Evaluation of water interventions in Bolivia

The projects generally use output indicators to monitor their progress in terms of number of systems constructed. Only one project, CARE, routinely monitors impacts by collecting nutritional and diarrheal disease data every 3 to 6 months. CCH did gather baseline diarrhea incidence data and is slated to conduct another follow-up survey later this year. No project measures infant mortality according to the Family Health Strategic Objective of improving child survival. Quantitative data from CARE projects indicated a positive impact on child health as related to nutritional status and diarrheal disease incidence. The projects in the Altiplano were able to demonstrate a decrease in 2-week diarrheal incidence from 27% in 1993 to 7% in 1994 and in Chuquibamba from 27% to 21% over the same time period. Among children 12-23 months old in the Altiplano/Valle areas, the prevalence of moderate malnutrition decreased from 66% to 53%, while severe malnutrition declined from about 24% to about 14%. In Chuquisaca/Cochabamba, the data show that children 1-2 years old experienced the most improvement in nutritional status: from 78% prevalence to 55% among the moderately malnourished group and 32% to 19% in the severely malnourished group. Since 1991, the Subsistema Nacional de Informacion en Salud (SNIS) system has included national data on diarrheal disease and nutritional status. If one uses 1992 as a baseline, there has been a consistent drop in the incidence of disease in 9 out of the 12 reporting areas. The most significant decrease was demonstrated in Pando (248 to 136 cases/1,000). For the country as a whole, there was a 16% decrease from 1992 to 1993. Demographic and Health Survey (DHS) data for children under 6 months of age show that the prevalence of diarrhea decreased from 25% in 1989 to 17% in 1994. The linkages among water supply projects are provided through Direccion Nacional de Saneamiento Basico (DINASBA), which has initiated activities aimed at ensuring coordination among the various technical and financial cooperation agencies and institutions through technical meetings with representatives from the government, NGOs, and PVOs. The coordination of other donors involved in water supply activities comes, in part, through DINASBA. Through a UNDP initiative, an operational matrix was established that lists and defines the role and objectives of each project and program with a view toward providing clear guidelines for the participation of international agencies. Project sustainability is mainly achieved through community participation in system administration. It is not clear if the Government of Bolivia (GOB) has attained increased institutional capacity to finance and provide support for these communities once the donors depart. The bulk of funding comes from the donors, with the communities investing on average 30% of the capital start-up costs. The overriding community selection criteria common to all projects appear to be the community's willingness to participate in administration, operation, and maintenance, plus its ability to pay recurrent costs. The availability of good quality water is another selection criterion all projects use. All projects do not use the criteria of need for services due to lack of resources (i.e., poverty, lack of access to services) and health status (mortality rates, diarrheal disease burden, or malnutrition). Projects use a similar process to choose the design of their systems. Considerations include population requirements, water resources, operation and maintenance, and the community's capacity to administer the system. The actual engineering components (materials and specifications), although not assessed in depth due to limited evaluation time, show some variation. CCH and CARE Programs have health components. While the projects may not necessarily have strengthened GOB water and sanitation directly, they have had a powerful impact on community development and democratization. This is demonstrated by the sustained activities of the water committees, the involvement of women, and the additional improvements in the systems which many communities have made on their own. For example, one community organized itself and paid an extraordinary amount to hire a lawyer to claim its water rights. The projects have had a profound impact on women's time, generating multiple social and child health benefits. It was not possible to determine true cost-effectiveness, due to the paucity of health impact data. Two cost-utility estimates were made, based on a mix of a qualitative and quantitative data and expected health impacts derived from project inputs and outcome measures. The analysis yielded results that generally favor lower cost programs (due to economies of scale) which use simpler technologies and include health education, sanitation, community participation, and emphasis on the concept of the user as a client. (Author abstract)