Water for Health in the Territory of Mambasa, Democratic Republic of Congo

Project location: Congo, Democratic Republic, Mambasa
Project start date: July 2012 - Project end date: August 2014
Project number: 2012-023
Beneficiary: Cesvi Fondazione ONLUS

The Democratic Republic of Congo (known as the Belgian Congo, formerly Zaire) continues to live an unstable situation. While the western part of the country, including the capital, Kinshasa, is no longer the scene of riots and violent demonstrations, in the eastern provinces there is a continuing presence of armed bands of non-governmental militias, ex-military and tribal groups, who carry out raids plundering resulting in massacres and indiscriminate violence of civilians.

Despite this situation, in the Democratic Republic of Congo most of the deaths are caused not by conflict but rather by malnutrition and diseases related to failure and collapse of the existing water and sanitation infrastructures.

Among the poorest countries in the world, the Democratic Republic of Congo (DRC) has a mortality rate of 129/1.000 births, and 205/1000 deaths of children under 5 years of age. The average life expectancy is 44 years, with most deaths related to diseases easily prevented, such as diarrhoea, respiratory infections, malaria or malnutrition. Nationally, less than 35% of the population has access to safe water and less than 30% has access to adequate health services. The lack of clean water, health and waste disposal mechanisms is exacerbated by a low level of awareness on hygiene practices. In rural areas there are no operational plans for improving drinking water quality and general investments in the water and sanitation sector by State ministries is limited and inadequate.

Local institutions show little capacity to promote initiatives in favour of human and environmental health, inadequate skills and insufficient technical and financial support for the development of water infrastructure and sanitation. At the national level, no annual plan or planning based on real needs in drinking water, hygiene and health has been defined in favour of vulnerable populations in rural areas, hence the government has not given any firm commitment in these areas and resources in government budgets are not sufficient to cover even 20% of needs. Moreover, in terms of absorption of donor funds, less than 50% of external commitments are for water and sanitation programs.

In the Eastern Province - Ituri District, unsafe water, inadequate health and poor hygiene are major risk factors for the spread of waterborne diseases, particularly in those areas where the humanitarian scenario is still characterized by violence against civilians, substantial population displacement due to insecurity and a crumbling infrastructure on the rise. Here are a few indicators of the context, through which you will understand the situation of the district where the project intervene:
- Total number of displaced people: 184,000 people;
- Total number of refugees from Ituri to neighbouring countries: 15,000 people in Uganda;
- Total number of returnees: about 75,000 people over the past 12 months;
- Maternal mortality rate: <1%;
- Infant mortality rate: 0.2 to 3.97 deaths / 10,000 pp / dd, 9 of the 30 health zones of the health district of Bunia show an infant mortality rate than the emergency threshold (IMD);
- Chronic malnutrition rate: 49.8%;
- Health care coverage (% of the Zone of Health): 58.7%;
- School attendance rate: 60%.

The project is implemented in the particular context of Mambasa Territory where unsafe water, inadequate sanitation and hygiene infrastructures are among the leading causes of diseases such as diarrhoea (with a mortality rate estimated at 25%), especially in those areas where the humanitarian scenario is still characterized by violence against civilians and by movement of displaced persons.
The territory of Mambasa remains one of the most vulnerable in terms of existing water points. Underinvestment and structural deficiencies in the national programs reflect the following issues:

- Access to drinking water only reaches 30.7% and people usually drink from shallow ponds and unprotected;
- Adequate medical coverage only reaches 4.5%, and the open-air defecation is a common practice in rural areas
- The limits of the geographical terrain (highlands, the presence of hills) discourage the dissemination of protected springs and of gravity water systems, surface water and shallow basins are therefore subject to contamination.

Following the analysis of local needs and the current situation of stability it was decided to intervene with the support of the European Union with a plan that would guarantee an improvement of access to safe water and adequate sanitation for the populations the Mambasa territory.

The project of Cesvi is aimed to the development of water infrastructure and programs of hygiene promotion supported by capacity building and strengthening of local communities and public institutions in order to ensure the durability of the results.
The technologies proposed are simple and they require little manpower to increase access to safe water.
The aim is to build protected water points with hand pumps in order to provide drinking water in targeted villages in the 3 area of the region in which Cesvi works. The infrastructure will be located along the main road of the area also to prevent the risk of violence against women and widespread insecurity of vulnerable groups in remote areas.
The impact of WASH (Water Sanitation Hygiene) interventions will be maximized by the diffusion of appropriate hygiene practices and the creation of management committees for the maintenance and sustainability of infrastructure.
Local institutions involved in the identification and evaluation of interventions in the initial phase of the project will be actively involved to monitor the positive impact on the beneficiaries of the intervention.
The SWOT analysis carried out by CESVI in August 2011, has allowed the identification of needs, risks and opportunities of this initiative, together with all relevant stakeholders: community leaders, representing the local committees, Central Area Offices and Headquarters District coordinators, UNICEF and wash cluster members.

The expected outcomes of the project, which received a grant from the Nando Peretti Foundation, are divided as follows: the first deals with the construction of structures that will have a direct impact on the quantity and quality of the water consumed by the local population. The activities of the second result will have a positive impact on the sustainability of the action as they foresee the improvement of the Local capacities of maintenance and management of WASH (Water and Sanitation) equipment. This activity will be mainly held by local partner PPSSP (Programme de Promotion de Soins de Santé Primaires).

RESULT 1: Improved access to safe water for 102.000 people of 27 Health Districts.

1.1 Construction of 100 protected springs
Such activity will be performed according to the following steps to ensure the full participation of target community and all stakeholders, and to guarantee quality delivery:
a) Community mobilization: together with the awareness campaign to sensitize people on the importance of safe water, adequate sanitation and proper hygiene practices, community participation will be encouraged through the Local Committees to institutionalize/formalize roles and responsibilities of community users, and to promote their active participation in terms of:
• Provision of construction material available locally (wood, sand, gravel ...)
• Provision of unskilled labour.
• Identification and selection of local skilled labour (1 mason) to lead the construction team on site.

b) Memorandum of Understanding: once the methodology and participative approach have been agreed, an official MoU (Memorandum of Understanding) will be signed at Zone de Santé level between CESVI, PPSSP (Programme de Promotion de Soins de Santé Primaires), the local Committee and the Steering Committee representatives to formalize mutual commitments and a shared work plan, upon which to support reciprocal accountability development.

c) Technical and logistic support for construction activities: provided by CESVI/PPSSP in terms of material (cement, iron bars, etc.), technical supervision and on the job-training, to guarantee quality delivery.

d) Each spring protection will follow the national guidelines and technical specifications needed. The captation area will be fit according to the morphology and the quality of absorption of the ground, such as to obtain a minimal capacity of 0,12 l/s. The captation area will be adequately protected from any possible contamination through layers of clay and plastic sheets. On top of the capitation area, a protection zone will be fenced and with restricted access in order to drastically reduce any chance of contamination. The gravel of the filter will be washed and selected. The incoming pipes and the overfull pipes will be in PVC material, 5cm diameter, PN10. The water collection area will be closed by an evacuation channel (minimal slope of 1,5%) which will end into an infiltration pond, at least 5m away from the spring.

e) Quality assurance and hand-over: once construction works have ended and upon quality assurance check by the Steering Committee (in the person of the SEA Superviseur Eau et Assainissement of the ZS), the infrastructure will be handed over to the Local Committee who will remain responsible for ordinary maintenance and management. Water quality testing before and after protection activities will guarantee safe water supply.

1.2 Construction of 300 protected dug wells and installation of 113 hand-pumps in those wells which serve Health Centres (n.42) and Schools (n.71).
- Community mobilization: as mentioned above
- Hand-pumps procurement process: to guarantee quality delivery, the procurement process will include the provision of specific technical training on hand-pump installation and maintenance to the Local Committee technicians in charge of ordinary maintenance; links will be developed at Zone de Santé level with the awarded service providers in order to strengthen the supply chain.
- Final site identification and selection: Crucial for the effectiveness of the activity proposed, site selection will be performed together with the Local Committee members and the SEA, in order to take into account specific needs related to the community's social fabric together with technical requirements.
- Memorandum of Understanding: as mentioned above
- Technical and logistic support for well development activities: provided by CESVI/PPSSP, in terms of material (cement, iron bars, casing, etc.), technical supervision and on the job-training, to guarantee quality delivery, with specific attention to pay on acceptance and understanding of the new technology proposed. Hand-dug wells will be equipped with hand-pumps in public infrastructure as Health Centres and Primary Schools, were the presence of local institutions and public administration staff (doctors, nurses, teachers, etc.) can strengthen and support ordinary maintenance and management activities. Specific training sessions on wells and pumping systems will complement on the job training activities in order to capacitate the Local Committee on the proper management of the new technology proposed (ref. activity 4.1)
- The hand dug wells will be deep averagely 15 m (min of water level 3 m) and will be 1,5 m large. The well casing will be done by reinforced concrete rings, each of them will be 50 cm high and 10 cm thick. The moulds for concrete casting will be prepared in steel in order to avoid any imperfection in the walls of the rings. Around the rings selected gravel will be posed as filter and on top of that selected cast quarry stones will be placed. The internal diameter of the well, after the completion of the casing procedure and the side filling will be of 1 m. The hand pumps (min recharge rate 0,7 m3/h) will be preferably of AFRIDEV quality, which have an easy maintenance. The well will have a base plug and a suspended slab constructed in reinforced concrete. The top of the well will be covered by a manhole with a metallic door for the protection of the water and the drawing up of the water for the wells with no hand pumps. The hand pumps wells will have a metallic manhole for water inspection and for the drawing up of the water in case the hand pumps might be out of order. The quality of the water will be according to SPHERE and WHO standards (absence of coliforms, PH among 6,5 and 9, turbidity less than 5 NTU, TSD less than 100gm/l)
- Quality assurance and hand-over: as mentioned above, with the addition of specific well disinfection procedures to assure water quality standards before final hand over.

RESULT 2: Improved sanitation facilities (R2)
2.1 Construction of 200 sanitation blocks of 2 latrines each, distributed in 71 Schools and 42 Health Centers.
Community mobilization: as per drinking-water sources, while focusing awareness on the importance of adequate sanitation and proper hygiene practices, community participation will be encouraged through the Local Committees (ref. to RESULT 3) to institutionalize/formalize roles and responsibilities of students and health centres' staff, and to promote the active participation of community members in terms of:
- Provision of construction material available locally (wood, sand, gravel, masonry).
- Provision of unskilled labour.
- Identification and selection of local skilled labour (1 mason) to lead the construction team on each working site.
- Memorandum of Understanding: as mentioned above, to support mutual accountability among all actors, a MoU will be signed for each Aire de Santé at Zone de Santé level between the Steering Committee representative, the Local Community and CESVI-PPSSP representatives.
- Technical and logistic support for construction activities: as mentioned above, to guarantee technical quality assurance, CESVI-PPSSP staff will supervise construction activities and provide on the job training for the construction of 2 sanitation blocks of 4 latrines each, designed for emptying purposes, and with a dedicated hand cleansing facility.
The latrines will be blocks of 2 VIP (Ventilated Improved Pits) with double alternated pit. The block will be fit with separated pits, each of them with a ventilation pipe and a common infrastructure. The ventilation system will be constructed by vent pipes (PVC Ø90 PN10) and covered by a tee and closed in each hole by mosquito nets. Each pit will have a manhole for inspection and emptying. Each latrine will have 2 defecation holes and 2 chambers for pit and will be used alternately so as while one is used, in the second one the sewage will place on the bottom and after one year of not use, it could be emptied with minor risks of contamination. The defecation holes will be covered by small slabs, hermetically closed, while not used and the slabs will be fit with handles to be lift over. On every door of the block pictograms will indicate the destination for sex and the block will be designed to be accessible for disable and elderly people, with a special attention for the height of the basement and the size of the door. The walls of the pit will have drainage layers that will permit the infiltration of the sewage. The top will be realized in zinc sheet (BG32) on wooden frames. All materials will go through a quality control of CESVI staff
Quality assurance and hand-over: as mentioned above, once construction works have ended and upon quality check by the SEA Superviseur Eau et Assainissement of the ZS, the infrastructure will be handed over to the Local Committee who will remain responsible for ordinary maintenance and management together with relevant public administration staff who can provide support in supervision and maintenance.

RESULT 3: Hygiene promotion - Performing an hygiene promotion campaign in the target 42 Aires de Santé.
Awareness raising and community mobilization with the support of BCZ Bureau Central de Zone de Santé: following the Programme Village Assaini PVA (National Program for Sanitation of Villages) methodology, to complement construction activities for improved drinking-water and sanitation facilities, the hygiene promotion campaign, led by PPSSP under CESVI's supervision, will aim at identifying and mobilizing community leaders for each Aire de Santé to facilitate know how transfer in terms of hygiene practices, and to promote proper hygiene behaviours as well. For this purpose, the following activities will be performed:
- Training sessions for trainers on environmental health and hygiene practices: the SEA Superviseur eau et Assainissement and the AC Animateur Communitaire (members of to ENFEA Equipe National de Formateurs Eau at Assainissement, supported by Unicef as well), who have benefitted of trainings and specific tools provided by Unicef during the first phase of the PVA (Programme Village Assaini), will support PPSSP social mobilizing team during dedicated training sessions to facilitate know-how transfer. Target participants of the training sessions will be community leaders, and selected staff of Health Centres and Primary School Teachers (at least 50% women for gender balance), who will then disseminate key hygiene messages and best practices to the community target audience. For this purpose, the selected participants will attend 12 training sessions
- Community sensitization workshops: each participant of the above mentioned trainings will replicated each session for about 15 households each to disseminate information and best practices; for this purpose PPSSP will promote and support specific workshops in each Aire de Santé and monitor progress.
- Distribution menstrual protection kits: Following Unicef and WASH (Water and Sanitation) cluster guidelines, Cesvi will distribute the kits (composed by rope for drying, water bucket, soap bar, slip) during women hygiene promotion sessions as a specific attention to gender The beneficiaries (around 7.850) will be girls of the 5th and 6th year of the targeted primary schools who will more easily understand the importance and the how to use the kits. The distribution will be done in 71 targeted schools and will be preceded by a proper awareness and followed by indications on their use, in the respect of local culture. Besides a session of sexual education and prevention of sexually transmitted diseases will be organized together with the distributing, The whole session will be held by feminine staff only to guarantee privacy and participation among the young women.
- Distribution of hygiene kits: pupils of 71 targeted schools will be involved in hygiene promotion session and will receive a basic hygiene kit, as a tool to start the adoption of proper practices and as a motivational input for participation to trainings. Kits will be composed of 2 items: a plastic cup to be used for potable water and one soap (or towel) to be used for personal hygiene.
- Distribution of latrine kits: the committees created for the management and maintenance for the latrines (the Brigades Scolaires for the schools and the Comités de gestion for the Health centre) will provided with kits for hygiene and maintenance of the works. 10 kits (composed by chlorine, broom, dustpan, and plastic bucket, gloves) will be distributed for each of the 71 targeted schools and 2 kits for each helath centres for a total of 794 kits.
- Production and dissemination of awareness material: following PVA templates, proper thematic awareness material will be produced and disseminated.
- KAP Surveys (Knowledge, Attitude and Practice) (initial/final): based on active community participation and on behavioural change in terms of hygiene practices, the action proposed relies on comprehensive and dynamic appraisal methodologies; Knowledge, Attitude and Practice surveys will be designed to be simple and of rapid data collection on samples of 10 to 20 households per target community, at activities start and end, in order to monitor progress and impact of the whole program. PPSSP will be in charge of this activity, since the SEA or the AC may lack neutrality, and to size awareness material and training sessions upon the results of the initial KAP surveys.

RESULT 4: Local capacities of maintenance and management of WASH (Water and Sanitation) equipment are improved.
4.1 Set up and support of 3 Provincial Steering Committees and 27 local Committees for the management of works.
a) Identification and Selection of committee members: to guarantee participation and commitment of end beneficiaries, the Local Committee members will be proposed in each Aire de Santé (n.42) upon their representativeness and leadership role among the communities, and approved by a consultation process; gender balance criteria will be taken into account, and public administration staff of Health Centres and Primary Schools will be privileged to support institutional development among public service providers. For each Zone de Santé of the Mamabasa territory (n.4) a Steering Committee will be set up as focal point for policy and administrative management for coordination and monitoring purposes at Zone level; besides the MCZ and the SEA and AC, representatives of the Local Committees for each Aire de Santé will be members of the Steering Committees together with CESVI/PPSSP.
b) Definition of the mandate of the committees, and program layout: Within each Committee a consultative process will be performed in order to agree on key roles and responsibilities within the framework of the proposed action and taking into account governance issues according to the PVA. In this sense, roles and responsibilities of the Local Committees will reflect those of the Committees set up in 25 villages targeted by the PVA from 2008. For the Steering Committee, given its coordination role at Zone de Santé level, specific task will be agreed in terms of coordination with the WASH Cluster, and other relevant institutional departments for policy and administrative management at District level. CESVI and PPSSP will facilitate information sharing at all levels, benefitting of the outputs of a specific WASH GIS (see following point).
c) Set up and operation of a WASH-Geographic Informative System: with the purpose of promoting a virtuous cycle of assessment, evidence base, policy formulation and consequent implementation, progressively from local, to Zone de Santé and District level, this activity aims at building an informative data base to consolidate ancillary information and provide evidence base for decision making.
Specific training on ancillary data collection and management will be provided by CESVI staff to the SEA and AC, who will operate the system, in order to set up a common data base at Zone de Santé level to monitor sensitive WASH indicators on a geographic base (i.e. wash coverage). Upon CESVI's close technical supervision and follow-up, KAP survey results and health statistic as raw data input, specific spatial analysis will be performed to provide thematic outputs as support to decision making and policy formulation and implementation. Regular progress and thematic reports for the Mambasa Territory will be disseminated at District level among relevant stakeholders (networking).

Cesvi, established in 1985, is an independent non-governmental organization which works in 30 countries throughout the world. Cesvi is dedicated to the reduction of suffering and works towards the ultimate elimination of poverty in the world's poorest countries through the mobilization and active participation of the recipients of aid.
According to CESVI's guiding values, the moral principle of human solidarity and the idea of social justice are transformed into humanitarian aid and development, reinforcing universal human rights.
Cesvi believes that helping the underprivileged in developing countries, or those in difficulty due to war or natural calamities, does not help only those who suffer, but also helps the well-being of the entire planet, which as our "common home" should be looked after for future generations.
In the acronym Cesvi, the words Cooperazione e Sviluppo (Cooperation and Development) underline the fact that Cesvi bases its philosophy on the idea of giving the recipients of aid a leading role, working together for their own natural benefit. It is for this reason that Cesvi is strongly committed to making sure that international aid does not become mere charity, and nor is it influenced by the donors' self-interest.

Cesvi is working in the Democratic Republic of Congo since 2001, with the dual objective of intervening in the emergency in the East of the country and of strengthening health, social and educational services, in the province of the capital Kinshasa and in the province of Bas-Congo. Cesvi presence in the country is divided in 2 parts: one in the West, in Kinshasa (national coordination) and one in the East, based in Bunia.

North East (Uélé Haut, Bas Uélé and Ituri)
Cesvi responded to the humanitarian crisis developed in the North East of Congo with emergency and post emergency projects, with a focus on reconstruction and rehabilitation in areas characterized by movements of displaced persons and refugees. Almost all the projects are located in the territories of Djugu, Mambasa and Mahagi in Ituri District and the territories of Dungu (Dungu, Duru et Doruma) and Ango in the districts of Haut and Bas Uélés.
In 2011 operations were concentrated mainly in the following sectors: Water, Sanitation and Food Security in favor of displaced victims of guerrilla attacks. The sector "Water and Sanitation" is a priority area in the North East and one of the main activities includes the construction of latrines, protection of springs and construction of wells for drinking water.
In the territory of Ituri, security issues and movements of the population have improved in the last years and Cesvi is therefore pursuing a strategy from emergency activities to start a more sustainable development phase. Following the analysis of local needs and the current situation of stability, it was decided to intervene with the support of the European Union with a plan that will guarantee an improvement of access to drinking water and adequate sanitation facilities for the populations of the territory of Mambasa, in the district of Ituri.