Balancing Financial Viability and User Affordability: An Assessment of Six WASH Service Delivery Models

This Topic Brief presents assessments of the financial performance of six WSUP-supported WASH service delivery models in Bangladesh, Madagascar, Mozambique and Zambia. Each model has been developed in partnership with locally mandated service providers to facilitate sustainable, at-scale improvements to low-income urban populations

A Ward-by-Ward Approach to Eliminating Open Defecation: Experience from Visakhapatnam, India

The Government of India launched the Swachh Bharat Mission (SBM) in 2014 with the ambitious aim to ensure hygiene, waste management and sanitation across the nation by the 150th anniversary of Gandhi's birth in October 2019. This document aims to build on existing knowledge by detailing how the challenge of achieving universal sanitation and Open Defecation Free (ODF) status has been approached by Visakhapatnam in Andhra Pradesh, presenting nine stepping stones which together constitute a pathway towards citywide ODF status

Smart meters: innovating to improve water supply in a post-COVID context

In cities across Africa, rapidly expanding low-income communities (LICs) pose unique technical and social challenges to utilities in expanding services – but they also present an opportunity to expand the customer base and generate revenues. COVID-19 is placing huge additional pressures on the financial viability of utilities, exacerbating the need for innovative service delivery models to this segment of the customer base. In the context of short and long-term challenges posed by COVID-19, water utilities must take every measure available to improve the efficiency of operations: service quality and attention to the customer will be even more important; greater control will be required over the distribution network; and billing and revenues will need to be maximized to support the bottom line.Smart Water Meters are a new technology with the potential to assist utilities in this process of transformation. The model offers greater control for the customer, through a flexible prepayment tailored to the spending habits of low-income households; and greater control for the utility, enabling real-time data on water demand across the supply area, and supporting a shift from reactive firefighting to preventative planning. Pilots of the technology to date have produced good results; however, more testing is needed, particularly in LICs. One project expected to inform the evidence base is a pilot of 500 smart meters recently underway in Watamu, in the Kenyan district of Malindi

Bringing toilets back to Kumasi's compound houses: landlord and tenant behaviours and motivators

In the low-income urban communities of Kumasi, Ghana, a large part of the population live in compound housing, where they often share the same living space with more than 20 tenants. Partly resulting from the high prevalence of public toilets in the city, the vast majority of these tenants have no access to ‘inhouse’ sanitation. Led by the Kumasi Metropolitan Assembly, a five-year strategy is being prepared to promote increased adoption, access, usage and maintenance of compound toilets in Kumasi’s lowincome communities. This paper shares the results of a desk and field-based study commissioned to inform the strategy: among the key challenges to be confronted are the clarification of responsibilities between landlords and tenants with regards to financing sanitation improvements, and the need to motivate landlords - at the hub of compound level sanitation governance - to improve the situation for the betterment of their tenants

Safe faecal sludge emptying and transport: compliance challenges and models for a public good

In the 81 countries where most urban dwellers rely on faecal sludge (FS) emptying and transport, services are frequently provided by a heterogeneous private sector. Considering the responses of service providers is essential to ensuring that the regulatory frameworks put into place achieve their intended outcomes and safeguard public and environmental health. Combining a literature review and expert practitioner input, we identify priority challenges for scaling safe FS emptying and transport (E&T) services and use these to adapt a holistic model of business compliance. We confirm well-documented challenges such as cost structures for compliance with regulation, the perception of services as low status, and an inadequate enabling environment. We identify the importance of trust in building voluntary compliance as a novel issue for sanitation but widely discussed in the regulation literature. We also identify a distinct role for the regulator as a catalyst for change. The role of disgust as a policy barrier and the application of behavioural theory to building compliance are areas warranting further research. This is the first paper to explicitly consider the regulation of FS E&T through a compliance lens, linking established areas of the regulation literature to new findings in urban sanitation.This research was funded by the UKRI Engineering and Physical Sciences Research Council (EPSRC grant number EP/S022066/1) through the Center for Doctoral Training in Water and Waste Infrastructure and Ser vices Engineered for Resilience (WaterWISER)H2Open Journa

Feasibility study for supporting medication adherence for adults with cystic fibrosis: mixed-methods process evaluation

Objectives: To undertake a process evaluation of an adherence support intervention for people with cystic fibrosis (PWCF), to assess its feasibility and acceptability. Setting: Two UK cystic fibrosis (CF) units. Participants: Fourteen adult PWCF; three professionals delivering adherence support (‘interventionists’); five multi-disciplinary CF team members. Interventions: Nebuliser with data recording and transfer capability, linked to a software platform, and strategies to support adherence to nebulised treatments facilitated by interventionists over 5 months (± 1 month). Primary and secondary measures: Feasibility and acceptability of the intervention, assessed through semistructured interviews, questionnaires, fidelity assessments and click analytics. Results: Interventionists were complimentary about the intervention and training. Key barriers to intervention feasibility and acceptability were identified. Interventionists had difficulty finding clinic space and time in normal working hours to conduct review visits. As a result, fewer than expected intervention visits were conducted and interviews indicated this may explain low adherence in some intervention arm participants. Adherence levels appeared to be >100% for some patients, due to inaccurate prescription data, particularly in patients with complex treatment regimens. Flatlines in adherence data at the start of the study were linked to device connectivity problems. Content and delivery quality fidelity were 100% and 60%–92%, respectively, indicating that interventionists needed to focus more on intervention ‘active ingredients’ during sessions. Conclusions: The process evaluation led to 14 key changes to intervention procedures to overcome barriers to intervention success. With the identified changes, it is feasible and acceptable to support medication adherence with this intervention. Trial registration number: ISRCTN13076797; Results

Supporting medication adherence for adults with cystic fibrosis:a randomised feasibility study

Background Preventative medication reduces hospitalisations in people with cystic fibrosis (PWCF) but adherence is poor. We assessed the feasibility of a randomised controlled trial of a complex intervention, which combines display of real time adherence data and behaviour change techniques. Methods Design: Pilot, open-label, parallel-group RCT with concurrent semi-structured interviews. Participants: PWCF at two Cystic Fibrosis (CF) units. Eligible: aged 16 or older; on the CF registry. Ineligible: post-lung transplant or on the active list; unable to consent; using dry powder inhalers. Interventions: Central randomisation on a 1:1 allocation to: (1) intervention, linking nebuliser use with data recording and transfer capability to a software platform, and behavioural strategies to support self-management delivered by trained interventionists (n = 32); or, (2) control, typically face-to-face meetings every 3 months with CF team (n = 32). Outcomes: RCT feasibility defined as: recruitment of ≥ 48 participants (75% of target) in four months (pilot primary outcome); valid exacerbation data available for ≥ 85% of those randomised (future RCT primary outcome); change in % medication adherence; FEV1 percent predicted (key secondaries in future RCT); and perceptions of trial procedures, in semi-structured interviews with intervention (n = 14) and control (n = 5) participants, interventionists (n = 3) and CF team members (n = 5). Results The pilot trial recruited to target, randomising 33 to intervention and 31 to control in the four-month period, June–September 2016. At study completion (30th April 2017), 60 (94%; Intervention = 32, Control =28) participants contributed good quality exacerbation data (intervention: 35 exacerbations; control: 25 exacerbation). The mean change in adherence and baseline-adjusted FEV1 percent predicted were higher in the intervention arm by 10% (95% CI: -5.2 to 25.2) and 5% (95% CI -2 to 12%) respectively. Five serious adverse events occurred, none related to the intervention. The mean change in adherence was 10% (95% CI: -5.2 to 25.2), greater in the intervention arm. Interventionists delivered insufficient numbers of review sessions due to concentration on participant recruitment. This left interventionists insufficient time for key intervention procedures. A total of 10 key changes that were made to RCT procedures are summarised. Conclusions With improved research processes and lower monthly participant recruitment targets, a full-scale trial is feasible

Surmonter les barrières institutionnelles et organisationnelles à l'assainissement : quoi de neuf ?

Ce rapport technique porte sur la manière de surmonter les barrières institutionnelles et organisationnelles au développement de l'assainissement. Il rassemble des communications de chercheurs et d'opérationnels sur des travaux qui renouvellent le regard sur cette question. Un consensus se dégage sur la reconnaissance de la multiplicité des modes de production du service de l'assainissement, tantôt collectif, tantôt autonome ou non conventionnel, qui accroit la complexité de sa gestion

Compliance frameworks for safe emptying and transport of faecal sludge

This record contains an extended abstract and MP4 presentation. Presented at the 43rd WEDC International Conference.</p

Bringing toilets back to Kumasi's compound houses: landlord and tenant behaviours and motivators

In the low-income urban communities of Kumasi, Ghana, a large part of the population live in compound housing, where they often share the same living space with more than 20 tenants. Partly resulting from the high prevalence of public toilets in the city, the vast majority of these tenants have no access to ‘inhouse’ sanitation. Led by the Kumasi Metropolitan Assembly, a five-year strategy is being prepared to promote increased adoption, access, usage and maintenance of compound toilets in Kumasi’s lowincome communities. This paper shares the results of a desk and field-based study commissioned to inform the strategy: among the key challenges to be confronted are the clarification of responsibilities between landlords and tenants with regards to financing sanitation improvements, and the need to motivate landlords - at the hub of compound level sanitation governance - to improve the situation for the betterment of their tenants