scaling up the hyposol for safe water: a philippine...

Scaling Up the Scaling Up the HHypoypoSSolol

For For SAFESAFE Water: A Philippine StrategyWater: A Philippine Strategy

MADELINE J. RETUTA, M.D.,MPH

DOH, Center For Health Development For LuPangIlocos

2008 International Symposium on Household Water Management 2-5 June 2008, Accra, Ghana

ContentsContents•• BackgroundBackground•• Responsibility sharingResponsibility sharing•• StrategiesStrategies•• Drivers of uptakeDrivers of uptake•• SustainabilitySustainability•• Barriers and solutionsBarriers and solutions•• Lessons learnedLessons learned

The Philippines

Diarrhea still in the top 10 leading causes of morbidity for 20 years

Total population: 88.5 M3 major islands15 regions

The Philippines

•11,338 people die each year or31 people die each day from diarrhea resulting from poor sanitation and hygiene

( WB-USAID Study, 2008)

Access to Safe Drinking Water Access to Safe Drinking Water and Sanitary Toilet, Philippinesand Sanitary Toilet, Philippines

81.8 83

91.5

73.9 75.4

87.7

0102030405060708090

100

2005 2006 2015

Access to safeDrinking WaterAccess to SanitaryToilet Facility

Source: FHIS 2005-2006; MDG Target 2015

The Philippines

•13 million people are at risk due to lack of access to safe water source

(PEM-WB, June 2007)

Devolved Health System

NATIONAL GOV’T (DOH)

LOCAL GOV’T

PROVINCIAL GOV’T

MUNICIPAL GOV’T

Policy-making

Advocacy

Monitoring/evaluation

Implementation

CENTERS FOR HEALTH

DEVELOPMENT ( CHDs)

The The HHypoypoSSolol For For SAFESAFE Water Water ProjectProject

BRINGING CLOSER ACCESS TO SAFE DRINKING WATER IN EVERY HOME

BACKGROUND

SITUATION

PILOT TEST

UPSCALING

EXPANSION

( REGIONWIDE)

(NATIONWIDE )

The HypoSol For SAFE Water Project Framework

2004

2005-2006

2006-2007

2007-

present

NATIONAL HWTS NETWORK

The Situation

Presenter

Presentation Notes

Region 1 or the CHD For LuPangIlocos is situated in the northernmost tip of the country. In 2994, an outbreak of diarrheal disease consistent with cholera occurred in two of its provinces, Pangasinan and La Union.

PANGASINAN

Anda

Bolinao

Bani

Alaminos City

Sual

Labrador

Lingayen Binmaley Dagupan City

Calasiao

Sta.Barbara

Mangaldan

Mapandan

Manaoag

San Jacinto

San Fabian

Sison

Pozzurubio

Laoac

Binalonan

Urdaneta City

MalasiquiSan Carlos City

BasistaBugallon

Aguilar

Mangatarem

Urbiztondo Bayambang

Bautista

AlcalaSto.Tomas

Villasis

RosalesBalungao Umingan

Sta.Maria

San Quintin

Natividad

San Nicolas

San Manuel

AsinganTayug

Infanta

MabiniDasol

Burgos

Agno

Fig. 1 SPOT MAP OF CONFIRMED CHOLERA CASES, PANGASINAN Fig. 1 SPOT MAP OF CONFIRMED CHOLERA CASES, PANGASINAN MAY 28, 2004 MAY 28, 2004 –– DECEMBER 31, 2004 N=476DECEMBER 31, 2004 N=476

45

PangasinanPangasinan

Presenter

Presentation Notes

Pangasinan is the biggest province which has about 4.5 million population. The red areas shows the magnitude of confirmed cholera cases. The central part of the province is below sea level, and was heavily hit during the epidemic. However, the westernmost with sporadic cases scattered all around the province.

Fig.2 CONFIRMED CHOLERA CASES PER MUNICIPALITY Fig.2 CONFIRMED CHOLERA CASES PER MUNICIPALITY LA UNION JUNE 1LA UNION JUNE 1-- OCTOBER 22, (N=152)OCTOBER 22, (N=152)

LEGEND

NO. OF CASES

Presenter

Presentation Notes

The neighboring province of La Union was not spared affecting the urban city heavily and neighboring towns, and with sporadic spread to almost the whole province.

Total of 9,975 Acute Gastroenteritis ( AGE ) cases; 55 deaths ( mostly children )

In three months: June-September, 2004

Presenter

Presentation Notes

A total of 9,975 Acute Gastroenteritis cases were reported from Surveillance facilities from May 28 to December 31, 2004. Of this number, Vibrio cholerae Ogawa El Tor was isolated in 94.3 % and Vibrio cholerae non 01 was isolated in 3.6%. At the height of the epidemic (June to August), recovery rate of the organism from the rectal swab samples ranged from 60% to 80%. The next slide These are pictures of cases admitted at the Pangasinan Provincial Hospital. As you can see they, are mostly children under five years of age.

High risk water sources

Presenter

Presentation Notes

The outbreak was found to be secondary to contaminated drinking water sources . The following slides show type of water sources in the areas where the outbreak occcurred. Most of these water sources are shallow wells which are either improved, near toilets and animal pens, or with broken tables.

Immediate InterventionImmediate Intervention

•• Household Container Disinfection ( HCD)Household Container Disinfection ( HCD)( ( Hypochlorite Hypochlorite granules) granules)

Low Compliance:Low Compliance:Tedious preparationTedious preparationShort shelf life ( 1 week)Short shelf life ( 1 week)People refused to drink the end product due People refused to drink the end product due

to smell and tasteto smell and taste

Presenter

Presentation Notes

The immediate intervention was household container disinfection ( HCD)using Sodium Hypochlorite solution in addition to massive information dissemination campaign. However, despite the life and death situation, people hardly wanted to drink the end product of HCD because of its strong smell and taste. Having found out that almost all water sources within the epidemic area were contaminated with the organism, the situation was eventually controlled with the massive chlorination of all water sources, use of HCD, and massive health promotion campaign.

MDG, Ten-point agenda of the president ( 2010)

SITUATION

PILOT TEST

Cholera epidemic,2004

Introduction of the SWS by the WHO

Constraints in establishing long term piped water structures

CHD-1

Need for an immediate, interim

intervention

Presenter

Presentation Notes

Given a critical situation, the financial and time constraints of establishing permanent water supply systems, and with the pressures of meeting the MDG goals and the 10-point agenda of the president of ensuring access access to safe and improved water sources by 2015and 2010 respectively, it was agreed upon that an immediate interim mechanism must be instituted to address the situation, hence the introduction of the SWS by the WHO. It was agreed upon that that the SWS be pilot tested and CHD-01 would take the lead.

PILOTProduct

unavailable locally

CONSTRAINTS

1. Immediate implementation

2. Upscaling, expansion, sustainability

Presenter

Presentation Notes

The unavailability of the product brought us further to two levels of constraint, first in the immediate implementation, and 2nd in the eventual scale up, and possibly expansion

PILOT

1. Immediate implementation

SOLUTION

Imported product( DOH, WHO, CDC,

AMANTIRTA Project in Indonesia )

Product unavailable

locally

1.25% Sodium Hypochlorite Solution ( HYPOSOL )

CONSTRAINTS

Presenter

Presentation Notes

In order to address the immediate problem, the product, a 1.25% Sodium Hypochlorite Solution, without label and commercial name was imported from Indonesia, the nearest country which has recently started an SWS project through the assistance of the WHO, CDC and the management of the AmanTirta project in Indonesia. During the conduct of the pilot, the imported product was named HypoSol, shortcut for Hypochlorite Solution. The term HypoSol became easier for households to identify the product . The project then evolved into the HypoSol For SAFE Water Project and then eventually adapted at the national level.

PANGASINAN

Anda

Bolinao

Bani

Alaminos City

Sual

Labrador


Calasiao

Sta.Barbara

Mangaldan

Mapandan

Manaoag

San Jacinto

San Fabian

Sison

Pozzurubio

Laoac

Binalonan

Urdaneta City


BasistaBugallon

Aguilar

Mangatarem


Bautista

AlcalaSto.Tomas

Villasis


Sta.Maria

San Quintin

Natividad

San Nicolas

San Manuel

AsinganTayug

Infanta

MabiniDasol

Burgos

Agno

45


Nalsian Norte & Cabatling

Payar & Isla

7 1 %

7 1 %

2005-2006: PILOT TEST

Presenter

Presentation Notes

The project was piloted in two of the most affected municipalities in Pangasinan, San Carlos City and Malasiqui. The pilot test covered 1,200 households, 300 each for the intervention sites and 300 for the control.

PILOT

Results

Solution was effective

Acceptable

Improved practices

Promising trend in diarrhea reduction

Efficacy of the solution

Social acceptability

Knowledge and practices

Impact on diarrhea reduction

Preparations for local production

Local product was successfully registered with the Bureau of Food and Drugs

Private Sector

DOH/CHD,

WHO,CDC as technical advisory

CHD-1

2005-2006

PILOT

NATIONAL POLICY

Positive results from the pilot study

LOCAL ORDINANCES

UPSCALE

LOCAL PRODUCT

AO 2007-0005

UNICEF

NGOs

ACADEME

MEDIA

2006-2007

Presenter

Presentation Notes

The positive results from the pilot study and the availability of the local product has set the stage for national government to take action through the issuance of a National Policy ( Administrative Order 2007-005) in support to the use of the SWS strategy which was later named HypoSol For SAFE Water ( HypoSol stands for Hypochlorite Solution- the name of the solution used during the conduct of the pilot study), while the registered product has a different brand name. This national policy redound into individual local ordinances as the local government took up the project, though at present, in fragmented proportions. At this point, with the legal mandate and the local product on hand, other organizations came on board which eventually enabled us to scale up the project.

PANGASINAN

Anda

Bolinao

Bani

Alaminos City

Sual

Labrador


Calasiao

Sta.Barbara

Mangaldan

Mapandan

Manaoag

San Jacinto

San Fabian

Sison

Pozzurubio

Laoac

Binalonan

Urdaneta City


BasistaBugallon

Aguilar

Mangatarem


Bautista

AlcalaSto.Tomas

Villasis


Sta.Maria

San Quintin

Natividad

San Nicolas

San Manuel

AsinganTayug

Infanta

MabiniDasol

Burgos

Agno

Scale Up sites: Scale Up sites: PangasinanPangasinan (7 municipalities)(7 municipalities)

45


Presenter

Presentation Notes

There were 7 scale up sites mostly within the central area, and one municipality in the westernmost part of the province which was also heavily affected during the epidemic.

LEGEND

NO. OF CASES

Scale Up site: La Union ( 1 city )Scale Up site: La Union ( 1 city )

Presenter

Presentation Notes

The project was also scaled to the neighboring province of La Union , its city being one of the most hardest hit.

AMORE COVERED PROVINCES

NON-ARMM SITES = 43 BARANGAYS

ARMM = 184 BARANGAYS

COLOR LEGEND:

Yellow = Non-ARMM

Blue = ARMM

Presenter

Presentation Notes

Meanwhile, the AMORE Project in the Southern part of the country, having seen the potential of the project, worked hand-in-hand with the CHD-1 and the local producer to bring the project to that part of the countryside.

ACCESS TO SAFE WATER: ACCESS TO SAFE WATER: A GIFT OF LIFE TO THE A GIFT OF LIFE TO THE

COUNTRYSIDECOUNTRYSIDE

Presenter

Presentation Notes

This slide show the project title given to the SWS in Mindanao where water is a scarce commodity not to mention its high salinity.

Water Peddling/rationing is a thriving business in island-villages where water is considered scarce.

Mostly, dug wells in the islands yield water with mild to high salinity contents.

WATER SCENES IN AMORE-COVERED BARANGAYS

Most of the wells in the island-villages are unprotected, and thereby susceptible to contamination.

Result of the Bacteriological Test conducted in one of the AMORE site in

Maguindanao.

RESPONSIBILITY SHARINGRESPONSIBILITY SHARING

SITUATION

PILOT

UPSCALING

NATIONAL GOVERNMENT

( DOH/CHD-1)

LOCAL GOVERNMENT

UNICEF,NGOs

ACADEME,MEDIA

PRIVATE SECTOR

( Local Production)

EXPANSION

RELIGIOUS GROUP

N A T I O N A L

P O L I C Y

L O C A L P R O D U C T

L O C A L

P O L I C I E S

Level of Participation of key stakeholders

Presenter

Presentation Notes

The 3 essential elements namely national and the local policies and the availability of a local product serving as a backbone, with the national and local governments in the lead in partnership with the private sector and all other local partners was the main enabling mechanisms for the project to expand.

Areas of collaboration

NATIONAL GOV’T

CHDS

Main Stakeholders

NGOs

RELIGIOUS GROUP

MEDIA

LOCAL GOV’T UNITS

LOCAL PRODUCER

POLICY, PROVISION OF LOGISTICS, IMPLEMENTATION AND MONITORING

PRODUCT PROMOTION

WHO,UNICEF

POLICY, OVERALL MANAGEMENT

IMPLEMENTATION, TECHNICAL, AND LOGISTICAL ASSISTANCE

TECHNICAL, LOGISTICAL , AND FINANCIAL ASSISTANCE

ADVOCACY AND HEALTH PROMOTION

Presenter

Presentation Notes

This slide shows the areas of collaboration of the main stakeholders. Central to the role of each stakeholder is the advocacy to promote the use of the HFSW strategy side by side with health promotion on water sanitation and hygiene. Specifically, the local government units (LGUs) play a very important role in the overall management of the project in their own areas. While instruments and a whole program package for the HFSW are being prepared, the CHDs are assisting closely the LGUs in the the project management.

SITUATION

PILOT

UPSCALING

RELIGIOUS

( DOH/CHD-1, WHO)

LOCAL GOV’T

EXPANSION

Logistics provision

Fully subsidized

Partially subsidized

Logistics sharing

UNICEF,NGO

Presenter

Presentation Notes

Fully subsidized- jerry cans, hyposol, and IEC materials were all provided for Partially subsidized- the jerry cans are either provided for or bought by the households; most of the time, hyposol is bought by the households

PANGASINAN

Anda

Bolinao

Bani

Alaminos City

Sual

Labrador


Calasiao

Sta.Barbara

Mangaldan

Mapandan

Manaoag

San Jacinto

San Fabian

Sison

Pozzurubio

Laoac

Binalonan

Urdaneta City


BasistaBugallon

Aguilar

Mangatarem


Bautista

AlcalaSto.Tomas

Villasis


Sta.Maria

San Quintin

Natividad

San Nicolas

San Manuel

AsinganTayug

Infanta

MabiniDasol

Burgos

Agno

Expansion sites : Expansion sites : PangasinanPangasinan (21 municipalities)(21 municipalities)

45


LEGEND

NO. OF CASES

SCALE UP SITES

EXPANSION SITES

Presenter

Presentation Notes

With the issuance of a legal mandate in support to the stratey, and with combined efforts in the advocacy, the project was taken up by the LGUs mostly on their own. At most, the assistance given by the CHD was more on the orientations and provisions of IEC materials. The LGUs provided for roll out orientation to the communities, launchings, provision of jerry cans and HypoSol for start up of poor families, and the subsequent supply of HypoSol was bought by the households. Monitoring teams is composed of CHD, the provincial and the municipal representatives. Most of the time during the upscaling , the producer and the project team go together during advocacy activities where the HFSW strategy is the one being promoted, while the producer talks only about the technical questions regarding the product. A full product promotion is done by the producer when they go alone in their advocacy. One NGO participant fully implemented the project in their community areas of coverage in the context of the DOH project policy, and another NGO provided for logistics in specific LGU areas of coverage. A religious group is also currently implementing in communities under their parish. The IEC materials Logistics are being sourced out by the Resources-sharing among all the stakeholders facilitated the.

Expansion sites: La Union ( ProvinceExpansion sites: La Union ( Province--wide)wide)

LEGEND

NO. OF CASES

SCALE UP SITES

EXPANSION SITES

Presenter

Presentation Notes

In La Union, through the initiative of the provincial government, the HFSW was launched and implemented province-wide.

STRATEGIESSTRATEGIES

NATIONAL GOV’T, CHDS

LOCAL GOV’Ts

Republic of the PhilippinesCITY OF SAN FERNANDO

Province of La UnionRESOLUTION NO. 07-34

RESOLUTION STRONGLY ENJOINING HOUSEHOLDS, BUSINESS ESTABLISHMENTS AND PRIVATE/GOVERNMENT OFFICE IN THE CITY OF SAN FERNANDO TO USE SODIUM HYPOCHLORITE SOLUTION (HYPOSOL) AS CHLORINE SOLUTION FOR RAW OR CONTAMINATED WATER AND FOR CONTAINER DISINFECTION.

WHO as technical advisor

1. POLICY FORMULATIONSTRATEGIES

Presenter

Presentation Notes

The most critical element is the policy formulation which serves as an enabling and facilitating mechanism for any project or program to start and gain wider and at the most nationwide coverage at a faster rate.

Pledge of Commitment Among Key StakeholdersPledge of Commitment Among Key Stakeholders

2. MULTISECTORAL ALLIANCESSTRATEGIES

Presenter

Presentation Notes

Multisectoral alliances collaborations stimulate cooperation and action among stakeholders which help build sustainable local and national capacities..

I. ADVOCACY AND I. ADVOCACY AND AWARENESS AWARENESS CAMPAIGNSCAMPAIGNS

2. MULTISECTORAL ALLIANCESSTRATEGIES

WITH DONORS AND POLICY MAKERS

ADVOCACY AND AWARENESS CAMPAIGNS


FAMILIES AND COMMUNITIES

IN SCHOOLS: PUPILS AND STUDENTS ARE VERY GOOD ADVOCATES OF POU


RELIGIOUS LEADERS ARE A STRONG INFLUENCE AMONG MEMBERS


THE MEDIA



PROJECT VISIBILITY DURING EVENTS AND FESTIVITIES

OUTBREAK RESPONSE


POLITICAL EVENTS


3. MONITORINGSTRATEGIES

CONSULTATIONS AMONG LOCAL PRODUCER, PRODUCT EXPERTS, AND PROJECT MANAGEMENT TO ENSURE PRODUCT QUALITY, AVAILABILITY AND ACCESSIBILITY


AMONG LOCAL EXECUTIVES, IMPLEMENTORS, AND USERS TO ADDRESS PRESSING ISSUES


TO LOOK INTO THE PROGRESS OF IMPLEMENTATION AND TO BOOST THE MORALE OF HEALTH WORKERS


DRIVERSDRIVERS OF HFSW UPTAKEOF HFSW UPTAKE

UPSCALE

2007-PRESENTEXPANSION

POCKETS OF OUTBREAKS

DRIVERS OF UPTAKE

“FEAR” FACTOR

IMPACT ON DIARRHEAL CONTROL


L O C A L

P O L I C I E S

N A T I O N A L

P O L I C Y

BEHAVIOR CHANGE

TESTIMONIES/EXPERIENCES OF IMPLEMENTORS AND CURRENT USERS

UPSCALE

2007-PRESENT

EXPANSION

COST- EFFECTIVENESS

ECONOMICAL

DRIVERS OF UPTAKE

ADVOCACY ON THE BENEFITS OF THE STRATEGY


L O C A L

P O L I C I E S

N A T I O N A L

P O L I C Y

SUSTAINABILITYSUSTAINABILITY

I. PASSAGE OF LOCAL ORDINANCEI. PASSAGE OF LOCAL ORDINANCE

II. Resolution No. 07II. Resolution No. 07--3434

Resolution strongly enjoining households, business Resolution strongly enjoining households, business establishments and private/ government offices in establishments and private/ government offices in the City of San Fernando to use Sodium the City of San Fernando to use Sodium Hypochlorite solution (Hypochlorite solution (HyposolHyposol) as Chlorine ) as Chlorine solution for raw or contaminated water and for solution for raw or contaminated water and for container disinfection.container disinfection.

2525thth day of September 2007day of September 2007

II. Inclusion of the HFSW II. Inclusion of the HFSW logistics in the regular logistics in the regular budget of the budget of the CHDsCHDs, , LGUsLGUs, and partner , and partner organizations.organizations.

III. Integration of the HFSW in the III. Integration of the HFSW in the regular programs/projects of regular programs/projects of

the governmentthe government

IIIA. Water and Sanitation IIIA. Water and Sanitation programs/projectsprograms/projects

IIIB. Maternal and Child Health IIIB. Maternal and Child Health and Nutrition Programand Nutrition Program

MOTHERSMOTHERS’’ CLASSESCLASSES

FOODHANDLERSFOODHANDLERS’’ CLASSESCLASSES

IVIV. . EPIDEMIOLOGICAL INVESTIGATIONEPIDEMIOLOGICAL INVESTIGATION

ACUTE GASTROENTERITIS (AGE) ACUTE GASTROENTERITIS (AGE) SURVEILLANCESURVEILLANCE

V. BOTIKA NG BARANGAYV. BOTIKA NG BARANGAY

VI. RESEARCHVI. RESEARCH

HEALTH , SOCIAL, ECONOMIC AND IMPACTS

BARRIERS AND SOLUTIONSBARRIERS AND SOLUTIONS

UPSCALE


HFSW PROGRAM PACKAGE

CONSTRAINT


L O C A L

P O L I C I E S

N A T I O N A L

P O L I C Y

STRENGTHEN AND SUSTAIN ADVOCACY

TECHNICAL RESOURCES FOR IMPLEMENTATION

UPTAKE: Food Vs. Water treatment GOV’T AND CIVIL

SOCIETY SUBSIDIES FOR THE POOREST OF THE POOR

SOLUTION

UPSCALE


CONSTRAINTS


L O C A L

P O L I C I E S

N A T I O N A L

P O L I C Y

MARKET LINKAGES AND PRODUCT PLACEMENTS

Manufacturer – Distributor’s forum

SOLUTION

Presenter

Presentation Notes

Market linkages: Botica ng Barangay (BNB)that serves as a distribution point in the grass root level. BNB is a facility that sells low-cost medicines at the barangay level initially subsidized by the national government, and subsequently operated and maintained by the community. Political Landscape- priority for infrastructure which takes a long time to realize and with a very limited coverage. Non-priority and belief in low-cost technology.

UPSCALE


CONSTRAINTS


L O C A L

P O L I C I E S

N A T I O N A L

P O L I C Y


SOLUTION

Identify potential, Identify potential, local distributor/s local distributor/s

and link them up and link them up with the regional with the regional distributor or distributor or manufacturer. manufacturer.

Assist them in the Assist them in the development of development of the market the market arrangement.arrangement.

Presenter

Presentation Notes


UPSCALE


CONSTRAINTS


L O C A L

P O L I C I E S

N A T I O N A L

P O L I C Y


SOLUTION

Company Direct Sales

Independent Distributors / Traders

Cooperatives & NGO initiatives

BOTICA NG BARANGAY

Presenter

Presentation Notes


UPSCALE


CONSTRAINTS


L O C A L

P O L I C I E S

N A T I O N A L

P O L I C Y

PROJECT IMPACT IN DISASTER / OUTBREAK RESPONSE

POLITICAL LANDSCAPE

Cost of the intervention and impact on diarrhrea reduction

SOLUTION

1. Preference for infrastructures

2. Low confidence in the low-cost technology

3. “ To see is to believe “

Presenter

Presentation Notes


LESSONS LEARNED

Political will at the national and local levels is vital in the institutionalization of mechanisms to carry out and sustain any project/program

LESSONS LEARNED

Strong multi-sectoral alliancesstimulate cooperation and stimulate cooperation and action among stakeholders action among stakeholders and helps build sustainable and helps build sustainable local and national capacities. local and national capacities.

LESSONS LEARNED

Project management that is Project management that is dedicated and focused on the dedicated and focused on the GOALS AND OBJECTIVESGOALS AND OBJECTIVES

LESSONS LEARNED

Regular consultations Regular consultations among project among project management, implementers management, implementers and beneficiariesand beneficiariesgenerate trust and generate trust and confidence in the strategyconfidence in the strategy


2007-PRESENT

EXPANSIONL O C A L

P O L I C I E S


L O C A L

P O L I C I E S

HWTS PROGRAM

REGIONWIDE NATIONWIDE

N A T I O N A L

P O L I C Y


L O C A L

P O L I C I E S

HWTS NETWORK

CHALLENGE

W A Y

O F

L I F E

IN SUMMARY:IN SUMMARY:

•• GovernmentGovernment--led, anchored led, anchored in multiin multi--sectoralsectoral alliances, alliances, impact driven, towards a impact driven, towards a National HWTS networkNational HWTS network..

ThinkThink BIGBIGStart Start smallsmall , , Act nowAct nowKEEP GOINGKEEP GOING

( never wait) !( never wait) !

The HFSW Project Team was conferred the First Public Health Bayani Award by the Philippine Public Health Association in their Diamond Jubillee Celebration, July, 2007

THANK YOU

scaling up the hyposol for safe water: a philippine...

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