Social mobilization and training for the prevention and control of cholera in Latin America and the Caribbean

GTZ shall participate in the mid project evaluation of selected project components.

Progress reports according to GTZ form shall be submitted to GTZ every six month in English language commencing August 1994, The disbursement procedures calls for the evidence to be furnished by PAHO proving that the amounts disbursed are used for the purpose stipulated.

A joint mid project evaluation of PAHO and GTZ shall be held to analyze progress, review program development. Both parties will mutually agree upon dates and location for this evaluation.

GTZ shall disburse the financial contribution upon call for disbursement by PAHO in accordance with the progress of the project. By separate agreement PAHO and GTZ shall agree on disbursement procedures and financial reporting in order to assure GTZ that project process is on schedule and that funds are being utilized as agreed.

Neither PAHO nor GTZ shall be responsible for obligation arising out this agreement with which it is unable to comply in whole or in part due to reason of force majeure including wars, natural disasters, civil and labor disturbances and any other cause beyond the control of the parties.

Amendments and additions to the financing agreement and any statements and notices, which shall be made under this agreement by the contracting parties, shall be in writing. Any such statement or notice shall be deemed to have been received as soon as it shall have been delivered.

A final report shall be prepared by PAHO for presentation to all parties concerned. This report shall contain the original objectives, activities and results envisaged, a chronogram of the program development, the results obtained, the comparison of achievements vis a vis objectives and recommendations.

3. Project description

The project was divided into 3 distinct parts as indicated in the project implementation arrangement. The respective allotments were:

The principal activities in the Andean and Central American components of the project were the following:

The principal activities of the Haitian component will be centered on the following activities:

4.1 The project was carried out during the period 1994-2000 with the overall objective to improve social conditions and welfare of the population in the beneficiary countries and to provide them with the opportunity to increase their capability to prevent and control cholera in Latin America and the Caribbean. The project in particular sought to strengthen national cholera prevention and control programs through the development and use of methodologies for social mobilization at community and district level and the demonstration of effective sanitation technologies.

The central office approved the work plans and the funds were disbursed according to the plan and progress of the national projects.

The central office in coordination with the countries planned regional and subregional activities.

The project was actively implemented in all the beneficiary countries Bolivia, Colombia and Peru in South America, El Salvador, Guatemala, Honduras Nicaragua and Panama in Central America, and Haiti in the Caribbean. In addition it helped other countries through dissemination of information and sharing of experience.

The following measures have been promoted and accomplished with the financial contribution of the Federal Republic of Germany, in collaboration with national and local health authorities and the Pan American Health Organization.

Development of pilot and demonstration projects in schools, urban and rural communities to promote practical, effective and low cost interventions for the prevention of diarrheal diseases and cholera.

Mobilization and training of health personnel and community leader to improve community cooperation through national and local workshops to develop appropriate education and preventive cholera programs.

Development and dissemination of health education materials and promotion of programs and campaigns in schools and communities for cholera and diarrheal prevention.

Improvement of rural water supplies and promotion of disinfection at household and community level, and training of local personnel in water quality management.

Subregional workshops to present the result of the pilot projects and lessons learned and to share experience and prepare proposals for expansion of the program and concept.

4.2 Modification during implementation

The Project was negotiated during 1993 however the agreements were only signed in 1994. By agreement dated July 1994, the expiration date was: 31 December 1996.

The start of the Project in Haiti was considerably delayed due to the political situation that included an embargo on foreign import in the country. The project was tailored to meet the overall objective of cholera prevention, health education and training but did not start before 1996.For this reason by fax dated 07-02-97 the project expiration date was extended until September 30, 1998.

By a letter dated 15 09 -99 (six months extension) the expiration date was extended to March 15 2000. This extension provided the opportunity to utilize the remaining funds for cholera prevention activities in El Salvador in view of the disaster created by Hurricane Mitch.

The final report was expected to be submitted by March 2000 according to the same letter.

Some problems were also due to the timing in fund disbursement that has resulted in some delay in program implementation at the country level.

In general the project has been implemented in an orderly manner which has made it possible to produce positive results and achieve the aim the German Contribution.

5. Project results

The circumstances already described such as the political disturbances in Haiti and the problems created by hurricane Mitch have caused the Project to be executed in three different phases. Phase I would be the implementation of the project in Andean countries and Central America. Phase II would be the implementation in Haiti and Phase III the utilization of the remaining funds for activities in El Salvador. Table 1 shows a chronogram of the activities of the Project.

In Central America the project provided a framework for introducing and testing appropriate environmental health interventions in each participating countries. The countries utilized different alternative technologies for the production of disinfectants, water treatment and water quality surveillance. Domestic filters were used for treatment of water. Portable water laboratories and chlorine comparators were used for the surveillance of water quality. Pilot projects were developed in schools and communities demonstrating methods for social mobilization and effective interventions for the prevention of cholera. Each country formulated its own national project with the participation of health personnel in a series of workshops. The projects were implemented in collaboration with the national and local authorities.

Social mobilization: Extensive activities were carried out in training for social mobilization at the local authority and municipal levels and promotion and education of the school age and adolescent population. These activities include local, regional and national workshops for community leaders to discuss important issues relevant to cholera prevention and to develop strategies and activities for controlling the disease. Many training sessions were carried out for students, health personnel and agriculture workers. All the countries had developed educational material for schools and communities and organized campaigns of cholera prevention. They also organized demonstration on the preparation of chlorine and installed chlorine banks, which supplies chlorine solution to rural communities and municipalities. Table 2 gives an overview of the extent of activities reported in Central America.

Demonstration projects: The objectives of the demonstration projects were to develop community projects using alternative technologies for disinfection, treatment and water quality surveillance and promote satisfactory arrangement and sustainability of these processes. The results would be evaluated and the information disseminated.

Disinfection technologies were at the center of all cholera activities in all countries, among the technologies utilized for the on-site generation of sodium hypochlorite different equipment from several manufacturers were purchased in particular: Dipcells, Sanilec and Chlorids. Aquachlor equipment was also later purchased.

These alternative technologies were utilized at the community as well as the household levels. Another technology utilized in the project in particular in Nicaragua was the water filtration at the household level, Portable type laboratories mainly from HACH CHEMICALS and Del Agua were purchased for water quality surveys and to strengthen water quality surveillance in the communities and municipalities.

The distribution of the 20 liter recipient developed by PAHO and CDC was carried out in Guatemala as preventive measures against cholera.

Integration in Public Health: Several activities contributed to the integration of cholera prevention in national health plans. Workshops on improvement of conditions favorable to the transmission of cholera and other acute diarrheal diseases were carried in all the countries and trained over 1000 persons. Health personnel were also trained in the prevention of cholera and acute diarrheal diseases. The oral rehydration units were strengthened in many countries in particular in Nicaragua and Honduras.

Health personnel initiated the demonstration projects by visiting the selected communities and informing them about the Project, which focused on the disinfection of water at household level through the installation of equipment for on-site generation of disinfectants. The pilot projects were located in the following communities:

The Project provided equipment for the production of sodium hypochlorite, which was successfully marketed under the name PURIAGUA. The Project also mobilized communities, municipalities and Non Governmental Organizations (NGO) in the process of prevention of cholera. As part of the demonstration project, 48,000 liters of PURIAGUA were produced. The use of PURIAGUA has reduced the morbidity caused by the consumption of contaminated water. The information available for the municipality of Osicala indicated a reduction in the prevalence of intestinal parasites from 220 in the first term of 1996 to 57 during the same period in 1997. The prevalence of diarrheal diseases also decreased during the same period. The population benefiting from the demonstration project was close to 50,000.

The acceptation of the disinfectant by the public reached a very high level, but not 100%. The equipment functioned well in the health establishment.

In conclusion, the Project, together with other complementary actions has contributed to the reduction of risks of cholera and provided a viable solution for emergency response to an outbreak. It is recommended to promote similar activities in more peri-urban and rural areas in view of the continuing deterioration of the drinking water quality. There is also some concern regarding the sustainability of the chlorine generating equipment.

The active part of this Project has been completed. Suggestions were made for consolidation of activities.

A series of training workshops was carried out on such subjects as epidemiological surveillance, water treatment, on site generation of hypochlorite, social mobilization and formation of micro-enterprises. Three communities were selected for the pilot projects Aurora of the municipality of Masagua, El Astillo of the municipality of Masagua, and Canada of the Municipality of Escuinta.

The activities that were carried out include the acquisition of onsite generation of hypochlorite, and the design and production of 20-liter containers for water storage and health education materials. The distribution of chlorine that necessitated the training of the local personnel was made through local committees. In summary, the work programmed was achieved.

The Project also facilitated the inter-institutional coordination with personnel of health centers, social security and several local organizations. Community mobilization was achieved through a series of meetings with teachers, mayors, and local authority personnel in the three pilot areas. In addition, executive committees in each community, which later assumed the responsibility of implementing the Project, were established.

With regard to the aspect of production and distribution of disinfectants, two production centers and one distribution center were established. About 1,000 especially designed recipients with taps were distributed to an equal number of families. Some problems in the taps, which required further interventions, were registered All the activities planned were realized although there was a feeling that more follow up could have been given. It was considered important to consolidate the achievement of the Project and to maintain the momentum for water disinfection.

In Honduras the Project was carried out in two different geographic regions: the municipalities of San Francisco de Coray and Langue of the department of la Valle and the municipality of Esquipulas of the department of Olancho. Priority was given to the improvement of the bacteriological safety of drinking water, the establishment of hygienic practices and the proper preparation and handling of food. Members of the three municipal councils and seventy community development councils have been trained. Seventy school directors in the same communities have also been trained in technologies of water disinfection and the norms for the control and handling food. Chlorine banks at the municipality level, where small communities come to obtain supplies of disinfectants were also developed. An extensive and innovative health education program was carried out in all schools of the Project area. The collaboration between the ministries of health and education allowed the school teachers and principals to play an active role and provide the necessary leadership and education to improve hygienic practices. Schools poster competition, effective displays of posters in key areas and involvement of the communities have contributed to the success of the Project.

The active part of the Project has been completed; however, there is a need to expand the experience to other communities.

The training and social mobilization effort was carried out in the selected communities belonging to the municipalities of San Dionisio, Tipitapa. The sectors of the municipalities most affected by cholera and other diarrheal diseases were selected for the Project. Baseline studies were carried out, including house to house surveys. Training activities were organized for promoters and sanitary inspectors on cholera prevention and surveillance. The production and distribution of chlorine solution were organized from on site generators purchased through the Project Plastic jugs for storing disinfected water were distributed to families. House filters also complemented the use of disinfectants. An intensive health education program supported the Project. A systematic control of the use of chlorine and epidemiological surveillance in each community was organized and periodic reports were prepared.

The Project provided the opportunity to improve the knowledge of local authorities and health professionals and technicians in social mobilization techniques and methodologies for control of cholera.

It also left an infrastructure that could be used to expand the geographic scope of cholera prevention activities. It is however felt that a consolidation phase could help develop strategies and methodologies for extending cholera prevention activities to other municipalities.

The province of Darien was chosen for a demonstration, in collaboration with the health authorities. Several workshops were organized for local authorities on the programming of activities to reduce the risks of cholera and other diarrheal diseases and provide methods of disinfection at the community and household levels. The knowledge of sanitary inspectors, operator of rural water supplies was also updated through courses and seminars in the communities of ‘Comarca and San Blas. Inspectors were also trained in the chemico-physical and bacteriological determinations of drinking water quality using portable analysis kits provided by the Project. Four onsite chlorine generators were acquired and utilized in the Project, one being a prototype that use solar energy for generating electricity for the production of disinfectants.

The Project also received some assistance from Bolivia regarding the application of basic sanitation technologies. All the targets set for the Project were achieved to some extent, although the scarcity of resources limited the scope of activities that could have been carried out.

Several factor facilitated the success of the project in the Andean countries The central core of the project remained the introduction of on site disinfectants for household disinfection and the design and distribution of a specially designed container to store essential quantity of water. The Communicable Disease Centre (CDC) and other agencies collaborated in studies to evaluate the efficacy of the interventions in reducing risks of diarreal diseases. Other projects supported by the German government in food control and appropriate technology development contributed to enhance sanitation activities in the region. The development of technologies such as hand pump, well drilling rig can be attributed to these projects. CEPIS also provided considerable assistance in health education and technological support to onsite generation of chlorine. The participation of Population Service International (PSI) has contributed to the development of social marketing strategies and educational material which proved to be essential in the promotion of the use of the disinfectant and the utilization of the specially designed water container.

The Bolivia Project has been successfully carried out and is being praised and used as model for other countries. The basic sanitation technologies utilized through the Project have been adopted in Peru Ecuador, Panama and Guatemala.

The development of micro-enterprises as a mean of sustainability was an integral part of the program. The Project also contributed to the improvement of sanitary facilities in ten schools in the district of Yacuiba. This improvement included the installation of sanitary blocs, water supplies and disinfection units. Training sessions were organized for principals and teachers in all the schools in the Project. The school sanitation project benefited a population of 5440 students.

A series of educational materials on hygiene and environmental health was developed and distributed. They included the following titles: Use and Water Quality in the School; Use and Maintenance of Sanitary Systems in the School; Organization in Schools for Hygiene and Health.

The Project also supported the demonstration on household disinfection, which was carried in several communities, including Montero, el Alto and Huaricana. The objective was to evaluate the effectiveness of point of use disinfection in reducing diarrheal disease. The Project demonstrated that the intervention was effective in the prevention of diarrhea in the families that used it. This approach resulted in the commercialization of CLARO, a solution of disinfectants for household use produced by on site generators. Public service announcements have been produced to promote the use of disinfectant in the home. This Project has been successfully completed.

Demonstration projects involving 500 families were organized in two communities, Santa Fe de Bogota and Cucuta. The objective was to increase water disinfection at the household level in homes that did not have access to safe water and to disseminate the information and experience at the national level. Specially designed containers were distributed to each family. For this purpose, onsite generators of chlorine were provided to the communities. Small community enterprises were responsible for the production of sodium hypochlorite. The disinfectant solution was also distributed to the families with specially designed containers.

Training and educational materials were developed on the following themes: Water Quality for Human consumption, Participation and Community Development, Training for Micro-Enterprises. All participants in the project received training in the proper use of the disinfectant and container and on the health benefits to be derived from disinfecting drinking water. In addition workshop were developed at the community and institutional levels on epidemiological surveillance and measures for prevention and control of waterborne diseases.

The short term strengths of the project were: the ability to motivate at both community and institutional levels, excellent receptivity on the part of the communities toward the technology of the onsite production of sodium hypochlorite, active participation of the population in the process and the organization of an epidemiological database.

The Project was implemented with the collaboration of CEPIS. The beneficiary communities were Santo Toribio de Mongrovejo (a periurban community), Dos de Mayo, Chucos, Quisto Central and Mapoyo. The objective was to test the effectiveness of the disinfection intervention in several geographical settings on the sierra and selva with variation in elevation from 300-2800 meters. In the preparatory phase promoters were required to go into the communities to demonstrate the use, storage and the maintenance of the containers. Disinfectants were produced from onsite chlorine generators purchased by the Project.

Specially designed water containers and bottles of disinfectants were distributed to each participating household.

The evaluation indicators used showed significant improvement in water quality, in the behavior of the population and in the reduction of the prevalence of diarrhea in children under the age of five. In addition, the local authorities and community leaders were sensitized about the importance of water quality and food safety in improving the health of the communities. The solar equipment used for the production of disinfectants also benefited the community by providing a mean for recharging of batteries. The success of the Project has encouraged the ministry of health to initiate a study for water disinfection and food hygiene for 20,000 people in poor areas.

CEPIS has assisted with the development and distribution of education materials and the consolidation of methodologies for social mobilization.

A coup d’etat in Haiti in 1991 originated in the country a political turmoil in Haiti which did not subside before 1995 The Project was initiated in l996 and was implemented during the period 1996-1999.

The project focused on the development of pilot projects in the prevention of diarrheal diseases using the community water supply as the central point of interventions. In view of the political and economic situation, many water systems built during the International Drinking Water and Sanitation Decade had fallen in disrepair. Because of the deterioration of these systems, the population in these areas was returning to collect water from rivers, ponds thus putting them at high risk of contacting acute diarrheal diseases due to the consumption of contaminated water.

Improvement and rehabilitation works on rural water supplies were carried out in eleven high risk communities in the Department South of the country. The first part of the Project included the risk assessment of water supply and sanitation in five rural communities, Chantal, Ducis, Dubreuil, St. Georges, and Morisseau d’Aquin. The work consisted of the rehabilitation and development of water sources, sedimentation tanks and reservoirs, the replacement of pipe and installation of public fountains and chlorinators. The social mobilization effort and health education activities were targeted to key groups to motivate the community leaders. A program for hygiene education and social mobilization has been implemented in collaboration with a non-governmental organization.

The improvement in six other localities were carried out in a second phase in six communities Chaveneau, l’Azile, Morisseau de l’Azile, Rousseau, Gros Marin and Martineau.

Several activities were focused on the promotion of sanitation, improvement of water committees and operations and maintenance of facilities and in health education in the schools. Health education activities were addressed to the health personnel, municipal agents, and nurses of the eleven communities. Communities groups and local authorities were strengthened in order to address basic sanitation issues in the communities.

World Concern ACC/AM, a non-profit organization specialized in education and social activities were contracted to collaborate with health and local authorities. They identified target groups such as youth associations, churches, and schools for health education and trained them in social mobilization and in the control and prevention of diarrheal diseases. They also prepared and distributed educational materials in the project areas. The project also organized community effort for proper operation and maintenance of water supplies and sanitary facilities in particular in the communities of Chantal, Ducis, Dubreuil, Morisseau and St. George.

In connection with Inter-American Water day the booklet: Getting to safe water: Let get involved was translated into French and distributed to several schools.

Another booklet in the local language Creole entitled: Pwogram Edikasyon Jen sou Keysion Anviwonman ak Lasante was prepared in collaboration with the Foundation for the Development of Haitian Children. (FEEH) This booklet was used to train monitors in several areas of the country to develop awareness in the youth population on issues related to health and the environment. Several Camps were organized for children. Three other basic modules to teach children about environmental health were also distributed.

Training sessions have been organized for plumbers and technicians of the localities in the project areas in basic plumbing and maintenance of water systems. Local authorities and water committees were trained in the management of rural water systems. Eighty persons have been trained in water disinfection and water quality control. Twenty plumbers in the eleven communities have been formed in modern techniques of operation and maintenance. Each community was provided with a set of required tools to maintain the system. More than 10,000 persons were sensitized to issue related to water, sanitation and, other aspects of environmental health.

The project engineer participated in the evaluation meeting in Bolivia and observed the manual well drilling techniques and other basic sanitation technologies that could be transferred to Haiti on a technical cooperation between countries basis. A project to that effect was planned.

In 1999, more than 156 cholera cases were registered in the country, 27.4% of them were treated in the San Rafael Hospital in the Department of Libertad. The first outbreak occurred at the beginning of the year and a second by the end of the year. In this department where 652,098 persons reside during the second outbreak in December 30 cases occurred.

This implementation took place in El Salvador during December 1999-February 2000 The funds were used to accomplish a series of activities of interprogramatic character with the participation of the units in charge of epidemiology, food control, health promotion and environmental health. The interprogrammatic approach was found more efficient to address the outbreak of cholera in an integrated manner.

The procurement of materials was provided in direct response to the needs expressed by the Ministry of Public Health and Social Assistance. All the activities were carried out conjointly with the ministry and its department units. There was also a close collaboration with National Administration of Water and Sewerage (ANDA) in all activities related to drinking water quality and massive disinfection. All the activities were implemented in the framework of the National Plan for the fight against cholera and focused mainly on the following:

Two subregional meetings were organized in 1997 to review the achievements of the Project, share experience and develop common approaches to the problems of the Region.

The first meeting took place in Tegucigalpa Honduras from March 13-16, 1997. Dr. Hartmut Kasischke Public Health Advisor in El Salvador represented GTZ in the meeting. He sent his observations directly to GTZ.

The meeting for the Andean countries took pace in Santa Cruz, Bolivia from August 19-22 1997. The GTZ representative in Bolivia participated in the meeting.

The meeting in Central America was successful in bringing together twenty five health personnel, social promoters and international experts, including a GTZ representative to examine the activities of the Project and its impact on the cholera situation. The Project was instrumental in developing concept and promoting activities for mobilization of the civil society for prevention and control of cholera. Local leaders together with health authorities have been trained and organized meetings in communities where the Project would intervene. Municipal leaders also became the main advocates for prevention of cholera in their districts. Strong actions for inter-institutional coordination, for organization of committees in the localities of the projects were also promoted. The review indicated that the Project has been successfully implemented in all countries of Central America however there was need for consolidation of activities at the national level. In particular all the countries expressed the need to strengthen water quality surveillance and continue the promotion of disinfection in more communities and to develop mechanism for expanding the experience of the pilot projects to country wide programs. At the subregional level the need for more interchange of social mobilization experience and to come out with unified methodologies for cholera prevention was felt.

One of the problems identified was that the fluctuation of the electrical energy in Central America interfered with the production of chlorine solution in the onsite generation process. It was also mentioned that the availability of spare parts could be a problem and the fact that the operational costs of the units were not always clearly defined may pose a problem for the communities.

As a result of this evaluation a survey of the operating conditions and experience of all onsite equipment generator of sodium hypochorite was carried out by a consultant. The results were presented at the Regional Seminar on Water Disinfection in Lima Peru in 1998.

The meeting in Santa Cruz de la Sierra was attended by 21 participants and reviewed the achievement of the Project in Bolivia, Colombia, Peru and Haiti. Ecuador and Venezuela were also invited for sharing experience and initiating the planning of a project on improvement of basic sanitation for indigenous communities. The meeting was particularly useful in demonstrating the appropriate technologies utilized in Bolivia in the promotion of basic sanitation in school and communities. Bolivia had the opportunity to benefit from other projects in appropriate technology development, PROTESA and the assistance of CDC, which provided back up for the activities of this Project. Since then the experience of Bolivia has been exploited by other countries, including Peru, Ecuador and Panama through technical cooperation between countries. All the three countries had completed the main requirements of the Project, however the need for consolidation of activities was also felt, in particular at the institutional level. The extensive experience of the countries in social mobilization in relation to the cholera situation needs to be properly recorded. A technology assessment of the utilization of onsite generator for chlorine production was done.

CEPIS prepared health education materials on cholera prevention and control and on improvement access and quality of drinking water for diarrheal diseases prevention. A video on the technologies used for cholera prevention was also developed to disseminate information to other communities about the interventions for cholera control. CEPIS also greatly assisted in developing specification, testing, trouble shooting and technology assessment the onsite generation of chlorine process. The document Cholera prevention in Latin America: Implication for Diarrheal Diseases Control and Environmental Health Indicators was prepared to consolidate information concerning the cholera prevention efforts in Latin America and the Caribbean since the XII pandemic arrived in 1991. Lessons learned and successful projects that contributed to the control of cholera were highlighted. Possible environmental indicators which are both feasible to collect and useful in their predictive value of environmental health risks were identified.

6. Analysis and assessment of results

The Project has provided incentives and opportunities for social mobilization for cholera prevention and control in Central America and South America.

National and local workshops in the Project area were held in each country and provided health and community leaders the opportunity to learn techniques of community mobilization and cholera prevention. These leaders in turn became the main advocates for improving environmental conditions for effective cholera control. The Project facilitated the coordination between ministries and agencies. The collaboration of the Ministry of Education and the participation of teachers were responsible for the success of the Project in many countries. Through effective social marketing the disinfection products gained more acceptation in the public which resulted in a wider use of water disinfection. A video on cholera prevention and basic sanitation technologies was produced, distributed and used by several agencies.

More than 5,000 persons have been trained in methods of disinfection, in cholera prevention and control of diarrheal diseases and cholera prevention. Community leaders have been trained in effective methods of community mobilization and on the importance of water and sanitation to the health of the communities. This training provided the basis for the sustainability of cholera prevention activities.

Technicians were also trained in sanitary surveys, water quality surveillance, plumbing and maintenance of water systems.

Because of its extensive activities in hygiene and health education the Project also provided the basis for sustainability of cholera prevention activities. The production and distribution of a large and diversified quantity of education and audiovisual materials was made possible in all countries. The educational component of the Bolivia Project has effectively supported the improvement program of sanitation in ten schools and many communities. Each country has developed the educational material suitable to its specific needs. In addition, CEPIS and the Regional office, using effective strategies in connection with regional or worldwide celebrations such as Inter-American Water Day, have developed and distributed educational materials for sanitation promotion for control of diarrheal diseases and cholera in all the countries.

Educational material easy to understand was prepared in the native language of the target population. Some of the health education campaign such as the signalization campaign in Honduras was very innovative.

A total of thirty demonstration projects have been implemented and completed mostly in rural communities and peri-urban areas where sanitary infrastructures are non existent, and the risk of diseases transmission high. For each demonstration, a sanitary survey of all the relevant communities in the zone of affectation of the Project was carried out in order to select the communities for intervention. These surveys provided valuable and epidemiological information on these communities. CEPIS developed a methodology for epidemiological and environmental surveys, which permitted to evaluate the efficacy of the Project interventions in the communities.

The intensive training, activities contributed to the institutional strengthening of health agencies, and provide ground work for integration of cholera prevention activities in the health activities. In particular water quality and water disinfection activities became priority in most local health department. The epidemiological and environmental profiles of the community helped the local authorities to develop integrated action programs for improvement in those communities.

In general, all the expected results have been accomplished in accordance with the project plan. The strengthening of cholera prevention program and the continuous effort to improve quality of water and food remain a long term objective.

7. Project impact

The Project has contributed to the development of sanitary infrastructures in water and sanitation in rural areas, indigenous communities in schools and markets. The technologies demonstrated in particular that the on site generation of disinfectants are being used as the corner stone for improving water quality in several countries and communities. Such technologies may also be integrated in other development projects. Project activities have been expanded in Bolivia to cover social marketing aspects of disinfection products. The onsite disinfection of water has proved to be very feasible for small communities and is being used for emergency and rapid deployment situations such as those created by the frequent hurricanes, and potential flood and drought situation created by climatic conditions such as El Niño.

New development in Solar technology has made possible to use of on-site disinfection generation in many remote communities of Latin America and has opened the possibility of increasing water disinfection coverage.

Activities in training and social mobilization have contributed to the strengthening of the various institutions involved in the prevention and control of cholera. The Project also contributed to the improvement in the coordination of health agencies, the ministries and non-governmental organizations at the central and local level to help communities take a more integrated approach in cholera prevention and control.

The project has contributed to a large extent to reduce the transmission of Vibrio cholerae during various outbreaks of cholera in several localities of Latin America and in the cholera outbreak at the end of 1999 in the Department of Libertad in El Salvador.

Through the procurement of disinfection equipment to all the countries the project has contributed to the increase in coverage of water disinfection in the countries. It has demonstrated the feasibility and provided the basis for several national initiatives for providing universal disinfection of water in the countries of Latin America and the Caribbean. Close to two hundred thousand US dollars (US 200,000) were spent in providing disinfection and water quality equipment.

The lessons learned during the project could serve regional initiatives such as Initiative 47 of Santa Cruz de la Sierra for the improvement of water quality in Latin America improve strategies for water surveillance and technological approach. . The project has contributed to the formulation of other projects including Water and Sanitation for Indigenous Communities.

The training of community leaders in matters related to health and environment in particular in personal, family and community hygiene and the reinforcement of institutional capability in the localities provide the basis for the long-term benefits and sustainability of the prevention and control of cholera.

The Project provided a seed for initiating programs for the prevention and control of cholera in Latin America and the Caribbean. It developed and demonstrated an approach and a methodology, which was followed by all the countries. In particular it addressed the special needs of rural and remote communities, which are often left out of the development process. It provided the means for strengthening institutional capabilities in the ministries of health and other government institutions.

The project was also timely in the sense that it was one of the first regional initiative to be funded and may be regarded as an important input in the social development of the countries. Future activities should aim at consolidating the achievement of this project. This has also been the desire that all the countries expressed in the evaluation meetings. The long-term benefits and sustainability will be attained through the reinforcement and development of institutional capability in the localities and the continuous training of personnel. A Future project along these line is suggested to consolidate and achieve long term benefits in cholera prevention and supporting the socio- economic development in the countries of Latin America and the Caribbean.

ACTIVITIES	HON	ELS	NIC	GUA	PAN
Training and local and municipal organization	c	c	c	c	c
Training of students, health and agriculture personnel	c	c	c	c
Printing and distribution of educational materials	c	c	c	c	c
Cleaning campaigns	c	c	c
Campaign on use and management of sanitary latrines	c	c		c	c
Course on food handling		c	c	c	c
Health Fair	c	c		c	c
Campaign of HTH and sodium hypochlorite	c	c	c	c	c
Home visit to verify disinfectant management and water quality	c	c	c	c
Strengthening of the social structure in the community	c	c	c	c	c
Organization of campaign on summer without cholera	c	c			c
Monitoring and follow up of educational activities	c	c	c	c	c
Installation of chlorine banks	c	c	c	c	c
Sanitary surveys	c	c	c	c	c
Water quality survey

Expected Results	BOL	COL	ELS	GUT	HAI	HON	NIC	PAN	PER
Workshop for community mobilization carried out	c	c	c	c	c	c	c	c	c
National and local training courses carried out	c	c	c	c	c	c	c	c	c
Health education materials developed and distributed	c	c	c	c	c	c	c	c	c
Diagnostic of water and sanitation carried out	c	c	c	c	c	c	c	c	c
Local demonstration projects Implemented	c	c	c	c	c	c	c	c	c
Cholera control as part of PHC/CDD Strengthened	c	c	c	c	c	c	c	c	c
Community initiative For cholera Encouraged	c	c	c	c	*	c	c	c	c
Project follow-up And consolidation	*	*	*	*	*	*	*	*	*

Up to DM 500,000	assigned to	The Andean Countries
Up to DM 340,000	assigned to	Central America
Up to DM 680,000	assigned to	Haiti

Andean Region:	MCP-CDD-110	US327,740	Bolivia, Perú, Colombia
Central America:	MCP-CDD-111	US222,863	El Salvador, Guatemala, Honduras, Nicaragua and Panama
Caribbean	MCP-CDD-112	US445,684	Haiti

No	Activity	1993	1994	1995	1996	1997	1998	1999	2000
1	Negotiation and signing of agreements	_____	____
2	Preparation and approval of country projects		__	__
3	Implementation of project in Andean region and Central America		__	____	_____
4	Implementation in Haiti				______	_____	_____
5	Subregional workshops					_ _
6	Special project in El Salvador							__	_
7	Progress and Final reports			_	_	_	_		_