A community demand-driven approach toward sustainable water and sanitation infrastructure development

International Journal of Hygiene and Environmental Health 214 (2011) 326–334

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A community demand-driven approach toward sustainable water and sanitation infrastructure development Brian Hubbard a,∗ , John Sarisky a,1 , Richard Gelting a,1 , Virginia Baffigo b,2 , Raul Seminario c,3 , Carlos Centurion b,2 a Environmental Health Services Branch, National Center for Environmental Health, United States Centers for Disease Control and Prevention, Department of Health and Human Services, 4770 Buford Highway, NE., MS F-60, Atlanta, GA 30341, USA b CARE Perú, Av. General Santa Cruz 659, Lima 11, Peru c Ministry of Health, Regional Government of Loreto, Loreto Regional Health Directorate, Cardozo Health Center, Av. 28 de Julio S/N, Punchana, Peru

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Article history: Received 29 July 2010 Received in revised form 14 April 2011 Accepted 17 May 2011 Keywords: Water Sanitation Community participation Demand-driven Health Sustainability

a b s t r a c t In September 2001, Cooperative Assistance and Relief Everywhere, Peru Country Office (CARE Peru), obtained funding from the United States Agency for International Development (USAID) to implement community-supported, condominial water and sanitation interventions in Manuel Cardozo Dávila, a settlement in Iquitos, Peru. With technical support from the Centers for Disease Control and Prevention (CDC), CARE Peru’s Urban Environmental Health Models (Modelos Urbanos de Salud Ambiental [MUSA]) project built on previous work from implementing the Protocol for Assessing Community Excellence in Environmental Health in this same community. The project led to the municipal water supply distribution system being extended 1.3 kilometers into the Southern zone of Iquitos, where it connected to the condominial water system. Altogether, 1030 households were connected to the water supply system after the installation of a condominial water and sewerage system in Cardozo. Diarrheal disease decreased by 37% for children less than 5 years of age from 2003 to 2004. This paper illustrates the strategy used by CARE Peru in conjunction with the Cardozo community to assure that the local demand for improved water and sanitation was met. Published by Elsevier GmbH.

Introduction Diarrheal disease is one of the leading causes of morbidity and mortality for children in the developing world (UNICEF/WHO, 2009; Kosek et al., 2003; Prüss et al., 2002). Worldwide, 884 million people do not have access to an improved drinking water source (i.e., when constructed, is protected from outside contamination, in particular, contamination from fecal matter), and 2.5 billion people lack improved sanitation (i.e., a facility that hygienically separates human excreta from human contact) (JMP, 2008). Approximately 1.5 million deaths per year in children under the age of five years have been caused by diarrhea related to unsafe water, lack of basic sanitation, and poor hygiene (JMP, 2008). High diarrheal morbidity also affects normal growth (Checkley et al., 2008), physical fitness, and cognitive function (Guerrant et al., 1999; Niehaus et al.,

∗ Corresponding author. Tel.: +1 770 488 7098; fax: +1 770 488 7310. E-mail addresses: [email protected], [email protected] (B. Hubbard), vbaffi[email protected] (V. Baffigo), [email protected] (R. Seminario). 1 Tel.: +1 770 488 7098; fax: +1 770 488 7310. 2 Tel.: +51 1 417 1100; fax: +51 1 433 4753. 3 Tel.: +51 965673485. 1438-4639/$ – see front matter. Published by Elsevier GmbH. doi:10.1016/j.ijheh.2011.05.005

2002). In 2000, the prevalence of diarrhea among children under 5 years in Peru was 15.4%, down from 17.9% in 1992 and 31.9% in 1986 (PAHO, 2002). In 2004, the percentage of the population with coverage for improved drinking water in Peru was 83%, and 63% for improved sanitation (JMP, 2006). In spite of these gains, many studies (Satterthwaite, 1993; Harpham and Stephens, 1991) have demonstrated diarrheal disease to be a major cause of morbidity and mortality in periurban areas where water and sanitation infrastructure is lacking, because population demands overwhelm environmental service capacity (Moore et al., 2002). Iquitos, the capital of the province of the Maynas, is located 996 kilometers northeast of the capital of Lima in the Loreto rainforest region of Peru (Fig. 1). Its population in 2001 was 167,844 (INEI, 2002). Rapid urbanization in Iquitos has led to the proliferation of periurban settlements near the city center and along the IquitosNauta highway in the southern zone of Iquitos. Manuel Cardozo Dávila (Cardozo), with a 2001 population of approximately 4750, is one such settlement. Cardozo – Latitude: 3◦ 46 29.11 S, Longitude: 73◦ 16 23.18 W – is similar to many other periurban settlements in the zone characterized by overcrowding, poverty, and lack of water and sanitation infrastructure. The population in Cardozo arrived as squatters, and although most have lived in the settlement since the 1980s, very few had gained legal title to their land. In July

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Fig. 1. Map of Lima and Iquitos, Peru.

2000, the Cardozo water supply system consisted of 13 communitymanaged, driven point wells with elevated storage tanks and an undetermined number of private shallow dug wells and private driven point wells. Houses were mainly one story dwellings: 51% constructed with brick or cement exteriors, 31% having wooden plank exteriors, and the remainder of households constructed with scavenged materials consisting of wood, brick, and woven bamboo mats (esteras, in Spanish). A little more than half of the dwellings had earthen floors – 58%, with the rest of households having cement or false cement flooring (i.e., a mix of earth and cement). Seventy-four percent of households used latrines, many of which were constructed over open canals. Only 22% of households were retrofitted with plumbing and bathrooms; however, these households discharged sewage directly into open street canals, which overflowed during heavy tropical rains. Improvements to one or both components of water and sanitation systems can substantially reduce rates of morbidity associated with diarrheal disease (Gross et al., 1989; Fewtrell et al., 2005; Moll et al., 2007) and other parasite infections (Esrey et al., 1991). In Cardozo, residents walked distances of up to 280 meters to collect and transport water for domestic use, which was then stored in unsanitary containers (i.e., no disinfection of water at the time of collection, storage in non-durable container, container lacking a secure top and tap) in the household (CDC, 2000). Water collected for domestic use often becomes re-contaminated or further contaminated by unsafe consumer storage and handling practices at the household level (WHO, 2002). A household survey completed by CARE Peru – Loreto in 2000 revealed that of the 93 households surveyed in the Southern Zone of Iquitos, the periurban area where Cardozo is located, 42 (45%) reported one or more children with diarrhea for more than 1 day during the 2-week period prior to the survey (Rojas and Rojas, 2000).

Project background In September 2001, Cooperative Assistance and Relief Everywhere, Peru Country Office (CARE Peru), obtained funding from

the United States Agency for International Development (USAID) to implement community-supported, condominial (Fig. 2) water and sanitation interventions in Manuel Cardozo Dávila. With technical support from the Centers for Disease Control and Prevention (CDC), CARE Peru’s Urban Environmental Health Models (Modelos Urbanos de Salud Ambiental [MUSA]) project built on earlier experiences from implementing the Protocol for Assessing Community Excellence in Environmental Health (PACE EH) (Hubbard et al., 2005; Baffigo et al., 2001) in this same community. The PACE EH methodology helps communities to understand and prioritize environmental health issues and to develop action plans to improve conditions associated with these priorities (NACCHO, 2000). The Cardozo community prioritized water, sanitation, and dust from poorly maintained unpaved roads as the main environmental health issues. The community selected increasing access to potable water and improved sanitation as priorities because these improvements enable families to improve hygienic conditions and health (Esrey et al., 1991; VanDerslice et al., 1994; Moll et al., 2007). CARE Peru worked with Cardozo residents to select technological solutions to improve water supply, sanitation, and personal hygiene; and determine how residents would participate in the action plans and interventions. This paper illustrates the strategy used by CARE Peru in conjunction with the Cardozo community to assure that the local demand for improved water and sanitation was met. Additionally, this paper describes the inaugural implementation of the condominial water and sanitation services in Peru and considers the sustainability of those interventions.

Methods Infrastructure development Cardozo was the primary focus of MUSA project interventions; however, installation of the condominial water and sewage infrastructure incorporated portions of 6 adjacent settlements in the zone: Oscar Ivan, Jessica Inchaustegui, Ciudad Jardín, Isla Kuwait, Las Colinas, and Sarita Colonia. The Cardozo community chose

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Fig. 2. Comparison of conventional and condominial system designs.

to implement a condominial water supply and sanitation system modeled on efforts from Bolivia and Brazil (Melo, 2005, 2007). The condominial system offers a less expensive alternative to conventional systems for several reasons. The unit of service is a block or cluster of houses instead of individual houses. Households are then connected to branch lines within each block instead of connecting every household directly to a principal line (Fig. 2). In Cardozo, both water lines and sewer lines within each block were also routed along existing sidewalks instead of being constructed in the streets. These factors reduced project costs by considerably shortening the length of trench excavated and reducing the diameter of the pipe installed. CARE Peru’s MUSA project estimated that installation of condominial systems would cost 40% less than a conventional system. The increased savings associated with the installation of condominial systems offer poorer communities a large advantage, since these savings can be applied to increased coverage. Significant operational advantages also exist with condominial systems because operational problems are isolated at the block or cluster level. Community maintenance of water and sewerage infrastructure is enhanced as any blockages or other problems in sewer or water lines affect multiple houses, helping to ensure that repairs are done quickly. CDC scientists and CARE Peru staff convened stakeholders from Iquitos to develop the Local Monitoring System for Environmental Health Risks (known by its Spanish acronym, SIMOLORSA), a local environmental health risk monitoring system, to monitor the installation and effectiveness of the condominial water and sanitation infrastructure in Cardozo. The basic components of

SIMOLORSA were comprised of source water quality analysis, sanitary inspection, and corrective action. SIMOLORSA consisted of 6 sanitary surveys: household sanitation, inspections for private (dug and driven point wells) and public driven point wells, household management and storage of drinking water, and municipal water infrastructure; and established more frequent laboratory microbiological analysis of water sources used by the community. The sanitary surveys were based on examples described in the second edition of the WHO Guidelines for drinking-water quality (WHO, 1997) that describe surveillance and control of community supplies. Hygiene education CARE Peru’s MUSA project used the Self Esteem, Associative Strengths, Resourcefulness, Action-Planning, and Responsibility – Participatory Hygiene and Sanitation Transformation (SARARPHAST) methodology to promote improved hygienic practices in the community (WHO/UNDP-WSP, 1997). By promoting health awareness and emphasizing the importance of making environmental and behavioral changes, the methodology encourages communities to take direct control of their water provision and sanitation-related services, an important sustainability component of a demand-responsive approach (World Bank, 1998). Additionally, CARE Peru encouraged community participation in training and data collection activities to strengthen the inclusion of local perspectives, an important measure to mobilize interest and ensure sustainability in development efforts (UNFPA, 2001). As part of

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Table 1 Evaluation results of knowledge of those families who participated in the SARARPHAST health and hygiene educational sessions. Group

Attended Not-attended Total

Number of correct responses out of 20 on SARAR-PHAST health and hygiene questionnaires (n = 73) >17

13–16

11–12

<10

Total

11 (26%) 0 (0%) 11 (15%)

17 (40%) 4 (13%) 21 (29%)

11 (26%) 11 (37%) 22 (30%)

4 (9%) 15 (50%) 19 (26%)

43 30 73

the SARAR-PHAST methodology, household visits and community meetings were used as opportunities to train residents on ways to use and maintain the new condominial water and sanitation facilities after installation. Noting the importance of traditional practices and attitudes (Gupta et al., 1998), CARE Peru took special consideration when addressing cultural mores to promote behavior change in the community. For example, particular emphasis was placed on educating families on proper usage and maintenance of indoor sanitation facilities and plumbing to prevent unnecessary blockages. Health The health clinic Local Communities for Health Administration (Comunidad Local de Administración de Salud [CLAS]) Cardozo strengthened surveillance of diarrheal disease to track changes in health. CLAS Cardozo collected diarrheal data by the MUSA project area (i.e., a small subset of the Cardozo settlement consisting of 11 blocks where CARE Peru originally organized project activities), and CLAS Cardozo service area and by age group. Results Hygiene education Care Peru trained community residents during March 2003 and April 2004 to form a cadre of voluntary environmental health promoters. Twenty-two teachers, 22 voluntary environmental health promoters, and 10 block representatives participated in a series of four workshops conducted by CARE Peru. The workshops prepared trainers to work with and train community members using nine health and hygiene educational modules developed using the SARAR-PHAST methodology: contamination routes; contamination barriers; sanitary hygiene; diarrheal disease; parasitic infections; water and wastewater services before and after new infrastructure; proper hand-washing technique; water and wastewater solutions; and drinking water disinfection. A total of 976 families from Cardozo and six adjacent communities attended from one to seven educational sessions using the SARAR-PHAST health and hygiene methodology. Of those families, 561 participated in four or more of the educational sessions. When training sessions were completed, CARE Peru randomly selected 73 families from the community: 43 who had participated in the health and hygiene educational sessions and 30 who had received no training. All families were administered a 20-question evaluation to test their knowledge of the nine health and hygiene modules (Table 1). Of the target population, 66% scored with 13 or more questions correct, compared to only 13% of the control group. Accompanied by CLAS Cardozo personnel, the voluntary environmental health promoters visited Cardozo households to teach households how to prepare a sodium hypochlorite solution to disinfect their household drinking water. The Loreto Regional Health Directorate had always provided granulated chlorine free to the community. Additionally, the CLAS Cardozo health clinic served as a resource center for residents from Cardozo and adjacent settlements seeking information on household disinfection of

Fig. 3. Households requesting granulated chlorine to disinfect drinking water in the CLAS Cardozo service area from January 2002 to December 2004.

drinking water. CLAS Cardozo tracked the number of households requesting granulated chlorine (Fig. 3) and reported that in the 3-year history of granulated chlorine being provided to community residents, demand had never exceeded supply until 2004. The voluntary environmental health promoters were trained by CDC scientists and Executive Environmental Health Directorate (Direccion Ejecutiva de Salud Ambiental [DESA]) environmental health specialists with the participation of CLAS Cardozo environmental health personnel. Upon the completion of training, the voluntary environmental health promoters received educational materials (i.e., visual flipcharts for use in households where literacy was an issue) and chlorine residual test kits. Every month, the voluntary environmental health promoters measured chlorine residuals from household drinking water containers and community-managed, driven point wells with elevated storage tanks that were sometimes chlorinated. The collected data on chlorine residuals and microbiological analysis formed the basis of SIMOLORSA and was essential for the management of drinking water quality. When low chlorine residuals were encountered, the voluntary health promoters solicited granulated chlorine from CLAS Cardozo, prepared chlorine solutions, and taught households how to disinfect household drinking water. The voluntary environmental health promoters and environmental health specialists from the DESA participated in the development and implementation of SIMOLORSA modeled on suggestions made in the WHO Guidelines for drinking-water quality (WHO, 1976, 1993, 1997, 2004). Voluntary environmental health promoters implemented and calculated sanitary survey risk scores, shared the results with households, and took steps to improve household handling and storage of drinking water. The health promoters also shared water quality results from the Iquitos drinking water reference laboratory and DESA laboratories (Figs. 4 and 5) with residents to encourage the collection of drinking water from the safest sources and to improve disinfection of household drinking water. Infrastructure development Care Peru’s MUSA project organized stakeholders and leveraged investments so that the distribution system of the Loreto potable water and sewage system service provider (EPS SEDALORETO SA in Spanish) was extended 1.3 kilometers into the southern zone of Iquitos, where Cardozo is located. In July 2004, EPS SEDALORETO SA tested municipal water being distributed into Cardozo’s condominial water system for biological contamination and chlorine residual. EPS SEDALORETO SA indicated that all results were satisfactory and complied with regulations. By August 2004, the

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Fig. 4. Percent of contaminated water samples by water source and by indicator organism in Cardozo Project area from November 2003 to November 2004.

EPS SEDALORETO SA reported that all 1030 households in the Cardozo project area had access to a connection and were receiving municipal water via the condominial system; by the end of September 2005, 836 of 1030 (81%) households had signed contracts. The costs for connecting to the new condominial water system and paying monthly water fees were subsidized under an agreement CARE Peru arranged with EPS SEDALORETO SA. The cost of connecting to the condominial water system to receive the municipal water supply was $16.75 (2005 exchange rate S/. 3.4 Peruvian Soles = $1.00 U.S.). Households were required to pay an initial $3.00 connection fee and to pay $2.75 for the following 5 months until the connection fee was fully paid. The usual connection fee in Iquitos in 2004–2005 was $97.00 and monthly water tariffs were $5.58. Cardozo residents were charged $2.64 per month for water services. The new condominial water system provided intermittent service depending on EPS SEDALORETO SA, with water being available for several two-hour intervals during the day. EPS SEDALORETO SA collected water samples monthly to monitor chlorine residual (Table 2). Free chlorine residual was maintained throughout the distribution system when the system was pressurized. In addition, this free chlorine residual would help to provide a barrier against microbial contaminants that could have entered the system during periods when the system was not pressurized. By October 2005, 10 of the existing 13 community-managed, driven point wells had been sealed off in Cardozo. Only three of the wells remained opened to serve as the main water sources for households bordering the Cardozo settlement that did not have access to the new condominial water supply system. At the close of MUSA project activities in 2005, the condominial sewerage infrastructure was nearing completion; Peru’s My Neighborhood Program (Programa Mi Barrio, in Spanish) had not started construction of the wastewater treatment component.

Fig. 5. Percent of contaminated water samples (n = 54) by indicator organism for household drinking water containers in Cardozo Project area from November 2003 to November 2004.

Health

installation of Cardozo’s condominial water system infrastructure was complete and households were receiving municipal water. EPS SEDALORETO SA promoted and monitored the registration of Cardozo households that signed new contracts to have connections to the municipal water supply (Fig. 6). In December 2004, voluntary environmental health promoters had verified that 517 (76%) of 680 homes had in-house connections, 46 (7%) were using a hose to bring water from the new condominial system into the household, and 117 (17%) had connections to the new condominial water system located outside of the household. In October 2004,

CLAS Cardozo serves approximately 18,000 residents living in and around the settlement of Cardozo. According to an environmental health survey conducted by CARE Peru’s MUSA Project in 2002, 78% of residents attended the clinic for medical services. The remaining 22% reported attending other clinics in the southern zone of Iquitos or using traditional medicine (i.e., folk medicine). Children less than 5 years of age made up 12% percent of the population. In Fig. 7, the number of cases of diarrhea for children less than 5 years of age is shown disaggregated by CLAS Cardozo service area and by MUSA project area. The number of diarrheal cases

Public Register of New Contracts-Connections to Municipal Water Supply, Cardozo, Peru from August 2004 to September 2005 81.2

300

90.0 80.0

350

70.0

64.3

60.0

250

50.0 200

40.0

150

30.0

100

20.0

50

10.0 0.0

0

Percent Contracted

Number of New Contracts

400

Month Percent Contracted

Number of New Contracts

Fig. 6. Public register of new contracts-connections to municipal water supply, Cardozo, Peru from August 2004 to September 2005.

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Table 2 Free chlorine residual in the distribution networks in Manual Cardozo Davila from September 2004 to October 2005, as reported by EPS SEDALORETO SA. Month

Number of samples

September 2004 October 2004 November 2004 December 2004 January 2005 February 2005 March 2005 April 2005 May 2005 June 2005 July 2005 August 2005 September 2005 October 2005

52 48 50 50 50 48 50 52 52 50 48 50 50 50

Percent of samples with free chlorine greater than or equal to 0.5 mg/l 98 97 98 98 97 100 100 98 98 97 97 98 98 98

in children less than 5 years of age decreased by 37% from 2003 to 2004 in the MUSA project area, and decreased 46% in the CLAS Cardozo service area. Discussion In 2000, the Cardozo community had been working for over 18 years to receive improved municipal services such as community water and sewer systems. Numerous barriers had prevented the community from achieving the goals of improved services and consequent better health. Prior to the start of CARE Peru’s activities in Cardozo, the community was disorganized and uncertain about environmental health issues and had failed to identify and communicate priorities to political leaders. Cardozo residents were not engaged in a process to set their priorities and did not have an action plan to move toward goals. Most residents in the Cardozo community lacked title to their land, a fact which weakened their standing when they tried to interact with district municipal authorities. With PACE EH, CARE Peru’s MUSA project used a community-centered, demand-driven process to mobilize residents and overcome these barriers. The degree to which residents can be mobilized is believed to reflect demand for condominial systems, and demand is linked to project success (Sara and Katz, 1997). CARE Peru’s MUSA project amplified community participation by empowering residents to also participate in construction and maintenance of the condominial water and sanitation infrastructure. By identifying the principal environmental health issues, formulating solutions to these issues, and empowering local decision-making, the Cardozo community as a whole was able to achieve access

Fig. 7. Number of cases of diarrhea in children less than 5 years of age in CLAS Cardozo service area and MUSA project site from January 2002 to September 2005.

Minimum free chlorine concentration, mg/l

Average free chlorine concentration, mg/l

Maximum free chlorine concentration, mg/l

0.3 0.3 0.3 0.3 0.4 0.5 0.6 0.3 0.4 0.3 0.3 0.4 0.3 0.4

1.5 1.4 1.6 1.5 1.5 1.8 1.7 1.5 1.6 1.4 1.3 1.4 1.6 1.5

2.2 2 2.5 2.4 2.5 2.6 2.6 2.4 2.5 2.3 2.1 2.2 2.5 2.4

to municipal piped water and sanitation. This stakeholder-based, demand-driven process also led to outcomes beyond this infrastructure, as further discussed below. The community maintained a consensus on priorities through large-scale political changes, helping to keep those priorities on the municipal agenda and attracting further resources to keep the process for eventually implementing the condominial water and sanitation interventions moving. Health, as measured by cases of diarrhea reported to the local clinic, also improved, and additional resources were devoted to the local health clinic. During 2001–2005, CARE Peru’s MUSA project guided the Cardozo community through a series of activities, goal setting and accomplishments, all of which empowered Cardozo residents to exert influence and bargain effectively with elected and appointed officials. Even during periods of expected and unexpected political changes in the local government, the community’s influence was consistent, and the priorities did not change. Having connections to municipal water and sanitation remained on the agendas of both the community and local elected officials such as district mayors. CARE Peru’s MUSA project established and convened residents through an inter-institutional committee to improve environmental health (Comite Interinstitucional para el Mejoramiento de la Salud Ambiental [CIIMSA]). This committee brought together state institutions, the community, private and public entities, and international cooperation to reach consensus on environmental action plans. CIIMSA was modeled after Coordinating Bodies for the Fight against Poverty (Mesas de Concertación para la Lucha contra la Pobreza), created by Peruvian law in 2001 to combat the effects of poverty. The CIIMSA concept, facilitated by CARE Peru and community representatives, kept residents and other stakeholders involved, and when needed, mobilization was sufficient in the community to overcome obstacles. This progress was especially apparent when lack of property titles threatened to derail the installation of the condominial intervention. CIIMSA meetings led to a threshold level of land tenure requests by families and tenants and kept the project activities moving forward. CIIMSA’s activities were formally recognized at the national level in 2004, when Mrs. Elina Rivas, the CIIMSA President, was awarded the Citizen’s Management Award (Gestion Ciudadana [Sumando Esfuerzos]), offered by the Network for the Development of Social Sciences in Peru, an entity supported by the Ford Foundation. Donors and financiers in the region became increasingly willing to support a community demand-driven process that had maintained clear priorities over time and engendered a good chance of project success. The Ministry of Work and Employment Promotion supported the project by paying local residents for their participation in the construction of the condominial system. In addition to the contributions from the Ministry of Work and Employment

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Fig. 8. Shared financial responsibility for the implementation of the Cardozo condominial water and sewerage project.

Promotion and community residents, CARE Peru’s MUSA project helped to leverage financial support from the provincial municipality of Maynas, the district municipalities of Belen and San Juan Bautista, the Urban Work Program (Programa a Trabajar Urbano), and EPS SEDALORETO SA, which reinforced the original United States Agency for International Development investment (Fig. 8). The initial investment in the community level PACE-EH process eventually led to the leveraging of all of these funds, resulting in a total investment of $501,747. In complement to the project, the CIIMSA Cardozo and the district municipality of Belen obtained $705,000 investment commitment from the national investment program My Neighborhood Program to construct an elevated water-storage reservoir with a capacity of 250 m3 (250,000 l) for Cardozo and a waste water treatment system to prevent contamination of the Itaya River, a tributary of the Amazon River. In October 2004, since CARE Peru and the organized community had leveraged so many additional resources to install the water and sanitation infrastructure, EPS SEDALORETO SA agreed to reduce the monthly water tariff for Cardozo residents from $5.60 to $2.75 per month. Additionally, the household cost of initiating a new contract in Cardozo was reduced $80.25. The Cardozo community, along with the majority of Iquitos, had a monthly fixed charge. EPS SEDALORETO SA had been installing water meters throughout Iquitos: 1000 in 2005, with 2000 installations planned for 2006. No meters were scheduled to be installed in Cardozo; therefore, consumers there would continue to have unlimited access to water through 2005. In 2005, EPS SEDALORETO SA staff expressed concern that the subsidy of water tariffs in Cardozo was not sustainable and risked causing problems in other sectors in the city that would continue to pay regular established fees. Another cause for concern was users with a connection supplying unconnected households, because there would be no corresponding increase in the water bills. By September 2005, most of this concern had subsided since more than 80% of the community had signed a new contact to have a connection to the condominial water supply. The subsidy to encourage households to connect to the system appeared to have achieved its intended result. In Cardozo, CARE Peru implemented the methodology SARARPHAST for the first time in the region. A group of voluntary environmental health promoters collected information for the local environmental health monitoring system, SIMOLORSA. Working closely with CLAS Cardozo, the staff from DESA, and the National Ministry of Health, inaugurated the SIMOLORSA on April 29, 2004; it was touted as a model project for other periurban areas throughout the country.

Populations at disproportionate risk from waterborne diseases need effective measures at the household level to ensure the provision of safe drinking water, prevent illness, and improve health. Foregoing effective measures at the household level until communities are provided piped, safe water is an inappropriate response (WHO, 2002). CARE Peru’s MUSA project promoted activities in Cardozo that ensured residents would receive education and training on both household and community level interventions to increase access to safe water. CARE Peru staff, voluntary health promoters, and CLAS Cardozo staff worked with residents to understand the risks associated with hauled water and a non-continuous water supply, poorly constructed wells, and the potential for recontamination during storage. The collaborative response forged by CARE Peru led to increased use of chlorine to disinfect household drinking water in 2004, before the EPS SEDALORETO SA piped water system was installed. Efforts to disinfect household drinking water supply remained strong for approximately 6 months. The decrease in the request for granulated chlorine to produce a hypochlorite solution to disinfect drinking coincided with decreased activities of the voluntary environmental health promoters working with CLAS Cardozo to distribute chlorine granules and the arrival of treated, piped water. The growing success of CARE Peru’s MUSA project not only resulted in the installation of the condominial water and sanitation infrastructure and improved community organization, but it also helped local organizations receive more support and recognition for their leadership. In January 2004, the CLAS Cardozo health clinic was moved to a new facility within the settlement and received additional staff and resources. Increases in personnel and equipment led to an amplification of the service area and a corresponding increase in the population served. In 2004, the number of cases of diarrhea for children less than 5 years of age decreased in the service area, even though CLAS Cardozo was able to attend to more patients. The 37% reduction in diarrheal disease in the MUSA project area, and the 46% reduction in the CLAS Cardozo service area need to be understood in the context that diarrheal incidence changes yearly as a result of multiple factors. Therefore, the ability to draw conclusions from comparisons of historical incidence rates is limited, and attributing diarrheal disease reduction solely to the interventions is not possible in this case. However, similar, rigorously evaluated water supply interventions have shown a median diarrheal disease reduction of 17% (Esrey et al., 1991). Additionally, meta-analysis of water, sanitation, and hygiene interventions, and their combination, suggests these types of interventions are effective at reducing diarrheal illness (Fewtrell et al., 2005). An important measure of sustainability for water supply systems considers whether the supply is adequate (e.g., access is improved by positively affecting indicators of quantity, quality, coverage, continuity, and cost – indicators known as adequacy of supply) (WHO, 2004). In Cardozo, adequacy of supply indicators improved. Providing household connections and water taps in yards had likely increased the quantity available because residents were no longer limited by what they could carry or by long wait times to collect water; others have reported that indoor water and sanitation facilities are associated with larger reductions in diarrheal morbidity (Howard and Bartram, 2003). The communities’ non-chlorinated water sources had been replaced by a condominial water supply system that delivered a treated municipal water supply. Treatment by EPS SEDALORETO SA included flocculation, sedimentation, and chlorination. Household members no longer walked long distances to collect water. Additionally, in-house water connections eliminated the likelihood that water would be contaminated during transport. The installation of condominial water and sewerage infrastructure not only included the Cardozo project area but also provided service connections to adjacent communities. Continuity of the water supply system was limited, but had

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improved sufficiently to convince residents that older community water sources were no longer necessary to maintain, as evidenced by the closing of 10 community-managed, driven point wells. Closing of the community-managed, driven point wells was significant because residents were no longer using non-chlorinated water sources that laboratory analysis and sanitary surveys demonstrated to be frequently contaminated (Figs. 4 and 5) as a result of surface water intrusion.

Future considerations Peru’s My Neighborhood Program assumed responsibility for finishing the condominial sewage treatment system and constructing an elevated water-storage reservoir that would serve Cardozo. CARE Peru MUSA staff anticipated that once construction of the reservoir was completed, residents would have improved access to water including increased quantity and continuous service of a treated water supply. Impacts on the reduction of diarrheal disease from improved water quality coupled with improved continuity and quantity are greater than just improved quality (Fewtrell et al., 2005; Esrey et al., 1985). Maintaining continuity of the new Cardozo water supply system is a challenge and may present some risk. Gaps and leaks in some sections of the water distribution system and intermittent water supply service allow the system to depressurize. The depressurization and gaps in water service lines may lead to intrusion of contaminants into the system and diminished disinfectant residuals. Over time, the lack of disinfectant residual, one of the main factors enhancing biofilm formation (EPA, 1992) will present on-going concern for deteriorating water quality until EPS SEDALORETO SA can improve continuity of service. To overcome problems with steep grades and rainwater runoff, the CARE Peru MUSA project planned for the construction of a separate drainage system for rainwater. At the termination of project activities in 2005, whether the drainage system would prevent rainwater from overwhelming the capacity of the condominial sewerage infrastructure was unclear. Health benefits resulting from improved water supply systems are amplified when accompanied by improved sanitation and better water storage practices (Checkley et al., 2004). Future efforts to assess sustainability of the condominial water and sanitation infrastructure in Cardozo should include an assessment of the condominial sewerage infrastructure and sewerage treatment system, sanitary surveys of the community, and indicate whether the construction of the water reservoir improved continuity of the piped-water supply to the Cardozo community.

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