Health, livelihood, and environmental impacts of the distribution of a carbon-credit-financed, large-scale water filter and improved cookstove programme in Rwanda
Authors: Christina Barstow, Thomas Clasen, Miles Kirby, Evan Thomas
Journal: The Lancet Planetary Health (2018)

In Rwanda, where two of the largest contributors to mortality among children younger than 5 years are pneumonia (11%) and diarrhoea (7%),1UNICEFCommitting to child survival: a promise renewed-progress report 2015.https://www.unicef.org/publications/index_83078.htmlDate: 2015Date accessed: April 7, 2018Google Scholar interventions that can improve access to clean drinking water and reduce exposure to harmful indoor air pollution have the potential to provide significant health impact. Additionally, with more than 80% of Rwandans relying on firewood as their primary fuel,2National Institute of Statistics of RwandaFourth Rwanda population and housing census.http://www.statistics.gov.rw/survey-period/fourth-population-and-housing-census-2012Date: 2012Date accessed: April 7, 2018Google Scholar decreased firewood demand could help reduce the shortage in firewood and the stress on forests. Cost and time savings from reduced fuelwood consumption could help curb some of the economic burden of roughly 60% of Rwandans who live on less than US$2 per day.3World BankPoverty headcount ratio at $1·90 a day (2011 PPP) (% of population). Indicators.https://data.worldbank.org/indicator/SI.POV.DDAY?locations=RW&view=chartlDate: 2018Date accessed: April 7, 2018Google Scholar The Tubeho Neza (Live Well) programme is a partnership between the Rwanda Ministry of Health and the social enterprise DelAgua Health to deliver environmental health technologies to some of the poorest Rwandan households. The programme distributed the EcoZoom Dura improved wood-burning cookstove (EcoZoom, Portland, OR, USA) and the LifeStraw Family 2.0 water filter (Vestergaard Frandsen, Lausanne, Switzerland) to more than 100 000 lower-income households in Rwanda's Western Province, followed by a further 250 000 cookstoves to households primarily in the Eastern Province, in 2015. The intervention included household-level education and behaviour-change messaging to each household through community health workers.4Barstow CK Ngabo F Rosa G et al.Designing and piloting a program to provide water filters and improved cookstoves in Rwanda.PLoS One. 2014; 9: e92403Crossref PubMed Scopus (20) Google Scholar, 5Barstow CK Nagel C Clasen TF Thomas EA Process evaluation and assessment of use of a large scale water filter and cookstove program in Rwanda.BMC Public Health. 2016; 16: 584Crossref PubMed Scopus (16) Google Scholar The programme was privately funded by DelAgua, and earns revenue, in part, through the generation and sale of carbon credits issued under the UN Clean Development Mechanism, tied proportionally to repeatedly measured use of the intervention.6Thomas EA Barstow C Clasen T Incentivizing impact—privately financed public health in Rwanda.in: Thomas E Broken pumps and promises. Springer, Cham2016: 99-131Crossref Scopus (0) Google Scholar To assess the effects of the intervention in Western Province, investigators undertook a randomised controlled trial7Nagel CL Kirby MA Zambrano LD et al.Study design of a cluster-randomized controlled trial to evaluate a large-scale distribution of cook stoves and water filters in Western Province, Rwanda.Contemp Clin Trials Commun. 2016; 4: 124-135Crossref PubMed Scopus (14) Google Scholar among 174 village-level clusters, half of which were randomly assigned to receive the intervention (filter, stove, and use promotion) and the other half to serve as controls. Investigators also undertook studies to estimate the economic and environmental impact of the intervention. The purpose of this Case Report is to describe the Tubeho Neza programme in western Rwanda, in the context of health, economic, and environmental benefits. Preliminary analysis of the results of the health impact study suggest that the intervention increased the proportion of households with no detectable faecal contamination in drinking water samples by 92% (p<0·0001), and reduced the prevalence of caretaker-reported child diarrhoea in the previous week by 30% (p=0·0002). Preliminary results also suggest that the intervention reduced the prevalence of reported acute respiratory infection in the previous week by 29% (p=0·0006). After conducting kitchen performance tests, we estimated that 120 000 tonnes of annual woodfuel savings in the Western Province might be attributable to the programme, decreasing to 102 000 tonnes in 2024. These estimates suggest that this programme alone might compensate for the government-projected deficit in woodfuel in the Western Province of 106 000 tonnes per year by 2020.8Ministry of Natural Resources, Rwanda Natural Resources Authority, Department of Forestry and Nature ConservationRwanda Supply Master Plan for fuelwood and charcoal. Final report. Update and upgrade of WISDOM Rwanda.http://rnra.rw/fileadmin/user_upload/Final_Report_SMP_Rwanda.pdfDate: 2013Date accessed: April 7, 2018Google Scholar Households that collect fuelwood might save around 48 days per year in collection of fuelwood, while households who previously boiled water might save around 23 days in boiling of water for drinking. We found that this intervention provides significant benefits that might continue to accrue if the programme continues to be supported. Ongoing support of this programme is contingent on viable revenue earned through carbon-credit generation and sales, a business model currently in jeopardy given the depressed carbon-credit market attributable in part to the USA's declaration of withdrawal from the Paris Climate Agreement. Funding DelAgua Health, Rwanda Ministry of Health. Contributors CB was responsible for the behaviour change design and environmental impact study. TC and MK designed and managed the health impact study. MK implemented and analysed the health impact study. ET designed and managed the overall programme concept and implementation. Declaration of interests CB and ET were financially compensated consultants for DelAgua as programme managers. TC and MK were compensated by their university through a grant from DelAgua.