample were found to be statistically valid. For example, the correlation coefficient between willingness-to-pay for pit maintenance, including emptying when full or covering the pit with top soil, digging a new one, and reconstruction, and education level of the participants was about 1.2 and was statistically valid with a t-statistic of about 2.2. Indicating that the more educated a participant was, the more they would be willing to pay for pit maintenance. None of the overall regressions explained enough of the variability in willingness-to-pay data to be considered statistically valid. Regressions for two scenarios, constructing a cement slab as an improvement to an existing latrine and sealing/lining the pit on an existing latrine with cement, explained 10.3% and 10.4% of the variability in willingness-to-pay data respectively. However, this did not meet the minimum criteria of 15%. While the willingness-to-pay data would have been useful to study partners that are piloting a Sanitation Marketing program in Mali, the main research objective of assessing the CLTS intervention was still met.

The provision of a basic water supply and sanitation service to the 12 million South Africans without an adequate water supply and the 21 million without basic sanitation is a mammoth task that is currently being undertaken by the Department of Water Affairs and Forestry. Billions of rands have been spent on, and committed to, water and sanitation projects that involve national, provincial and local spheres of government, as well as parastatals, non-government organisations and private developers. It is acknowledged that important successes have been achieved in the water and sanitation sector. However, despite the provisions provided in national and local legislation, internationally lauded policy directives, the numerous studies undertaken and recommendations made by institutions such as the Water Research Commission, problems have continued to emerge in the sustainable delivery of water and sanitation projects, particularly in the peri-urban and rural areas. It is clear that the installation of physical structures such as pipes, taps and ventilated improved pit latrines in these areas have created a sense of 'delivery' however, little thought seems to have gone into how these projects are to be sustained. International experience has shown that the concept of 'community ownership' is very important in providing sustainable water and sanitation services. The most important principles in achieving sustainability are community participation and community decision-making throughout both the development of the project as well as the further operation and maintenance of the system. International experience has also shown that financial contributions towards the scheme from the community (in cash, labour or materials), also assists in obtaining community ownership. Over the past decade emphasis in South Africa has shifted towards community participation and the empowerment of previously disadvantaged communities where communities play an active role in determining the level of service provided and the manner in which these services are delivered. However, current government policy advocates that water must be treated as an economic resource to achieve sustainability and this does not always lie comfortably with the policy of delivering free basic water. As a result of these two often-juxtaposed concepts, the delivery of sustainable water and sanitation services, a function performed by local government, is thus made more difficult. This study assesses the importance of delivering a potable water supply and adequate sanitation service to enhance the quality of lives of people. It also considers the key issues that contribute towards sustainable water and sanitation service delivery, with particular reference to the concept of 'community ownership'. The complex nature of the policy, legislative and institutional framework for water supply and sanitation is considered along with an analysis of the Msunduzi Municipality's water supply and sanitation policy and objectives. The study then focuses on the delivery of water and sanitation services to one such project, Edendale Unit RR (commonly known as Newtown), as an in-situ upgrade case study. A Provincial Housing Board funded project has, over the last five years, provided housing units, roads, stormwater drains, and water and sanitation infrastructure to this community. This initial research is undertaken with the intention of providing an evaluation of the installation of the water supply and sanitation service to the in-situ upgrade of Newtown. / Thesis (M.Sc.)-University of Natal, Pietermaritzburg, 2003.

The aim of this study was to assess the environmental sanitation conditions with regard to water, sanitation, waste management and personal hygiene of households of Dukem town in Ethiopia. A cross-sectional study design was used to conduct the research. A total of 391 households had participated in the study. Majority of households had access to improved source of drinking water. The mean per capita per day water consumption of the households was low. Two-thirds of households had improved toilet facilities. Availability of improved waste management was grossly inadequate. Two-thirds of households had washed hands after visiting toilet. Generally households had good domestic environmental sanitation conditions but it also emerged that the households were deprived from full range of access to the most essential environmental sanitation services. Therefore, the inadequate level of service to the study area could be seen as opportunity for further focused improvements towards universal access to improved environmental sanitation. / Health Studies / M.A. (Public Health)

INTRODUÇÃO: As doenças relacionadas ao saneamento ambiental inadequado (DRSAI) continuam presentes em áreas metropolitanas no Brasil. OBJETIVO: Analisar as hospitalizações por DRSAI na rede pública da região metropolitana de Porto Alegre (RMPA)/RS de 2010 a 2014. MÉTODOS: Análise das hospitalizações com diagnóstico principal dos códigos CID-10 correspondente às DRSAI a partir do Sistema de Informações Hospitalares SIH/SUS, disponíveis publicamente. RESULTADOS: Do total de 13.929 hospitalizações por DRSAI de residentes na RMPA, no período de 2010 a 2014, a maioria relaciona-se às doenças de transmissão feco-oral como diagnóstico principal. Dentre as internações, o maior número (20,4%) corresponde ao de crianças de 1 a 4 anos de idade (28,1 hospitalizações/10.000 hab./ano). As internações por 10.000hab./ano variam de 1,4 em Glorinha e Nova Santa Rita a 27,6, em Triunfo. A taxa de letalidade hospitalar pode ser avaliada como baixa, pois a cada 100 internações ocorrem 2,2 óbitos, mas se considerarmos que esse tipo de doença é evitável e que não deveria gerar internação temos um número expressivo. Dentre as causas de óbito segundo CID-10, as mais frequentes foram as doenças de transmissão feco-oral. A utilização de UTI atingiu 2,0% (284), cujo destaque foram as hospitalizações por leptospirose, com uso de UTI em 13,2%. O gasto total com as internações foi cerca de R$ 6,1 milhões. O valor médio de internação mais elevado foi no município de Viamão (R$ 626,82) e o mais baixo em Alvorada (R$ 258,36). Entre todos os municípios da RMPA, São Sebastião do Caí foi o município com maior percentual (100%) de internações dos próprios residentes no total de internações por DRSAI. CONCLUSÃO: Ainda hoje as DRSAI são um importante problema para saúde pública e, por meio de trabalhos como este, é possível mapear a situação para promoção de ações para seu devido enfrentamento e melhor alocação de recursos. / INTRODUCTION: Diseases Related to Inadequate Environmental Sanitation (DRSAI, in Portuguese) still represent a burden in metropolitan areas in Brazil. OBJECTIVE: To analyze the hospitalizations for DRSAI in the public health network of the Metropolitan Region of Porto Alegre (MRPA)/RS during 2010-2014. METHODS: Analysis of hospitalizations with primary diagnosis of ICD-10 codes corresponding at DRSAI of a national public hospitalization basis (SIH / SUS). RESULTS: We found 13,929 hospitalizations for DRSAI of the MRPA´s residents during 2010-2014, most related to feco-oral transmission diseases as first-listed diagnosis. The largest number (20.4%) among the admissions corresponded to children 1 to 4 years old (28.1 hospitalizations / 10,000 inh/year). The admissions (10.000 inh/year) ranged from 1.4 in Glorinha and Nova Santa Rita up to 27.6 in Triunfo. The hospital mortality rate was low, for each 100 admissions deaths occur in 2.2, but if we consider that this kind of disease is preventable and should not generate hospitalization, it may represent a significant number. Among death causes according to ICD-10, feco-oral transmission disease was the most frequent. Use of Intensive Care Unity (ICU) reached 284 hospitalizations (2.0%) and Leptospirosis with ICU use was the highest (13.2%). Total expenditure on hospital admissions was approximately R$ 6.1 million. The average hospital stay cost was higher in Viamão (R $ 626.82) and lowest in Alvorada (R$ 258.36). Among all municipalities of MRPA, Sao Sebastião do Cai had the highest percentage (100%) of admissions of residents own a total of hospitalizations for DRSAI. CONCLUSIONS: DRSAIs are still today a major problem for public health, and that through research like this, it´s possible to map the situation for promoting actions for their proper coping and better resource allocation.

Dissertation submitted in partial fulfilment of the requirements for the degree Master of Technology: Business Administration in Project Management in the Faculty of Business at the Cape Peninsula University of Technology 2014 / This research seeks to investigate the relationship between the use of Operational Research (OR) tools or techniques or the lack thereof, and the possible impact on decision-making amongst management of the City of Cape Town’s (CoCT) Water and Sanitation Department (WSD) and its impact on service delivery. The CoCT is the municipality, which governs the city of Cape Town, its suburbs and exurbs, and falls under the South African local government sphere. The Department is responsible for ensuring water quality. WSD extracts and analyses water samples to identify bacteria or chemicals that may be present, whilst taking action to resolve problems when necessary. For actions to be taken to resolve problems, decisions are taken, and these decisions determine how problems are resolved to deliver quality services to the public on time and in a cost effective manner. OR is a scientific approach to managerial decision making which eliminates guesswork and emotions from decision making. OR is also described as a discipline that focuses on application of information technology for informed decision-making. The research question this study set out to answer is to what extent do managers at the CoCT’ s WSD use OR. It also seeks to discover the relationship between OR and decision-making, whether any relationship between decision-making at the WSD and service delivery exists, and whether there is any link between politics and decision making in the organisation. This research investigated the efficiency of current decision-making tools that are utilized at the WSD. A questionnaire was developed and used as a tool to acquire inputs to satisfy the research question. The analysed data lead to recommendations for the WSD to support and improve on its existing decision-making tools. This study is based on material that was collected from a wide range of journals, extending from regular OR literature to many application journals, articles and published books.

INTRODUÇÃO: As doenças relacionadas ao saneamento ambiental inadequado (DRSAI) continuam presentes em áreas metropolitanas no Brasil. OBJETIVO: Analisar as hospitalizações por DRSAI na rede pública da região metropolitana de Porto Alegre (RMPA)/RS de 2010 a 2014. MÉTODOS: Análise das hospitalizações com diagnóstico principal dos códigos CID-10 correspondente às DRSAI a partir do Sistema de Informações Hospitalares SIH/SUS, disponíveis publicamente. RESULTADOS: Do total de 13.929 hospitalizações por DRSAI de residentes na RMPA, no período de 2010 a 2014, a maioria relaciona-se às doenças de transmissão feco-oral como diagnóstico principal. Dentre as internações, o maior número (20,4%) corresponde ao de crianças de 1 a 4 anos de idade (28,1 hospitalizações/10.000 hab./ano). As internações por 10.000hab./ano variam de 1,4 em Glorinha e Nova Santa Rita a 27,6, em Triunfo. A taxa de letalidade hospitalar pode ser avaliada como baixa, pois a cada 100 internações ocorrem 2,2 óbitos, mas se considerarmos que esse tipo de doença é evitável e que não deveria gerar internação temos um número expressivo. Dentre as causas de óbito segundo CID-10, as mais frequentes foram as doenças de transmissão feco-oral. A utilização de UTI atingiu 2,0% (284), cujo destaque foram as hospitalizações por leptospirose, com uso de UTI em 13,2%. O gasto total com as internações foi cerca de R$ 6,1 milhões. O valor médio de internação mais elevado foi no município de Viamão (R$ 626,82) e o mais baixo em Alvorada (R$ 258,36). Entre todos os municípios da RMPA, São Sebastião do Caí foi o município com maior percentual (100%) de internações dos próprios residentes no total de internações por DRSAI. CONCLUSÃO: Ainda hoje as DRSAI são um importante problema para saúde pública e, por meio de trabalhos como este, é possível mapear a situação para promoção de ações para seu devido enfrentamento e melhor alocação de recursos. / INTRODUCTION: Diseases Related to Inadequate Environmental Sanitation (DRSAI, in Portuguese) still represent a burden in metropolitan areas in Brazil. OBJECTIVE: To analyze the hospitalizations for DRSAI in the public health network of the Metropolitan Region of Porto Alegre (MRPA)/RS during 2010-2014. METHODS: Analysis of hospitalizations with primary diagnosis of ICD-10 codes corresponding at DRSAI of a national public hospitalization basis (SIH / SUS). RESULTS: We found 13,929 hospitalizations for DRSAI of the MRPA´s residents during 2010-2014, most related to feco-oral transmission diseases as first-listed diagnosis. The largest number (20.4%) among the admissions corresponded to children 1 to 4 years old (28.1 hospitalizations / 10,000 inh/year). The admissions (10.000 inh/year) ranged from 1.4 in Glorinha and Nova Santa Rita up to 27.6 in Triunfo. The hospital mortality rate was low, for each 100 admissions deaths occur in 2.2, but if we consider that this kind of disease is preventable and should not generate hospitalization, it may represent a significant number. Among death causes according to ICD-10, feco-oral transmission disease was the most frequent. Use of Intensive Care Unity (ICU) reached 284 hospitalizations (2.0%) and Leptospirosis with ICU use was the highest (13.2%). Total expenditure on hospital admissions was approximately R$ 6.1 million. The average hospital stay cost was higher in Viamão (R $ 626.82) and lowest in Alvorada (R$ 258.36). Among all municipalities of MRPA, Sao Sebastião do Cai had the highest percentage (100%) of admissions of residents own a total of hospitalizations for DRSAI. CONCLUSIONS: DRSAIs are still today a major problem for public health, and that through research like this, it´s possible to map the situation for promoting actions for their proper coping and better resource allocation.

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No. of bitstreams: 1 Dissertação - Gabriela Araújo Romão - 2018.pdf: 1644925 bytes, checksum: 020bef250ff299f276aa266bdb7f7edf (MD5) Previous issue date: 2018-05-18 / Fundação de Amparo à Pesquisa do Estado de Goiás - FAPEG / This research aimed to analyse the public policy formulation regarding basic sanitation in municipalities of Goiás, based on the 9th article of Law no. 11,445/2007 and the 23rd article of Regulatory Decree no. 7,217/2010, in which seven principles are considered to be necessary for the city to formulate and sanction its Municipal Sanitation Policy. Considering the importance of answering whether such public policy was formulated based on federal law, three analysis were performed: the first one aimed at answering if the surveyed municipalities elaborated their Municipal Basic Sanitation Plans (MBSPs) considering the minimum content, which corresponds to the first principle required by law; The second one further analysed whether the other six principles were also considered and the third attempted to identify which difficulties were prevalent when formulating such policy, from the drafting process of the MBSP to sanctioning the Municipal Sanitation Law. The undertaken strategy in the present research was the comparative cases study, focusing on the municipalities of Pontalina, Itapirapuã, Terezópolis de Goiás, Mossâmedes and Uirapuru. Secondary data and semistructured interviews were used to collect data; a content analysis was carried out in order analyse such data. From this, it was concluded that the five surveyed municipalities formulated their Public Policy on Basic Sanitation respecting most of the requirements previously set out in the seven principles stated in the Federal Sanitation Law, which means that their plans were elaborated almost entirely according to the minimum content and the other six considered principles. Regarding difficulties, the main barriers reported by the governmental and non-governmental actors throughout the MBSP elaboration process were: a) the municipality does not participate in the formulation of the Federal Sanitation Policy; b) lack of qualified technical staff to elaborate the MBSP; c) changes in management team; among others. In relation to possible obstacles after the conclusion of the MBSP formulation, each municipality managed the basic sanitation in a specific way. In Pontalina, the plan was shelved; in Itapirapuã, priority was given to the construction of Water Treatment Plant and Sewage Treatment Plant, whereas Mossâmedes and Uirapuru sought to raise financial resources. Additionally, with regards to sanctioning the Municipal Sanitation Policy, only the municipalities of Mossâmedes and Uirapuru have already instituted it. / Esta pesquisa analisou a formulação da Política Pública de Saneamento Básico em municípios goianos, tendo como base o art. 9º da Lei nº 11.445/2007 e do art. 23º do Decreto de Regulamentação nº 7.217/2010, em que são apresentados sete preceitos necessários para o município formular e sancionar a sua Política Municipal de Saneamento. Considerando a importância de responder se a política foi formulada com base na lei federal, foram feitas três análises. A primeira, se os municípios pesquisados elaboraram os respectivos Planos Municipais de Saneamento Básico (PMSB’s) fundamentados no conteúdo mínimo, que corresponde ao primeiro preceito exigido em lei. O segundo, se os outros seis preceitos também foram considerados e o terceiro, tratou de identificar quais foram os dificultadores na formulação da política, desde a elaboração do PMSB até a sanção da Lei Municipal de Saneamento. A estratégia utilizada nesta pesquisa foi o estudo comparativo de casos, tendo como foco de trabalho os municípios de Pontalina, Itapirapuã, Terezópolis de Goiás, Mossâmedes e Uirapuru. Para a coleta de dados, foram utilizados dados secundários e entrevistas semiestruturadas. O tratamento ocorreu mediante análise de conteúdo. Os resultados apontaram que os cinco municípios formularam a sua Política Pública de Saneamento Básico respeitando a maior parte das exigências expostas nos sete preceitos da Lei Federal de Saneamento, isto é, os seus planos foram elaborados, quase que inteiramente, de acordo com o conteúdo mínimo e com os outros seis preceitos considerados. No que diz respeito aos dificultadores, os principais relatados pelos atores governamentais e não governamentais no processo de elaboração do PMSB foram: a) a não participação do município na formulação da Política Federal de Saneamento; b) corpo técnico não capacitado no município para elaborar o PMSB; c) a troca de gestão; entre outros. Em relação aos possíveis dificultadores após a conclusão do PMSB, cada município geriu o saneamento básico de maneira específica, ou seja, em Pontalina o plano foi engavetado, em Itapirapuã se priorizou a construção da Estação de Tratamento de Água (ETA) e Estação de Tratamento de Esgoto (ETE) e em Mossâmedes e Uirapuru, procurou-se angariar recursos financeiros. E no que diz respeito à sanção da Política Municipal de Saneamento, apenas os municípios de Mossâmedes e Uirapuru a instituíram.

Este trabalho investiga o efeito do saneamento sobre educação, ou seja, as consequências educacionais das crianças que apresentam estado de saúde debilitado por terem contraído Doenças Relacionadas ao Saneamento Ambiental Inadequado (DRSAI). Nesse sentido, condições de infraestrutura dos domicílios, expressas pela variável de acesso a saneamento básico, por impactar a saúde dos indivíduos, é mais um dos determinantes dos indicadores educacionais. A partir de dados municipais e distritais, o efeito do saneamento sobre educação foi obtido em duas etapas. Na primeira, utilizou-se dados por município do Censo Demográfico (IBGE), Censo Escolar (INEP), Sistema Nacional de Informações Sobre Saneamento (SNIS), entre outros, para anos 2000 e 2010, com o objetivo de avaliar o efeito do saneamento sobre educação. Na segunda etapa, verificou-se a hipótese que dá suporte ao efeito da etapa anterior: o efeito do saneamento sobre a saúde. Essa investigação foi realizada por meio de dados por distrito construídos a partir do Censo Demográfico do Universo por setor censitário (IBGE), Cadastro Nacional de Endereços para Fins Estatísticos (CNEFE, 2011), Diretório Nacional de Endereços (DNE, 2015) e Departamento de Informática do Sistema Único de Saúde (DATASUS, 2010). Ambas etapas fizeram uso de econometria espacial e não-espacial para estimação dos dois efeitos. Os resultados da primeira etapa indicam que o efeito do aumento de uma unidade percentual no acesso a saneamento está associado a um aumento de 0,11 pontos percentuais na taxa de frequência escolar, a uma queda de 0,31 pontos percentuais na taxa de distorção idade-série e a também uma queda de 0,12 pontos percentuais na taxa de abandono escolar. Os resultados da segunda etapa indicam que, em geral, o acesso aos serviços de saneamento inadequados causa impacto positivo na taxa de incidência de internações por DRSAI (por mil habitantes), a variável de saúde considerada nesse estudo. Para a população de todas as idades, o impacto total médio do aumento de 1% na parcela de domicílios servidos por água da chuva armazenada em cisterna ou caixa de cimento é 0,217 casos por mil habitantes. Quando se considera a porcentagem dos domicílios que tem banheiro conectado a uma fossa rudimentar, esse impacto é 0,035 casos por 1000 habitantes. Por outro lado, no que diz respeito à variável adequada de saneamento, o impacto total médio de 1% na porcentagem de domicílios particulares permanentes conectados à rede de distribuição de água e que, além disso, na quadra onde estão localizados é inexistente condições de esgoto a céu aberto é -0,166 casos por mil habitantes. A variável de maior impacto total médio refere-se à porcentagem de domicílios que não tem banheiro e, além disso, possuem presença de esgoto a céu aberto em suas condições de entorno. O aumento em uma unidade percentual nessa variável gera aumento de 3,281 na taxa de incidência de internações por DRSAI. Outro resultado desse estudo é que a população mais jovem é a mais atingida pelo acesso a condições inadequadas dos serviços de saneamento básico tanto em relação à saúde quanto à educação. Por fim, a recomendação de política pública apontou que, se fossem implementadas políticas de mitigação das condições inapropriadas de saneamento, iniciando por diminuir em um por cento a porcentagem de domicílios que não têm banheiro e estão expostos a condições de esgoto a céu aberto o setor público da saúde economizaria recursos num valor correspondente a 4,4% do gasto federal total investido por ano em saneamento. Dessa forma, essa política pode ser uma estratégia para acelerar as metas de universalização do acesso aos serviços de saneamento básico no Brasil. / This dissertation studies the effect of sanitation on education, in other words, the educational consequences for children whose health has been affected by Diseases Related to Inadequate Environmental Sanitation (DRIES). In this sense, infrastructure conditions of dwellings, expressed by the variable of access to basic sanitation, for impacting the health of individuals, is one of the determinants of educational indicators. The effect of sanitation on education was obtained in two steps, from municipality and district level data. At the first step, we applied data at municipality level, from the Population Census (IBGE), the School Census (INEP), the National Information System on Sanitation (SNIS), among others, for the years 2000 and 2010, with the goal of evaluating the effect of sanitation on education. At the second step, we analyzed the hypothesis that supports the effect of the previous step: the effect of sanitation on health. This analysis was conducted applying data at district level, which was constructed from the results from the universe of the Population Census (IBGE) by census tract, the National Register of Addresses for Statistical Purposes (CNEFE, 2011), the National Address Directory (DNE, 2015) and the Department of Informatics of the Unified Health System (DATASUS, 2010). Both steps made use of spatial and non-spatial econometrics techniques for estimating the two effects. The results of the first step indicate that the effect of one percentage increase in access to sanitation is associated with an increase of 0.11 percentage points in school attendance rate, a decrease of 0.31 percentage points in age-grade distortion rate, and also a decrease of 0.12 percentage points in the school dropout rate. The results of the second step indicate that, in general, access to inadequate sanitation services has a positive impact on the incidence of hospitalizations because of DRIES (per thousand inhabitants), the health variable considered in this study. For the population of all ages, the average total impact of a 1% increase in the share of dwellings served by rain water (stored in cisterns or cement tanks) is 0.217 cases per thousand inhabitants. Considering the percentage of dwellings with toilets connected to rudimentary cesspools, this impact is 0.035 cases per thousand inhabitants. On the other hand, with regard to the appropriate sanitation variable, the average total impact of 1% increase in the share of permanent dwellings connected to the water distribution network and whose block does not present open sewage conditions is -0.166 cases per thousand inhabitants. The variable with highest average total impact refers to the percentage of dwellings that have no toilet and, moreover, have the presence of open sewage in their surrounding conditions. The increase in a percentage unit in this variable generates an increase of 3.281 in the rate of incidence of hospitalizations because of DRIES. Another result of this study is that the younger population is the most affected by the poor conditions of access to basic sanitation services, both in terms of health on education. Finally, the public policy recommendations pointed out that, if the policies for mitigating inadequate sanitation conditions were implemented, starting with a one percentage decrease in the share of dwellings that do not have toilets and are exposed to open sewage, the health sector would save an amount corresponding to 4.4% of total federal spending invested annually in sanitation. Therefore, this policy can be a strategy to accelerate the targets for universal access to basic sanitation services in Brazil

Water, sanitation and hygiene-related diseases are responsible for 7% of all deaths and 8% of all disability adjusted live years (DALYs), as well as the loss of 320 million days of productivity in developing countries. Though laboratory and field trials have shown that household water treatment (HWT) technologies can quickly improve the microbiological quality of drinking water, questions remain about the effectiveness of these technologies under real-world conditions. Furthermore, the value that rural communities attach to HWT is unknown, and it is not clear why, in spite of the fact that rural African households need household water treatment (HWT) most, they are the least likely to use them. The primary objective of this multi-level study was to assess the post-implementation effectiveness of selected HWT technologies in the Nyanza and Western Provinces of Kenya. The study was carried out in the rainy season between March and May, 2011 using a mixed method approach. Evidence was collected in order to build a case of evidence of HWT effectiveness or ineffectiveness in a post-implementation context. A quasi-experimental design was used first to conduct a Knowledge, Attitudes and Practices (KAP) survey in 474 households in ten intervention and five control villages (Chapter 3). The survey assessed the context in which household water treatment was being used in the study villages to provide real-world information for assessing the effectiveness of the technologies. An interviewer-administered questionnaire elicited information about the water, sanitation and hygiene-related KAP of the study communities. A household water treatment (HWT) survey (Chapter 4) was carried out in the same study households and villages as the KAP study, using a semi-structured questionnaire to gather HWT adoption, compliance and sustained use-related information to provide insight into the perceived value the study households attach to HWT technologies, and their likelihood of adoption of and compliance with these technologies. The drinking water quality of 171 (one quarter of those surveyed during KAP) randomly selected households was determined and tracked from source to the point of use (Chapter 5). This provided insights into HWT effectiveness by highlighting the need for HWT (as indicated by source water quality) and the effect of the study households’ KAP on drinking water quality (as indicated by the stored water quality). Physico-chemical and microbiological water quality of the nineteen improved and unimproved sources used by the study households was determined, according to the World Health Organisation guidelines. The microbiological quality of 291 water samples in six intervention and five control villages was determined from source to the point-of-use (POU) using the WHO and Sphere Drinking Water Quality Guidelines. An observational study design was then used to assess the post-implementation effectiveness of the technologies used in 37 households in five intervention villages (Chapter 6). Three assessments were carried out to determine the changes in the microbiological quality of 107 drinking water samples before treatment (from collection container) and after treatment (from storage container) by the households. The criteria used to assess the performance of the technologies were microbial efficacy, robustness and performance in relation to sector standards. A Quantitative Microbial Risk Assessment (QMRA) was then carried out in the HWT effectiveness study households to assess the technologies’ ability to reduce the users’ exposure to and probability of infection with water-borne pathogens (Chapter 7). The KAP survey showed that the intervention and control communities did not differ significantly in 18 out of 20 socio-economic variables that could potentially be influenced by the structured manner of introducing HWT into the intervention villages. The majority of the intervention group (IG) and the control group (CG) were poor or very poor on the basis of household assets they owned. The predominant level of education for almost two-thirds of the IG and CG respondents was primary school (completed and non-completed). Though very few were unemployed in IG (8.07%) and CG (14.29%), the two groups of respondents were predominantly engaged in subsistence farming — a low income occupation. With regard to practices, both groups had inadequate access to water and sanitation with only one in two of the households in both IG and CG using improved water sources as their main drinking water source in the non-rainy season. One in ten households in both study groups possessed an improved sanitation facility, though the CG was significantly more likely to practice open defecation than the IG. The self-reported use of soap in both study groups was mainly for bathing and not for handwashing after faecal contact with adult or child faeces. Despite the study groups' knowledge about diarrhoea, both groups showed a disconnection between their knowledge about routes of contamination and barriers to contamination. The most frequent reason for not treating water was the perceived safety of rain water in both the IG and CG. / The HWT adoption survey revealed poor storage and water-handling practices in both IG and CG, and that very few respondents knew how to use the HWT technologies correctly: The IG and CG were similar in perceived value attached to household water treatment. All HWT technologies had a lower likelihood of adoption compared to the likelihood of compliance indicators in both IG and CG. The users’ perceptions about efficacy, time taken and ease of use of the HWT technologies lowered the perceived value attached to the technologies. The assessment of the drinking water quality used by the study communities indicated that the improved sources had a lower geometric mean E. coli and total coliform count than the unimproved sources. Both categories of sources were of poor microbiological quality and both exceeded the Sphere Project (2004) and the WHO (2008) guidelines for total coliforms and E. Coli respectively The study communities’ predominant drinking water sources, surface water and rainwater were faecally contaminated (geometric mean E. coli load of 388.1±30.45 and 38.9±22.35 cfu/100 ml respectively) and needed effective HWT. The improved sources were significantly more likely than the unimproved sources to have a higher proportion of samples that complied with the WHO drinking water guidelines at source, highlighting the importance of providing improved water sources. The lowest levels of faecal contamination were observed between the collection and storage points which coincided with the stage at which HWT is normally applied, suggesting an HWT effect on the water quality. All water sources had nitrate and turbidity levels that exceeded the WHO stipulated guidelines, while some of the improved and unimproved sources had higher than permissible levels of lead, manganese and aluminium. The water source category and the mouth type of the storage container were predictive of the stored water quality. The active treater households had a higher percentage of samples that complied with WHO water quality guidelines for E. coli than inactive treater households in both improved and unimproved source categories. In inactive treater households, 65% of storage container water samples from the improved sources complied with the WHO guidelines in comparison to 72% of the stored water samples in the active treater households. However the differences were not statistically significant. The HWT technologies did not attain sector standards of effective performance: in descending order, the mean log10 reduction in E. coli concentrations after treatment of water from unimproved sources was PUR (log₁₀ 2.0), ceramic filters (log₁₀ 1.57), Aquatab (log₁₀ 1.06) and Waterguard (log₁₀ 0.44). The mean log10 reduction in E. coli after treatment of water from improved sources was Aquatab (log₁₀ 2.3), Waterguard (log₁₀ 1.43), PUR (log₁₀ 0.94) and ceramic filters (log₁₀ 0.16). The HWT technologies reduced the user’s daily exposure to water-borne pathogens from both unimproved and improved drinking water sources. The mean difference in exposure after treatment of water from unimproved sources was ceramic filter (log₁₀ 2.1), Aquatab (log₁₀ 1.9), PUR (log₁₀ 1.5) and Waterguard (log₁₀ 0.9), in descending order. The mean probability of infection with water-borne pathogens (using E.coli as indicator) after consumption of treated water from both improved and unimproved sources was reduced in users of all the HWT technologies. The difference in reduction between technologies was not statistically significant. The study concluded that despite the apparent need for HWT, the study households’ inadequate knowledge, poor attitudes and unhygienic practices make it unlikely that they will use the technologies effectively to reduce microbial concentrations to the standards stipulated by accepted drinking water quality guidelines. The structured method of HWT promotion in the intervention villages had not resulted in more hygienic water and sanitation KAP in the IG compared to the CG, or significant differences in likelihood of adoption and compliance with the assessed HWT technologies. Despite attaching a high perceived value to HWT, insufficient knowledge about how to use the HWT technologies and user concerns about factors such as ease of use, accessibility and time to use will impact negatively on adoption and compliance with HWT, notwithstanding their efficacy during field trials. Even though external support had been withdrawn, the assessed HWT technologies were able improve the quality of household drinking water and reduce the exposure and risk of water-borne infections. However, the improvement in water quality and reduction in risk did not attain sector guidelines, highlighting the need to address the attitudes, practices and design criteria identified in this study which limit the adoption, compliance and effective use of these technologies. These findings have implications for HWT interventions, emphasising the need for practice-based behavioural support alongside technical support.