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• 1. [Article] Making Gains in Rwanda: It Will Take New Business Models, not Small Donations, to Provide Meaningful Development

  Nearly a billion people in the world drink dirty water. Two billion don't have a sanitary toilet. Three billion use campfires every day. Governments and charities spend billions of dollars every year to ...

  Citation × Citation Citation Abstract Copy Title: Making Gains in Rwanda: It Will Take New Business Models, not Small Donations, to Provide Meaningful Development Author: Thomas, Evan A. Year: 2015 Nearly a billion people in the world drink dirty water. Two billion don't have a sanitary toilet. Three billion use campfires every day. Governments and charities spend billions of dollars every year to address these problems. And there are big successes in some places, but more innovation is needed. Title: Making Gains in Rwanda: It Will Take New Business Models, not Small Donations, to Provide Meaningful Development Author: Thomas, Evan A. Year: 2015 Nearly a billion people in the world drink dirty water. Two billion don't have a sanitary toilet. Three billion use campfires every day. Governments and charities spend billions of dollars every year to address these problems. And there are big successes in some places, but more innovation is needed. Close

• 2. [Article] A Proposed Integrated Data Collection, Analysis and Sharing Platform for Impact Evaluation

  Global poverty reduction efforts value monitoring and evaluation, but often struggle to translate lessons learned from one intervention into practical application in another intervention. Commonly, data ...

  Citation × Citation Citation Abstract Copy Title: A Proposed Integrated Data Collection, Analysis and Sharing Platform for Impact Evaluation Author: Kipt, Andreas, Brunette, Waylon, Kellerstrass, Jordon, Podolsky, Matthew, Rosa, Javier, Sundt, Mitchell, Wilson, Daniel, Borriello, Gaetano, Brewer, Eric, Thomas, Evan A. Year: 2015 Global poverty reduction efforts value monitoring and evaluation, but often struggle to translate lessons learned from one intervention into practical application in another intervention. Commonly, data is not easily or often shared between interventions and summary data collected as part of an impact evaluation is often not available until after the intervention is complete. Equally limiting, the workflows that lead to research results are rarely published in a reproducible, reusable, and easy-to-understand fashion for others. Information and communication technologies widely used in commercial and government pro- grams are growing in relevance for international global development professionals and offer a potential towards better data and workflow sharing. However, the technical and custom nature of many data management systems limits their accessibility to non-ICT professionals. The authors propose an end-to- end data collection, management, and dissemination platform designed for use by global development program managers and researchers. The system leverages smartphones, cellular based sensors, and cloud storage and computing to lower the entry barrier to impact evaluation. Title: A Proposed Integrated Data Collection, Analysis and Sharing Platform for Impact Evaluation Author: Kipt, Andreas, Brunette, Waylon, Kellerstrass, Jordon, Podolsky, Matthew, Rosa, Javier, Sundt, Mitchell, Wilson, Daniel, Borriello, Gaetano, Brewer, Eric, Thomas, Evan A. Year: 2015 Global poverty reduction efforts value monitoring and evaluation, but often struggle to translate lessons learned from one intervention into practical application in another intervention. Commonly, data is not easily or often shared between interventions and summary data collected as part of an impact evaluation is often not available until after the intervention is complete. Equally limiting, the workflows that lead to research results are rarely published in a reproducible, reusable, and easy-to-understand fashion for others. Information and communication technologies widely used in commercial and government pro- grams are growing in relevance for international global development professionals and offer a potential towards better data and workflow sharing. However, the technical and custom nature of many data management systems limits their accessibility to non-ICT professionals. The authors propose an end-to- end data collection, management, and dissemination platform designed for use by global development program managers and researchers. The system leverages smartphones, cellular based sensors, and cloud storage and computing to lower the entry barrier to impact evaluation. Close

• 3. [Article] Process Evaluation and Assessment of Use of a Large Scale Water Filter and Cookstove Program in Rwanda

  Background: In an effort to reduce the disease burden in rural Rwanda, decrease poverty associated with expenditures for fuel, and minimize the environmental impact on forests and greenhouse gases from ...

  Citation × Citation Citation Abstract Copy Title: Process Evaluation and Assessment of Use of a Large Scale Water Filter and Cookstove Program in Rwanda Author: Barstow, Christina K., Nagel, Corey, Clasen, Thomas, Thomas, Evan A. Year: 2016 Background: In an effort to reduce the disease burden in rural Rwanda, decrease poverty associated with expenditures for fuel, and minimize the environmental impact on forests and greenhouse gases from inefficient combustion of biomass, the Rwanda Ministry of Health (MOH) partnered with DelAgua Health (DelAgua), a private social enterprise, to distribute and promote the use of improved cookstoves and advanced water filters to the poorest quarter of households (Ubudehe 1 and 2) nationally, beginning in Western Province under a program branded Tubeho Neza (“Live Well”). The project is privately financed and earns revenue from carbon credits under the United Nations Clean Development Mechanism. Methods: During a 3-month period in late 2014, over 470,000 people living in over 101,000 households were provided free water filters and cookstoves. Following the distribution, community health workers visited nearly 98 % of households to perform household level education and training activities. Over 87 % of households were visited again within 6 months with a basic survey conducted. Detailed adoption surveys were conducted among a sample of households, 1000 in the first round, 187 in the second. Results: Approximately a year after distribution, reported water filter use was above 90 % (+/−4 % CI) and water present in filter was observed in over 76 % (+/−6 % CI) of households, while the reported primary stove was nearly 90 % (+/−4.4 % CI) and of households cooking at the time of the visit, over 83 % (+/−5.3 % CI) were on the improved stove. There was no observed association between household size and stove stacking behavior. Conclusions: This program suggests that free distribution is not a determinant of low adoption. It is plausible that continued engagement in households, enabled by Ministry of Health support and carbon financed revenue, contributed to high adoption rates. Overall, the program was able to demonstrate a privately financed, public health intervention can achieve high levels of initial adoption and usage of household level water filtration and improved cookstoves at a large scale. Title: Process Evaluation and Assessment of Use of a Large Scale Water Filter and Cookstove Program in Rwanda Author: Barstow, Christina K., Nagel, Corey, Clasen, Thomas, Thomas, Evan A. Year: 2016 Background: In an effort to reduce the disease burden in rural Rwanda, decrease poverty associated with expenditures for fuel, and minimize the environmental impact on forests and greenhouse gases from inefficient combustion of biomass, the Rwanda Ministry of Health (MOH) partnered with DelAgua Health (DelAgua), a private social enterprise, to distribute and promote the use of improved cookstoves and advanced water filters to the poorest quarter of households (Ubudehe 1 and 2) nationally, beginning in Western Province under a program branded Tubeho Neza (“Live Well”). The project is privately financed and earns revenue from carbon credits under the United Nations Clean Development Mechanism. Methods: During a 3-month period in late 2014, over 470,000 people living in over 101,000 households were provided free water filters and cookstoves. Following the distribution, community health workers visited nearly 98 % of households to perform household level education and training activities. Over 87 % of households were visited again within 6 months with a basic survey conducted. Detailed adoption surveys were conducted among a sample of households, 1000 in the first round, 187 in the second. Results: Approximately a year after distribution, reported water filter use was above 90 % (+/−4 % CI) and water present in filter was observed in over 76 % (+/−6 % CI) of households, while the reported primary stove was nearly 90 % (+/−4.4 % CI) and of households cooking at the time of the visit, over 83 % (+/−5.3 % CI) were on the improved stove. There was no observed association between household size and stove stacking behavior. Conclusions: This program suggests that free distribution is not a determinant of low adoption. It is plausible that continued engagement in households, enabled by Ministry of Health support and carbon financed revenue, contributed to high adoption rates. Overall, the program was able to demonstrate a privately financed, public health intervention can achieve high levels of initial adoption and usage of household level water filtration and improved cookstoves at a large scale. Close

• 4. [Article] Study Design of a Cluster-Randomized Controlled Trial to Evaluate a Large-scale Distribution of Cook Stoves and Water Filters in Western Province, Rwanda

  Background: In Rwanda, pneumonia and diarrhea are the first and second leading causes of death, respectively, among children under five. Household air pollution (HAP) resultant from cooking indoors with ...

  Citation × Citation Citation Abstract Copy Title: Study Design of a Cluster-Randomized Controlled Trial to Evaluate a Large-scale Distribution of Cook Stoves and Water Filters in Western Province, Rwanda Author: Nagel, Corey L., Kirby, Miles, Zambrano, Laura D., Rosa, Ghislaine, Barstow, Christina K., Thomas, Evan A., Clasen, Thomas Year: 2016 Background: In Rwanda, pneumonia and diarrhea are the first and second leading causes of death, respectively, among children under five. Household air pollution (HAP) resultant from cooking indoors with biomass fuels on traditional stoves is a significant risk factor for pneumonia, while consumption of contaminated drinking water is a primary cause of diarrheal disease. To date, there have been no largescale effectiveness trials of programmatic efforts to provide either improved cookstoves or household water filters at scale in a low-income country. In this paper we describe the design of a clusterrandomized trial to evaluate the impact of a national-level program to distribute and promote the use of improved cookstoves and advanced water filters to the poorest quarter of households in Rwanda. Methods/Design: We randomly allocated 72 sectors (administratively defined units) in Western Province to the intervention, with the remaining 24 sectors in the province serving as controls. In the intervention sectors, roughly 100,000 households received improved cookstoves and household water filters through a government-sponsored program targeting the poorest quarter of households nationally. The primary outcome measures are the incidence of acute respiratory infection (ARI) and diarrhea among children under five years of age. Over a one-year surveillance period, all cases of acute respiratory infection (ARI) and diarrhea identified by health workers in the study area will be extracted from records maintained at health facilities and by community health workers (CHW). In addition, we are conducting intensive, longitudinal data collection among a random sample of households in the study area for in-depth assessment of coverage, use, environmental exposures, and additional health measures. Discussion: Although previous research has examined the impact of providing household water treatment and improved cookstoves on child health, there have been no studies of national-level programs to deliver these interventions at scale in a developing country. The results of this study, the first RCT of a large-scale programmatic cookstove or household water filter intervention, will inform global efforts to reduce childhood morbidity and mortality from diarrheal disease and pneumonia. Title: Study Design of a Cluster-Randomized Controlled Trial to Evaluate a Large-scale Distribution of Cook Stoves and Water Filters in Western Province, Rwanda Author: Nagel, Corey L., Kirby, Miles, Zambrano, Laura D., Rosa, Ghislaine, Barstow, Christina K., Thomas, Evan A., Clasen, Thomas Year: 2016 Background: In Rwanda, pneumonia and diarrhea are the first and second leading causes of death, respectively, among children under five. Household air pollution (HAP) resultant from cooking indoors with biomass fuels on traditional stoves is a significant risk factor for pneumonia, while consumption of contaminated drinking water is a primary cause of diarrheal disease. To date, there have been no largescale effectiveness trials of programmatic efforts to provide either improved cookstoves or household water filters at scale in a low-income country. In this paper we describe the design of a clusterrandomized trial to evaluate the impact of a national-level program to distribute and promote the use of improved cookstoves and advanced water filters to the poorest quarter of households in Rwanda. Methods/Design: We randomly allocated 72 sectors (administratively defined units) in Western Province to the intervention, with the remaining 24 sectors in the province serving as controls. In the intervention sectors, roughly 100,000 households received improved cookstoves and household water filters through a government-sponsored program targeting the poorest quarter of households nationally. The primary outcome measures are the incidence of acute respiratory infection (ARI) and diarrhea among children under five years of age. Over a one-year surveillance period, all cases of acute respiratory infection (ARI) and diarrhea identified by health workers in the study area will be extracted from records maintained at health facilities and by community health workers (CHW). In addition, we are conducting intensive, longitudinal data collection among a random sample of households in the study area for in-depth assessment of coverage, use, environmental exposures, and additional health measures. Discussion: Although previous research has examined the impact of providing household water treatment and improved cookstoves on child health, there have been no studies of national-level programs to deliver these interventions at scale in a developing country. The results of this study, the first RCT of a large-scale programmatic cookstove or household water filter intervention, will inform global efforts to reduce childhood morbidity and mortality from diarrheal disease and pneumonia. Close

• 5. [Article] Evaluating Cellular Instrumentation on Rural Handpumps to Improve Service Delivery—A Longitudinal Study in Rural Rwanda

  In rural sub-Saharan Africa, where handpumps are common, 10–67% are nonfunctional at any one time, and many never get repaired. Increased reliability requires improved monitoring and responsiveness of ...

  Citation × Citation Citation Abstract Copy Title: Evaluating Cellular Instrumentation on Rural Handpumps to Improve Service Delivery—A Longitudinal Study in Rural Rwanda Author: Nagel, Corey, Beach, Jack, Iribagiza, Chantal, Thomas, Evan A. Year: 2015 In rural sub-Saharan Africa, where handpumps are common, 10–67% are nonfunctional at any one time, and many never get repaired. Increased reliability requires improved monitoring and responsiveness of maintenance providers. In 2014, 181 cellular enabled water pump use sensors were installed in three provinces of Rwanda. In three arms, the nominal maintenance model was compared against a “best practice” circuit rider model, and an “ambulance” service model. In only the ambulance model was the sensor data available to the implementer, and used to dispatch technicians. The study ran for seven months in 2014–2015. In the study period, the nominal maintenance group had a median time to successful repair of approximately 152 days, with a mean per-pump functionality of about 68%. In the circuit rider group, the median time to successful repair was nearly 57 days, with a per-pump functionality mean of nearly 73%. In the ambulance service group, the successful repair interval was nearly 21 days with a functionality mean of nearly 91%. An indicative cost analysis suggests that the cost per functional pump per year is approximately similar between the three models. However, the benefits of reliable water service may justify greater focus on servicing models over installation models. Title: Evaluating Cellular Instrumentation on Rural Handpumps to Improve Service Delivery—A Longitudinal Study in Rural Rwanda Author: Nagel, Corey, Beach, Jack, Iribagiza, Chantal, Thomas, Evan A. Year: 2015 In rural sub-Saharan Africa, where handpumps are common, 10–67% are nonfunctional at any one time, and many never get repaired. Increased reliability requires improved monitoring and responsiveness of maintenance providers. In 2014, 181 cellular enabled water pump use sensors were installed in three provinces of Rwanda. In three arms, the nominal maintenance model was compared against a “best practice” circuit rider model, and an “ambulance” service model. In only the ambulance model was the sensor data available to the implementer, and used to dispatch technicians. The study ran for seven months in 2014–2015. In the study period, the nominal maintenance group had a median time to successful repair of approximately 152 days, with a mean per-pump functionality of about 68%. In the circuit rider group, the median time to successful repair was nearly 57 days, with a per-pump functionality mean of nearly 73%. In the ambulance service group, the successful repair interval was nearly 21 days with a functionality mean of nearly 91%. An indicative cost analysis suggests that the cost per functional pump per year is approximately similar between the three models. However, the benefits of reliable water service may justify greater focus on servicing models over installation models. Close

• 6. [Article] Assessing the Impact of Water Filters and Improved Cook Stoves on Drinking Water Quality and Household Air Pollution: A Randomised Controlled Trial in Rwanda

  Diarrhea and respiratory infections remain the biggest killers of children under 5 years in developing countries. We conducted a 5-month household randomised controlled trial among 566 households in rural ...

  Citation × Citation Citation Abstract Copy Title: Assessing the Impact of Water Filters and Improved Cook Stoves on Drinking Water Quality and Household Air Pollution: A Randomised Controlled Trial in Rwanda Author: Rosa, Ghislaine, Majorin, Fiona, Boisson, Sophie, Barstow, Christina, Johnson, Michael, Kirby, Miles, Ngabo, Fidele, Thomas, Evan A., Clasen, Thomas Year: 2014 Diarrhea and respiratory infections remain the biggest killers of children under 5 years in developing countries. We conducted a 5-month household randomised controlled trial among 566 households in rural Rwanda to assess uptake, compliance and impact on environmental exposures of a combined intervention delivering high-performance water filters and improved stoves for free. Compliance was measured monthly by self-report and spot-check observations. Semicontinuous 24-h PM2.5 monitoring of the cooking area was conducted in a random subsample of 121 households to assess household air pollution, while samples of drinking water from all households were collected monthly to assess the levels of thermotolerant coliforms. Adoption was generally high, with most householders reporting the filters as their primary source of drinking water and the intervention stoves as their primary cooking stove. However, some householders continued to drink untreated water and most continued to cook on traditional stoves. The intervention was associated with a 97.5% reduction in mean fecal indicator bacteria (Williams means 0.5 vs. 20.2 TTC/100 mL, p,0.001) and a median reduction of 48% of 24-h PM2.5 concentrations in the cooking area (p = 0.005). Further studies to increase compliance should be undertaken to better inform large-scale interventions. Title: Assessing the Impact of Water Filters and Improved Cook Stoves on Drinking Water Quality and Household Air Pollution: A Randomised Controlled Trial in Rwanda Author: Rosa, Ghislaine, Majorin, Fiona, Boisson, Sophie, Barstow, Christina, Johnson, Michael, Kirby, Miles, Ngabo, Fidele, Thomas, Evan A., Clasen, Thomas Year: 2014 Diarrhea and respiratory infections remain the biggest killers of children under 5 years in developing countries. We conducted a 5-month household randomised controlled trial among 566 households in rural Rwanda to assess uptake, compliance and impact on environmental exposures of a combined intervention delivering high-performance water filters and improved stoves for free. Compliance was measured monthly by self-report and spot-check observations. Semicontinuous 24-h PM2.5 monitoring of the cooking area was conducted in a random subsample of 121 households to assess household air pollution, while samples of drinking water from all households were collected monthly to assess the levels of thermotolerant coliforms. Adoption was generally high, with most householders reporting the filters as their primary source of drinking water and the intervention stoves as their primary cooking stove. However, some householders continued to drink untreated water and most continued to cook on traditional stoves. The intervention was associated with a 97.5% reduction in mean fecal indicator bacteria (Williams means 0.5 vs. 20.2 TTC/100 mL, p,0.001) and a median reduction of 48% of 24-h PM2.5 concentrations in the cooking area (p = 0.005). Further studies to increase compliance should be undertaken to better inform large-scale interventions. Close

• 7. [Article] Designing and Piloting a Program to Provide Water Filters and Improved Cookstoves in Rwanda

  Background: In environmental health interventions addressing water and indoor air quality, multiple determinants contribute to adoption. These may include technology selection, technology distribution ...

  Citation × Citation Citation Abstract Copy Title: Designing and Piloting a Program to Provide Water Filters and Improved Cookstoves in Rwanda Author: Barstow, Christina K., Ngabo, Fidele, Rosa, Ghislaine, Majorin, Fiona, Boisson, Sophie, Clasen, Thomas, Thomas, Evan A. Year: 2014 Background: In environmental health interventions addressing water and indoor air quality, multiple determinants contribute to adoption. These may include technology selection, technology distribution and education methods, community engagement with behavior change, and duration and magnitude of implementer engagement. In Rwanda, while the country has the fastest annual reduction in child mortality in the world, the population is still exposed to a disease burden associated with environmental health challenges. Rwanda relies both on direct donor funding and coordination of programs managed by international non-profits and health sector businesses working on these challenges. Methods and Findings: This paper describes the design, implementation and outcomes of a pilot program in 1,943 households across 15 villages in the western province of Rwanda to distribute and monitor the use of household water filters and improved cookstoves. Three key program design criteria include a.) an investment in behavior change messaging and monitoring through community health workers, b.) free distributions to encourage community-wide engagement, and c.) a private-public partnership incentivized by a business model designed to encourage ‘‘pay for performance’’. Over a 5- month period of rigorous monitoring, reported uptake was maintained at greater than 90% for both technologies, although exclusive use of the stove was reported in only 28.5% of households and reported water volume was 1.27 liters per person per day. On-going qualitative monitoring suggest maintenance of comparable adoption rates through at least 16 months after the intervention. Conclusion: High uptake and sustained adoption of a water filter and improved cookstove was measured over a five-month period with indications of continued comparable adoption 16 months after the intervention. The design attributes applied by the implementers may be sufficient in a longer term. In particular, sustained and comprehensive engagement by the program implementer is enabled by a pay-for-performance business model that rewards sustained behavior change. Title: Designing and Piloting a Program to Provide Water Filters and Improved Cookstoves in Rwanda Author: Barstow, Christina K., Ngabo, Fidele, Rosa, Ghislaine, Majorin, Fiona, Boisson, Sophie, Clasen, Thomas, Thomas, Evan A. Year: 2014 Background: In environmental health interventions addressing water and indoor air quality, multiple determinants contribute to adoption. These may include technology selection, technology distribution and education methods, community engagement with behavior change, and duration and magnitude of implementer engagement. In Rwanda, while the country has the fastest annual reduction in child mortality in the world, the population is still exposed to a disease burden associated with environmental health challenges. Rwanda relies both on direct donor funding and coordination of programs managed by international non-profits and health sector businesses working on these challenges. Methods and Findings: This paper describes the design, implementation and outcomes of a pilot program in 1,943 households across 15 villages in the western province of Rwanda to distribute and monitor the use of household water filters and improved cookstoves. Three key program design criteria include a.) an investment in behavior change messaging and monitoring through community health workers, b.) free distributions to encourage community-wide engagement, and c.) a private-public partnership incentivized by a business model designed to encourage ‘‘pay for performance’’. Over a 5- month period of rigorous monitoring, reported uptake was maintained at greater than 90% for both technologies, although exclusive use of the stove was reported in only 28.5% of households and reported water volume was 1.27 liters per person per day. On-going qualitative monitoring suggest maintenance of comparable adoption rates through at least 16 months after the intervention. Conclusion: High uptake and sustained adoption of a water filter and improved cookstove was measured over a five-month period with indications of continued comparable adoption 16 months after the intervention. The design attributes applied by the implementers may be sufficient in a longer term. In particular, sustained and comprehensive engagement by the program implementer is enabled by a pay-for-performance business model that rewards sustained behavior change. Close