This week, we've explored monitoring and evaluation of HWTS from a variety of angles, from the validation of specific technologies to understanding why effective and consistent use of HWTS is important for achieving health improvements. We've also examined how to choose among the many treatment and storage approaches, especially in terms of cost effectiveness. During this module, we'll look at how some of these important issues are being confronted within our rural water supply program in Nepal. In this case study, you'll see how drinking water quality goals were defined, how water quality data was collected in remote communities with very limited resources, and finally, how this information is being used to choose an effective and viable water treatment and storage strategy. The water supply and treatment group here in SANDEC, aims to merge research with development cooperation, to improve the lives of people in the Global South. So, our objectives are really twofold. We plan and implement water supply projects in cooperation with our partner organizations, and we also conduct systematic research and share our study results at conferences and also in peer reviewed publications. We learned about the HELVETAS Swiss Intercooperation Water Resource Management Project, or WARM, in Nepal. For many years now, HELVETAS has been working throughout Nepal to identify water resources and foster effective, equitable, and efficient use at the local level. This is mainly done through a participatory process, which leads to a master plan, and this plan is then adopted and owned by the community members themselves. Within the WARM project, there's a specific goal to integrate household water treatment and safe storage, or HWTS, to improve the health and hygiene of people living within the program area. To ensure sustainability of the project, promotion and implementation of HWTS will harness local markets and also focus on meeting household demand for these products. So now, HELVETAS and SANDEC are working together to conduct a study across the program area to better understand what sort of treatment strategy can work well in this setting. Overall, the main objective of the study is to devise one or more effective water treatment and safe storage solutions for the WARM project area. This includes assessing drinking water quality at taps and in storage containers within homes, often in communities where households are extremely remote and where data on water quality is quite lacking. Water quality information was needed to understand the extent to which treatment was required, and also to asses the impact of possible water treatment intervention. We also needed to understand behavioral aspects of household water management, such as individual's perceptions about the quality of their drinking water source. And also, whether households are currently using any treatment or safe storage practices. And finally, since HELVETAS is focused on a market driven approach to implementing HWTS, we undertook a survey of local market conditions, as well as customers' priorities for future investments, and their willingness to pay for water treatment technologies. >> A researcher is not a business person. Indeed, we also have to keep in mind that at certain times and in certain contexts, there could be alternatives that are more suitable than market-based interventions. Let us recall that our ultimate objective is a general health of the population. Are we replacing the role of government by placing priority on what sells? In which context should one leave the provision of safe water for the government? With water quality as a subject of consumer protection. >> So what does a study look like this on the ground? Well, mostly it's a lot of time spent collecting and processing water samples, sometimes under very challenging conditions. >> We aim that a testing procedure that meets the WHO guidelines, suits the field conditions, and keeps costs for consumables at a reasonable level. The membrane filtration method performed best, while other quantitative methods like the multi tube, or our most probable method are still several times more expensive. >> I think we have a lot to offer this year from our staff, first is the electricity because in case of remote water quality, you need to have efficient electricity, because if you conduct this kind of analysis, you have to make sure you have 24 hour activity for your incubator. The second one is the overall study because in the case of Nepal, you have heavy amounts or you have, sometimes you have to work maybe two three hours to reach the objective or, that is the most, at least that is enough for me. >> It was necessary to build an incubator for the compact dry plates, using a solar voltaic array, and also using special lightweight materials so that the incubator could be carried to communities across this mountainous terrain. For the behavior study, we held in-person interviews with hundreds of people to understand more about their daily life and their needs regarding water. We asked questions about their main priorities and concerns, because sometimes as water researchers, it's easy to forget that there's more to worry about than a clean drinking water supply. There's also employment, access to healthcare, electricity, food security, the list goes on. So the survey also looked closely at how people perceive the quality of their own water, whether they believed it presented a health risk to them and to their families, and also how they treated their water supply currently, if at all. All of this information is important for planning a viable HWTS strategy, because if demand for a treatment product is very low, it can't really be expected that people will be willing to change their behavior and treat their own drinking water consistently. >> We can learn from people's demand for similar products, services, or proxies. Their consumer preferences and their general approach to health issues and other risks. Why don't they currently treat their water? We tried to find out whether they simply disliked the products currently available in the market, or whether they just do not perceive their water as risky. How many times does one have to suffer from diarrhea before he or she starts boiling or filtering their water several times a day? >> To investigate the contextual factors, we interviewed doctors, pharmacists, merchants, NGO and government representatives, and also consumers, like patients and households. We combine these interviews with structured observations and data from health institutions and markets to understand the low priority that most households currently place on preventing diarrhea. Pharmaceuticals are often available at no cost. People seem to prefer using them for severe sicknesses, while overlooking minor digestive disorders and preventative options. Yet, exposure to pathogens also has long term effects, like stunting, and can generally impair the immune system. This is a connection that most households do not seem to make. And we can observe a similar attitude among Western city dwellers suffering from smog, but choosing not to wear protective masks, despite known health hazards. >> The results from our study are still coming out, but already, we're seeing a very interesting story. We know that, in many cases, the water at the point of collection is relatively free of fecal contamination. But, on the other hand, some taps have very high concentrations of E coli, and this presents a real health risk to the local community. This heterogeneity and quality is important because nearly all of the water points visited are classified as an improved water source, according to the definition used by the millennium development goals. Yet, we see that its categorization is not enough to reliably ensure a safe drinking water source in this setting. We're also learning that households generally do not practice water treatment or safe storage consistently. Most households perceive their water source to be relatively clean and the risk to health to be relatively low. So really, it makes sense that they're not motivated to treat their own water. And the market study has also revealed that despite the availability of many HWTS products locally, they are not actually prioritized by households when they consider the many other things that they could spend their money on, such as food, housing, soap, and toilets. All of these items were typically a higher priority investment among survey respondents. So in the next phase of this study, we'll work closely with HELVETAS to develop a strategy for improving household water quality based on the results from this baseline evaluation. It's clear that a market-driven approach will need to confront many issues, including highly variable water quality at the point of collection, also relatively low demand for HWTS products among water users. So, possible strategies could include an information campaign to raise awareness among water users or maybe testing innovative technologies like passive chlorination at the tap. Possibly even promotion of a really aspirational product of some kind, which households might value more. Finding a sustainable solution really requires constant dialogue with our partners, and especially the potential customers who will be using these products. Our team is really excited to see how this project will unfold going forward.