In our discussion of implementation models, we talked about the differences between profit maximizing approaches and those that prioritize social goods, like disease reduction. We looked at how different strategies might be applied by conventional, profit oriented businesses, or not for profit organizations, or social businesses, kind of combining some aspects of both. But success of HWTS is not only about the private sector and NGOs, governments have very important roles to play, but which governments and what roles? Well, one important role of governments is around national policies and regulations. And in fact, the international network for HWTS, has set targets around national policies and regulations. First is that, by 2015, at least 30 countries should have established national policies or regulations about HWTS. And this one is on track. There was a survey done a few years ago, in 2012, which found eight countries already with targets and more than 22 with policies. And the second target is to reach 50 countries by 2020, which have achieved countrywide scale up of project based HWTS. And this second target, at least in 2012, wasn't yet on track. The international network for HWTS, which was introduced by Michael Forson a few weeks ago, made a global review of the policy and regulatory environment around HWTS a few years ago. And they received responses from 46 countries, nearly half from Africa, but with at least some responses from all around the world. In over half of these countries, the ministry of health was identified as the lead in issues relating to HWTS. And in several other countries, the ministries of water or environments were the leads. But there were a number of other government agencies listed including the ministry of rural development in Cambodia. The Ministry of Social Affairs in Estonia and the Ministry of Housing and Construction in Syria. Regardless of which ministry is the lead, HWTS is a cross cutting issue and requires coordination between different ministries. Like the ones above. But also, frequently, information on HWTS is integrated into school curricula. So, ministries of education must be involved. And if technologies are to be certified, or endorsed, National Bureaus of standards or other regulatory authorities may be involved. In fact, this survey found that more than 90% of countries reported having a collaboration between two ministries. And in more than half of countries, three or more ministries were involved. Now, all that sounds great. In practice, it can mean that progress is slow, since everybody has to get on board. So, nearly 2/3rds of the countries in that survey had established an inter-ministerial committee to coordinate HWTS activities. And that's mostly at the national level. Many of these ministries have presences at the regional district and local levels or municipalities in the case of large cities. Or there may be big gaps in knowledge and capacity about HWTS. But these government workers are the ones who would need to be involved with any field level implementation of HWTS. So, there are certainly multiple different government entities that could play roles in HWTS. How can we classify or organize all the different roles that governments could play with respect to HWTS? Well, there are, of course, many different ways, but one that I like is to approach the role of government from a human rights perspective. There's been a lot written about the responsibilities of governments regarding human rights and the UN has recently recognized access to safe drinking water as a human right, so it seems appropriate. And in the human rights framework, the responsibilities of government, states, can be divided into three sets. The obligations to respect, to protect, and to fulfill rights. Respecting rights means that governments should not interfere, either directly or indirectly, with a human right. And protecting rights means that governments should prevent other parties from interfering with human rights. For instance, the government could pass laws or regulations that prevent pollution of drinking water resources. In this last category, the duty to fulfill human rights, that can be further broken down. States can facilitate a right by taking positive measures that help people to enjoy the right to safe drinking water. States can promote a right by, for example, making sure that there's adequate education around the importance of safe water, and sanitation and hygiene. And states are obliged to provide a right when people are unable, for reasons beyond their control, to realize that right on their own, and with the means at their disposal. Let's take some concrete examples. One important role that government can play is about access to information. Making sure that complete and correct information is available to those who need it. Governments can make themselves aware, at different levels and in different sectors, about the links between HWTS and health. They can take stock of the existing drinking water situation, especially considering household water quality. And see if people could benefit from using HWTS. National health and water coverage statistics are available in nearly all countries, managed by the government. But might not be widely known to all. So a first step that governments could support could be to do a situation assessment, a review of the situation, and compile the relevant information in one place. Another important role, that is another kind of facilitation, is the role of coordination. There are many different stakeholders involved in HWTS, and governments can make a really important contribution by ensuring that these stakeholders know about each other. This can be achieved through a survey of ongoing HWTS activities and stakeholders. And local universities or research institutions could be brought in to fill knowledge gaps, and the government can host sector forums, to share experiences in a very productive way. Another part of coordination is the need for monitoring and evaluation. This is a key responsibility of government which might require establishing new indicators and monitoring systems, building up capacity, especially at local levels, and perhaps investments in new facilities and equipment. If we next consider promotion, HWTS will definitely be more credible if its promotion is endorsed or led by governments. A common action here is to support development and funding of a national communication strategy and campaign. Usually these are non-branded since governments often don't want to be seen as giving preference to one commercial entity over another. Governments, typically, are willing to endorse or promote only technologies that have been verified. And there's currently a real lack of systems and capacity for doing piloting and assessing of technologies before scale up. And ideally, there should be a range of options available that could be promoted for different audiences and use some different circumstances. WHO has recently launched a scheme for evaluation of household water treatment technologies described in this report. And we'll have a guest lecturer from the WHO go over the scheme in more detail next week. Finally, promotion of HWTS can be linked with other health or development priorities as we saw the example of integration of HWTS with education or health initiatives. And these kinds of integrations often require a supporting policy environment. Finally, governments do have a responsibility to provide services if other actors do not provide them in a way that's accessible to all. This doesn't mean that services have to be provided for free, but they do have to be available at an affordable price. So, there is a possible role for subsidy of HWTS which could take different forms. There could be direct subsidies in the form of reduced prices for products which might be targeted only towards the poor. Or there could be indirect subsidies. For example, by supporting the costs of promotion through media or distribution through human resources and institutions. And a third kind of subsidy, an indirect subsidy, could be to relax the import duties on HWTS products that have to be imported. If government workers, from whatever sector, become involved with provision of HWTS products and services, they will typically need substantial support and capacity development at different levels. This is another aspect of government's role in creating an environment where HWTS can succeed. Well, there are a lot of different types, obviously, of roles that governments can play and of actions that could be taken. And a convenient way to package them together in a coherent framework is that of national action planning. And the HWTS Network has some guidance and some templates on elements that should go into national action planning. First of all, there should normally be a background and rationale to have an HWTS action plan that involves things like the literature review and assessment and diagnosis of the situation. Next, establishing an overall purpose, which might be to reduce disease, since there is a health focus. And guiding principles, such as targeting vulnerable groups to achieve the greatest gains. Another important principle to establish is that HWTS is not in competition with or replacing conventional water supply. But is seen as a complementary, short-term measure until the long-term goals of safe, sustainable water at home can be achieved for all. Certainly a concrete, element in a national action plan should be a goal. Which should be time based by some certain year, and might have some specific proportion of the population, who don't yet have sustainable access to piped water supply in the house. Who are practicing an effective HWTS method, in a way that makes the water safe to drink or in compliance with national standards. Once that goal is established then, a number of strategies and action items can be determined, which will be very context specific. And another activity that's very context specific is a clear delineation of the responsibilities of the different stakeholders involved. Both the government stakeholders and the non-government ones, including, private sector, NGOs, universities, research institutes, development partners, etc. By now there are many countries, more than 22, that have established action plans and policies for HWTS, but one nice example I like to share is that of Tanzania. And in preparation for establishing an HWTS strategy and plan. The first thing that was done was a sector review. A situation assessment. Where there's very high mortality from diarrhea. This shows Tanzania ranking quite high in the distribution of countries, in terms of diarrheal deaths per 100,000 population. Also, there was a high use of unsafe water. These are national coverage estimates from the joint monitoring program of WHO and UNICEF. Showing really high and persistent use of surface water and other kinds of unimproved water in rural areas. And HWTS was being promoted in the country. It was aligned with government policies but there was no coordination mechanism, so there was actually a lot of inefficiency. So, the government hosted and convened an international conference in February 2009, led by the relevant Ministries and supported by the International Network and some key development partners there. And they prepared a nice background document to go into the meeting. Laying out the reasons, the justification to develop an HWTS sector plan. So, having done their homework, the government of Tanzania then hosted this workshop in February 2009. Brought in 108 people from many different countries. And set out four key objectives. First, to learn from international experiences, both within the region and the broader global community. To review and strengthen national initiatives on expanding HWTS. To develop and strengthen partnerships, both nationally and internationally. And finally, to share experiences and document the different programs taking place within and outside the country. So a lot of the objectives here are around information management and facilitation. The conference had a number of actionable outcomes, there were 15 specific action points that were identified, I won't go into them here. But there were five broad recommendations that, that were also endorsed through the conference. The first being that the ministry, the lead ministry in this case of health and social welfare, should develop a national action plan, and strategy. That the ministry should strengthen those international partnerships. And also that the government, along with partners and other stakeholders, should allocate funds, financial resources, towards the strategic plan. That the government should play this information management and coordination role through strengthening the evidence base, through monitoring and evaluation, through developing standards. And then finally, that the government should play the overarching role of coordination and networking in the HWTS sector. These findings were shared in other regional workshops. And other countries in the region have gone through similar processes. So, that international conference really set the ball rolling in Tanzania. And within a relatively short period of time, of just a few years, the country had developed, finalized, and endorsed a strategy and plan for scaling up HWTS over this five year period. It included a national vision, and goal, and target. So, the vision being, to have communities accessing safe drinking water at the household level. And a specific target to increase by 20%, the usage of acceptable HWTS by 2016. So that's a concrete, measurable, thing. HWTS has been taken up in a number of national policies, including the National Heath Policy, the Health Sector Strategic Plan, but also the Environmental health, hygiene and sanitation strategies. And there are lists of specific actions that the government must take to achieve these goals. And I give here just a few examples of the types of activities that government is doing here. Around facilitation, around coordination, around monitoring and evaluation. So, while it takes some time and some good ground work to establish the foundations, and develop a national strategy and action plan, that's really just the beginning. The implementation of the plan is where HWTS can really be scaled up and realize health gains. And here government play such critical roles. First, in securing the political supports and the resources necessary for implementation. Government has to play this role of coordination and leading, and can also, provide adequate financing and human resources. On the implementation of the specific measures identified in an action plan, government has many key roles, especially around building awareness in capacity at the lower levels. And finally, all of these activities that are implemented through an action plan and strategy have to be continuously modified, monitored, modified if necessary and evaluated. And here, governments, again, play the central role and one can think back to that human rights framework and consider that these actions should all be implemented in a way that is not discriminatory to any particular group, including the poor. And that though participation and transparency more long-lasting, sustainable results can be achieved. Going back to that survey that the International Network conducted of 46 countries about HWTS policies and practices. The survey identified key challenges towards policy implementation, and the the top one was around monitoring of use and impact. Other important ones were the lack of regulation and evaluation, limited awareness within government of the role of HWTS and limited coordination among ministries, and today we've talked about how government can contribute to all of those challenges. WHO also has a number of resources available through its Internet site that specifically target these challenges. For instance, there's a toolkit for monitoring and evaluation to address this challenge. There's a scheme for evaluation of household water treatment options that gets at the regulation and evaluation steps. And there are specific guidances on other topics such as integration with HIV programs, national planning and coordination in general. So, there are a lot of rich resources that can support governments in developing and implementing these national strategies and action plans. And again, on the PDF version of these slides, you'll be able to hyperlink you'll be able to click on these icons and get those reports directly. So, to summarize then, we've looked at the many responsibilities and roles that can be played by government agencies with HWTS. We've looked at them through a lens of human rights approach, thinking about the responsibilities of government to respect, to protect and fulfill rights. And we've shown that fulfilling rights can be broken down into facilitation, such as collecting and managing information, and in coordinating stakeholders, promotion, establishing policies, and strategies, action plans, endorsing certain technologies, and conducting public health campaigns. And finally, provision of services, especially targeting particular vulnerable groups. And we've seen how national strategies, and action plans can bring together these different responsibilities and roles of government into a coherent package.
