Evaluation of DG ECHO s Action in the Water and Sanitation/Public Health Sector in Zimbabwe

Transcription

1 Evaluation of DG ECHO s Action in the Water and Sanitation/Public Health Sector in Zimbabwe March 2011-May 2011 Submitted by Peter DeVillez (Team Leader) Christine Bousquet Nyasha Lawrence Nyagwambo On behalf of Cost of the report in : Evaluation costs as percentage of budget evaluated: 0,92 % Contract Number: ECHO/ADM/BUD/2011/01201 The report has been financed by and produced at the request of the European Commission. The comments contained herein reflect the opinions of the consultants only.

2 Table of Contents LIST OF ACRONYMS... II EXECUTIVE SUMMARY...1 QUESTION...2 CONCLUSIONS...2 RECOMMENDATIONS BACKGROUND AND INTRODUCTION METHODOLOGY DG-ECHO IN ZIMBABWE THE WERU APPROACH EVALUATION QUESTIONS RELEVANCE EFFECTIVENESS EFFICIENCY COHERENCE, COMPLEMENTARITY (LRRD) CROSS-CUTTING ISSUES CONCLUSION AND RECOMMENDATIONS i -

3 List of Acronyms ACF ACP ARI CAP CFR CPU CTC CTU C4 DDF DEHT DfID DHO DMO DWSSC EDC EDF EHT FPA FRC GAA GIZ GoZ HDPCG HERU HIP HTF IDSR IEC IMC INGO IRC IWRM IWSD LRRD Action Contre la Faim African Caribbean and Pacific Acute Respiratory Infections Consolidated Action Plan Case Fatality Rate Civil Protection Unit Cholera Treatment Centre Cholera Treatment Unit Cholera Command and Control Centre District Development Fund District Environmental Health Technician Department for International Development (UK) District Health Office District Medical Officer District Water Supply and Sanitation Committee Department of Epidemiology and Disease Control European Development Fund Environment Health Technician Framework Partnership Agreement French Red Cross German Agro Action German Technical Cooperation Agency Government of Zimbabwe Health Development Partners Coordination Group Health Emergency Response Unit Humanitarian Implementation Plan Health Transition Fund Integrated Disease Surveillance Response Information Education and Communication International Medical Corps International Non-Governmental Organisation International Rescue Committee Integrated Water Resources Management Institute of Water and Sanitation Development Linking Relief to Rehabilitation and Development - ii -

4 MDM MDTF M&E MoHCW MoU MWRDM NAC NCU NFI OCHA OFDA ORP ORS PHHE PLWWH/A PMD RDT RRT SAG ToR UNICEF USAID VHW VLOM VMAHS WASH WERU WES WHO WVI Médecins du Monde Multi-Donor Trust Fund Monitoring and Evaluation Ministry of Health and Child Welfare Memorandum of Understanding Ministry of Water Resources Development and Management National Action Committee National Coordination Unit Non Food Item Office for the Coordination of Humanitarian Affairs Office of U.S. Foreign Disaster Assistance (USAID) Oral Rehydration Point Oral Rehydration Salts Public Health and Hygiene Education People Living with HIV/AIDS Provincial Medical Directorate Rapid Diagnostic Test Rapid Response Team Strategic Advisory Group Terms of Reference United Nations International Children Fund U.S Agency for International Development Village Health Worker Village Level Operation and Maintenance Vital Medicines Availability and Health Services Water Sanitation and Hygiene Cluster WASH Emergency Response Unit Water Environmental Sanitation World Health Organization World Vision International ZimAHEAD Zimbabwe Applied Health Education and Development (NGO) ZINWA Zimbabwe National Water Authority - iii -

5 Executive Summary 1. At independence in 1980 Zimbabwe had a well developed and professionally managed municipal water and sanitation infrastructure in all major towns and cities. Between 1980 and 2000 the rural water and sanitation sector benefited from a comprehensive programme of development resulting in the overall WatSan sector being the envy of other developing countries at the end of the century. From 2000 onwards Zimbabwe suffered a dramatic decline in governance standards resulting in a catastrophic collapse in the social, economic and health sectors culminating in hyper-inflation, wide unemployment and political instability. During the same period the water and sanitation sector suffered from under investment and the abandonment of repair and maintenance programmes across the country resulting in the physical collapse of the water supply systems and sewage treatment facilities. In the rural areas the majority of water points fell into disrepair and the primary health care system all but ceased to function. 2. In 2008 cholera outbreaks occurred in some high density urban areas and infected the communities and the water and sanitation networks. Cholera rapidly spread to become an epidemic affecting nearly every region of the country; nearly 100,000 people were infected and 4,288 deaths from the disease were recorded. The epidemic peaked in January 2009 and had subsided to a minimal level by the middle of During the cholera peak, 55 out of the country s 62 districts were affected, including major urban populations such as Harare, Kadoma and Chegutu. In 2010, twenty districts were affected and the Case Fatality Rate was still at 2.1% but the number of cholera cases was reduced to 1,022 with 22 deaths. In 2011 ten districts remain the focus of cholera alerts, mostly in Masvingo, Manicaland, and Mashonaland West provinces. 3. At the time of the cholera outbreak the Government of Zimbabwe was unable to respond to the epidemic in any meaningful way and it fell to the NGO community to fill the gap as best it could. Initially two, then later four and eventually six, international NGOs who were already working in the WatSan sector came together in 2008 to form what eventually became known as WERU (WASH Emergency Response Unit) in an attempt to deal with the rapidly spreading emergency. With grant funding from ECHO these WERU partners shared responsibility for the emergency response on a geographic basis and set up response teams to assess the water supply needs of the clinics who were reporting suspected cholera cases. The WERU partners developed a collective response strategy over the next two years which included time based targets for responding to cholera alerts, establishing potable water supplies and distributing non-food water treatment items to affected communities. By prepositioning WASH supplies in regional stores the response teams were able to reduce the response times to a minimum given the huge areas being covered by the teams. While this strategy was not well documented at the time the WERU partners achieved a high degree of commonality in their individual implementation strategies and co-operated with other local and international NGOS throughout the 2008 to 2010 period under review. UNICEF appointed a WASH cluster co-ordinator based in Harare and the WASH cluster met every month to report on and to review progress across the country. UN-OCHA was funded by ECHO to assist with co-ordination and management of data and information. 4. This evaluation was conducted between April and May 2011 and has attempted to document the chronology of the evolution of the WERU approach in Zimbabwe and then to evaluate the WERU covering the period 2008 to As this was not a pre-planned - 1 -

6 intervention programme with data collection or monitoring components built in it has been difficult to assemble verifiable indicators of past performance for comparison against preset targets. Consequently much of the evaluation has been subjective rather than objective and based on anecdotal evidence and direct observations by the evaluation team. Although this is not an ideal modality it has been possible to develop an understanding of the nature of the WERU and achieve an assessment of its performance against the prescribed DAC criteria. The Terms of Reference for this evaluation appear in Annex to this report. 5. From discussions at all levels in the water and sanitation sector in Zimbabwe the overall impression is that the work done by WERU partners during and shortly after the peak of the cholera crisis in 2008 and 2009 was a major contributing factor to the control of the disease and was greatly appreciated by the Government of Zimbabwe. Their post-emergency activities continued to address the chronic short-comings in the water and sanitation infrastructure and contributed to the eventual suppression of the disease. Nevertheless, the poor quality of technical workmanship seen during the evaluation field trips does not generate confidence in the longevity of the rehabilitated water systems and this factor should be addressed during the next phase of the evolution of WERU or its successor. Similarly the coordination mechanisms operated during the latter stages of WERU activity are not considered to be ideal in that they are entirely voluntary and do not have any executive powers to enforce technical or health sector standards. This should also be addressed during the next phase of WERU. 6. The following matrix shows the major finding and recommendations of the evaluation. The questions are taken directly from the Terms of Reference for this assignment. Question Conclusions Recommendations Q1: Relevance. In the WatSan sector in Zimbabwe at the time there was no active GoZ leadership in place. To what extent have the considerations taken into account when establishing the WERU contributed to the achievement of its objectives and the positive impacts on the ground? The WERU response was not anticipated nor pre-planned. The formulation of the WERU response was voluntary, iterative and appropriate. WERU followed a continuously evolving development pattern in response to changing conditions. Emergency preparedness should be planned in advance: support should be given to the re-emerging GoZ sector co-ordination structures. Capacity should be built into the emerging GoZ WatSan structures to achieve an appropriate response to any new emergency. Q2: Effectiveness. To what extent has the WERU concept and its individual projects achieved the stated objectives? The WERU response was coordinated centrally by a UNICEF appointed co-ordinator but the voluntary nature of the appointment restricted effectiveness. The adoption of time based targets made a positive contribution to the effectiveness of the Co-ordination should be vested in a properly empowered body with executive powers. Support should be given to rebuilding the GoZ WatSan institutional structure. The planning of future technical response - 2 -

7 Q3: Efficiency. To what extent have the existing implementation and coordination processes, as well as the resources available, contributed to a positive impact? Q4: Coherence and complementarity. How does the WERU approach fit into the LRRD context and facilitates transition to longer term development strategies? implementation. The flexibility of the WERU partners allowed for effective responses to emerging problems. The use of ad hoc procedures for the assessment of technical issues led to inconsistent and poorly planned rehabilitations. Standardised technical selection and installation procedures were not followed. The WERU intervention was instrumental in saving lives and empowering the degraded rural health clinics. Despite the urgency of the situation at the time of the outbreak of cholera it should have been possible to record the de facto situation parameters at an early stage. The large geographical areas covered by each of the WERU actors stretched their human and material resources to the limit. Field staff were not closely supervised and would have benefited from more technical and managerial support from their internal structures. The WERU approach is an emergency response developed in unique Zimbabwean circumstances and therefore does not easily lend itself to replication or transition. During emergency response activities it is still necessary to consider long term effects as well as short term gains. The externalizing of transition and delegation of the LRRD process from WatSan actors to sector wide bodies does not contribute to convergence of LRRD strategies strategies should include the preparation of standardized assessment tools and response procedures. All future installations and rehabilitation standards should comply with prescribed technical standards. Further efforts should be made during the transition process to consolidate the Health institutions progress achieved during the cholera crisis. The data collection and analysis functions of the State WatSan and Health sector agencies should be reinforced to re-establish their import roles in managing information for planning purposes. In future crises of this nature more attention should be paid to recruiting adequate numbers of appropriately qualified and experienced staff. The LRRD question should be addressed at all levels in the WatSan sector: partner level, WatSan NGO sector and within GoZ institutions. Convergence of these individual processes can be achieved by creating links to the parallel structures at all levels. The LRRD process being initiated at all levels within the WatSan sector should - 3 -

8 Q5. Cross-cutting issues: To what extent have DG- ECHO and its partner organizations taken into account cross-cutting issues such as gender, children, environmental protection and HIV/AIDS, in the planning and implementation of the action? and implementation. The suddenness and unique nature of the cholera emergency in Zimbabwe did not readily lend itself to developing special considerations for specific subsectors of the affected population. Despite being established WatSan actors the WERU partners did not appear to pay adequate attention to some sector-wide cross-cutting issues such as IWRM and environmental protection. embed sustainability into the next phase of sector progress. In the next phase of development of the reemerging WatSan sector more consideration should be given to the overarching considerations in the WatSan sector such as IWRM and environmental issues. 7. While the emergency phase of WERU was considered to be successful the next phase must pay more attention to the transition process from relief towards recovery. This will continue to be challenging while the GoZ structures that are ultimately responsible for development and management of the national water resources remain weak and ineffective. However, the newly resurgent Ministry of Water Resources Development and Management and its National Action Committee are positive signs of a new attitude within Government towards the WatSan Sector. 8. The MoWRDM has recently received an improved budget from Treasury and has convened a WASH sector task force with invitations to all the current NGOs in the sector to contribute to its work. While recognising their still weakened and under-budgeted status the Ministry is actively courting the involvement and support of the parallel structure put in place during the cholera crisis (including the WERU partners) and is adopting an inclusive and proactive stance in the sector. This presents the WASH cluster members and the WERU partners with an opportunity to contribute positively to the development of the WatSan sector over the next year and more. This opportunity should be seized and every effort should be made to integrate the current water and sanitation sector actors and activities into a viable and sustainable strategy for the future

9 1. Background and Introduction 9. The Directorate General for Humanitarian Aid and Civil Protection of the European Commission (DG-ECHO) is responsible for formulating EU humanitarian aid policy and for funding humanitarian aid to victims of conflicts and disasters in non-eu countries. Its mandate is to save and preserve life, to reduce or prevent human suffering and to safeguard the integrity and dignity of those affected by humanitarian crises. EC regulations concerning humanitarian aid lay down rules for the establishment and implementation of regular evaluations of which this report is one output. 10. Between 2008 and 2010 DG-ECHO was instrumental in the development and funding of a response to the cholera epidemic which broke out during that period in Zimbabwe; this response came to be known by the acronym WERU standing for Water, sanitation and health Emergency Response Unit. As the cholera emergency response in Zimbabwe eventually moved from relief into recovery it became important to consolidate the WERU approach in order to optimize the impact and build on the gains made. Since 2010 the Zimbabwe situation has required more developmental, structural actions to ensure sustainability of the water supply and sanitation infrastructure in the country, activities which are outside the scope and mandate of DG-ECHO and constitute integral components of linking relief, recovery and development otherwise known as the LRRD process. 11. As public health interventions have been the focus of DG-ECHO s strategy and funding in Zimbabwe since 2008 and will continue to be the sole focus during 2011 an evaluation of these actions became fully justified and particularly useful in light of the current preparations being made for new grant and contribution agreements scheduled for the end of July In December 2010 Terms of Reference were drawn up for an evaluation of DG-ECHO s involvement in WERU and a selection of consulting consortia was invited to bid on the contract. The evaluation contract was awarded to AGEG of Germany in February 2011 and the proposed consulting team comprised a senior water and sanitation specialist (team leader), a senior public health specialist and a Zimbabwean water and sanitation sector consultant. The team had been carefully selected to fulfil the specific requirements of the assignment in Zimbabwe as well as to provide a wide range of related experience in the evaluation process and in the sector internationally. 2. Methodology 12. The team commenced work on the assignment with a briefing session in Brussels at the DG-ECHO offices where staff involved in the WERU programme were interviewed and some documentation was provided for subsequent review and assessment. It became apparent at that briefing session that there was insufficient documentation available specifically explaining the formulation of the WERU approach and detailing its main features and implementation modality. Inputs and intended outputs had been identified in the fichops 1 but the important features of the methodology and logistics were not well documented. It was resolved at that stage that documenting the WERU approach should be included in the list of tasks to be performed during the evaluation assignment. 1 Fichops: Project documentation maintained by ECHO for each funding application

10 13. After all available documents were reviewed an inception report was prepared and presented to DG-ECHO at the beginning of April; a final version of this report was agreed and the team assembled in Harare on the 11 th of April. The first week was spent meeting the ECHO team and the WERU partners in Harare. Contacts were established with other members of the WASH Cluster and the Cluster co-ordinator in UNICEF (See Annex for the List of Persons Met). 14. A programme of field visits was drawn up for the second week and new documents were assembled for review at the weekend. The selection of sites to be visited took into account a range of representative projects in rural and urban areas, including those that were implemented in provinces reporting cholera outbreaks and provinces free of cholera. The itinerary therefore aimed for a balance of geographical locations, taking into account the constraints of travel to remote areas and the time available. (See Annex for the programme of activities). During the 2 nd and 3 rd weeks field trips to the four partner areas were organized and undertaken as well as extra meetings with various members and stakeholders both in the field and in the capital, Harare. The last week of the in-country part of the assignment was spent attending follow-up meetings, compiling notes and an aide mémoire, conducting a debriefing workshop for all partners and attending a meeting with the Minister of Water Resources Development and Management (MWRDM). The list of documents reviewed and minutes of key informant interview, group discussions and direct observations conducted while in Zimbabwe appears in Annex to this report. The consulting team s international members left Harare on the 7 th of May. 15. During the field visit to Zimbabwe efforts were made to gather any and all documentation that would assist in drawing a clearer picture of what WERU was, how it was planned and implemented and what are the critical features of the WERU approach which would be pertinent to the development of an LRRD strategy. This effort was only partially successful as the WERU approach itself and the application of it to the cholera crisis in Zimbabwe is sparsely documented. The picture that was eventually developed was largely based on anecdotal evidence from those parties who had been instrumental in both the development of the approach and its implementation in the field. In some instances the anecdotal evidence was consistent across the range of actors in the field but in several cases there were inconsistencies and even some lack of agreement on core principles. These agreements and disparities have been recorded and discussed in the main text of this report. 3. DG-ECHO in Zimbabwe 16. DG-ECHO has been present in Zimbabwe since 2002, mainly focusing on food security. Other sectors were also covered, including Home Based Care HIV/AIDS; water and sanitation; nutrition; UN Co-ordination; Orphans and other Vulnerable Children; and Internally Displaced Populations. In September 2006, priorities were redefined and DG- ECHO supported social services and actions in health, epidemics, and Water and Sanitation. For the period , DG ECHO has made available 110,654,1193 and responded to the needs of approximately 22,151,799 beneficiaries. 17. In the period of 2008 to the present DG-ECHO has mainly provided support in the areas of Water and Sanitation, health and food security. During this period, DG ECHO has been instrumental in the support and development of the WASH cluster. In mid-2009, in response to the magnitude and the spread of cholera, DG-ECHO employed the WERU approach. Through this approach, DG-ECHO has targeted cholera outbreaks in every province of the - 6 -

11 country. Six and, and later in 2010, four key international Non Governmental Organisations (INGOs) and two UN agencies have been the main implementers of the approach (see Annex for the list of projects funded under WERU). For the period , the total amount allocated to WERU implementation has been estimated at 9,528, In February this year DG-ECHO Zimbabwe updated its Humanitarian Implementation Plan (HIP) reducing their contribution from 15M in 2010 to 10M in 2011 as food assistance is phased out completely following a successful exit strategy from the sector. The new budget will be largely channelled into actions to support the delivery of integrated public health services and making progress towards more sustainability in the transition phase. 4. The WERU approach 19. During the preparatory phase of this evaluation it became clear that the activities funded by DG-ECHO under the acronym WERU had not been planned and executed in the project mode as would have taken place if WERU were funded as a development intervention under the European Development Fund (EDF) system. There were no identification or formulation documents available and no project document to which specific reference could be made. Consequently there were no independent mid-term or final evaluations performed on any of the individual programmes funded by ECHO although there were internal project reports contained within the fichops. There were separate fichops on each annual phase of individual intervention programmes implemented by the various WERU partners some of which referred directly to WERU by name while others alluded to WERU without mentioning the acronym specifically. During the course of the evaluation two documents came to light which directly addressed the WERU concept; one an dated November 2009 from the WASH coordinator discussing the creation of a WERU and the other being an attachment to an prepared by OXFAM in June 2010 which mentions the proposed composition of the WERU partners. Both documents outline the general principles of WERU but neither one specifies the WERU mandate within the national context nor any hierarchy of responsibilities or chain of command and neither document mentions any external reporting, monitoring or evaluations requirements. 20. Despite the lack of formalized documentation it is clear that the collective understanding of the WERU approach was a voluntary agreement by the four organizations who had signed partnership agreements with UNICEF (Framework Partnership Agreements or FPAs) were signed with German Agro Action (GAA), OXFAM, Action Contre la Faim (ACF) and Mercy Corps) and the numerous members of the WASH Cluster who participated in the programme of activities to work in a collaborative and structured manner in tackling the WASH aspects of the cholera crisis. 21. The main features of the approach that came to be referred to as WERU developed over time and are now known to include the following: 1. At the time of the cholera peak, health partners did not have full capacity to respond to the outbreak and four WASH partners and two other organizations (World Vision International-WVI and CARE) assumed leadership roles in six clearly defined geographical areas of Zimbabwe and all members of the WASH cluster working in 2 Note that there has not been an official list of specific WERU projects. Rather, the list has been compiled by the evaluation team in Harare following discussions with DG ECHO s Head of Office

12 those areas agreed to co-operate with the lead organizations in delivering the WatSan services at health institutions. 3. (See the WERU map on next page and in Annex.) 2. The response to a cholera alert should commence within 24 hours of receiving the alert. This response should start with an assessment of the water supply needs of the rural health clinic reporting the alert (For the administrative and logistical organisation of the health system in Zimbabwe, see Annex.) 3. Within 72 hours of receiving an alert the partner should have established an emergency water supply of potable water, sufficient in both quality and quantity to sustain the staff and caseload being managed by the clinic. 4. Within 14 days of receiving the alert the partner should have established a sustainable supply of potable water which does not require the further intervention of the WERU team. 5. Sphere standards should be used in determining the quantity and quality of water supply delivered to the clinic. 6. A WERU tracking system is used to monitor the performance of the partners against the agreed target times. 7. Common assessment tools are used for initial rapid assessment of clinic WASH requirements. 8. A standard District Emergency Response Kit (hardware) should be used by partners during their initial response to a reported alert. 9. Post-response assessment should be done by partners twice a week after completion of the initial WERU response. 10. WASH emergencies are not confined to cholera only. 22. Although all ten items listed above appear in the proposal for a WERU not all ten have been adopted universally by all partners. This is not to say that the ten principles have not been accepted but as the association of voluntary organizations is not a contractual agreement it only requires a member of the WASH cluster to voluntarily agree to the overall principles of the WERU approach for them to be considered to be WERU members. As mentioned earlier there is no hierarchy of responsibility within the WASH cluster and all partners and members have an equal status within the grouping. 23. During the course of the evaluation and its many meetings WERU was referred to variously as a response unit, a response system, a programme, an approach, a concept, a methodology and also as an EU Programme. It is clear from this wide range of understandings that WERU evolved to mean different things to different people and not a fixed programme or philosophy which can be defined, refined and replicated outside the context within which it developed. In order to understand how this came about it is necessary to understand the background of the sector which gave rise to the WERU response. 3 WVI and Care subscribed to the approach but were not fully implementing it all throughout the period. WVI received one funding tranche during the cholera outbreak (January August 2009). CARE received one funding tranche too (July 2009 March 2010)

13 Map showing geographical areas of responsibility for WERU actors 24. A detailed chronology of the evolution of the WERU idea, as well the background to cholera response in Zimbabwe ( ) are contained in Annex to this report but it is important to note some significant factors which define and ultimately limit its application and replicability. Between 1980 (independence for Zimbabwe) and 2000 great efforts were made and impressive progress was achieved across the country in the water and sanitation sector culminating in Zimbabwe having extensive coverage of community operated and maintained water supply points in all rural areas of the country. Hygiene promotion had been spearheaded by the Ministry of Health and Child Welfare (MoHCW) and rural water supply and sanitation technology successfully developed by the Blair Research arm of the MoHCW. The rural water sector itself was ably overseen by the National Action Committee (NAC) whose secretariat (the National Co-ordinating Unit or NCU) was pro-active in its management and co-ordination along Integrated Water Resources Management (IWRM) principles 4. In the urban areas water reticulation and sewerage systems were also highly developed and well maintained by the responsible local governments in the larger cities and towns and by the national government in the smaller towns and Growth Points. As a result of the dramatic decline in Government of Zimbabwe (GoZ) funding and under investment in the sector, due in part to the hyperinflationary macroeconomic environment during that period, the entire water and sanitation sector fell into almost total disrepair and dysfunction within six years whereby urban water utilities become moribund and rural water supplies had ceased to 4 Integrated Water Resources Management is a systematic process for the sustainable development, allocation and monitoring of water resource use in the context of social, economic and environmental objectives. Its basis is that the many different uses of finite water resources are interdependent

14 function or receive any supervisory attention. There was no rural extension services actively promoting or maintaining the national water sector interests and hygiene promotion in rural areas had stopped entirely. 25. The huge gap in water sector support services after 2000 was only partly being filled by NGOs, both national and international, which were active in the rural areas. When the cholera arrived in the country (possibly brought in by migrant workers from neighbouring countries) the breakdown in the water and sanitation sector had created ideal conditions for the rapid spread of the disease across the country, initially form urban to rural areas. As the reports of cholera started to come in ever increasing numbers the Government was powerless to respond and the leading INGOs diverted their already thinly spread resources from development oriented WatSan work to relief oriented activities in an attempt to stem the tide of the disease. While working in isolation the NGOs had only limited effect and so the idea of a combined and co-ordinated response was borne out of necessity and in the absence of any GoZ guidance or assistance. 26. Due to the application of restrictions on donor funding to the Zimbabwe Government (implemented under Article 96 of the Cotonou Agreement) the EC was not inclined to fund Government activities directly through the EDF and so the ECHO funding route became the most suitable for addressing the humanitarian crisis. DG-ECHO was able to consider direct grants to suitably qualified and organized INGOs on a one year basis and their flexibility in processing funding applications made it possible for DG-ECHO to effect prompt and suitable funding. This situation was further complicated by the prevailing economic crisis in Zimbabwe at the time with hyper-inflation having rendered the local currency (the former Zimbabwe Dollar) virtually worthless and of no use as a financial instrument in funding the humanitarian response to the cholera outbreak. 27. This fragmented and dysfunctional background to the evolution of the WERU approach explains why the focus of this evaluation (the WERU approach itself) is not recorded in a definitive project document or legally enforceable contract. It must also be noted that the scope of this evaluation covers the period 2008 to 2010 only and does not include the current activities variously funded under the WERU label and still ongoing to this day. Since the end of the cholera epidemic the WERU partners have further refined their strategic approach to their response to the possibility of further cholera outbreaks and this has resulted in further changes to the WERU philosophy. These later changes to the WERU approach are now addressing the issue of transition and sustainability of gains made earlier in the WERU life cycle. 28. Since the middle of 2010 the cholera epidemic has been completely downgraded to a post-crisis operation with two main focuses referred by DG ECHO as to the connected vessels. On the one hand the WERU partners are expected to maintain their cholera response preparedness by keeping their response teams available for any new alerts that may be raised anywhere within their geographical areas of responsibility. This response preparedness now includes the ability to respond to any other water borne disease which would benefit from the provision of a sustainable potable water supply at any clinic in the country. This widening of the focus from one specific disease to include other diarrhoeal diseases is a welcome outcome of the original intervention philosophy even if in practice there has been an almost exclusive focus on cholera. 29. At the same time as maintaining their response capacity the WERU partners are also using their logistical capacity (staff, transport and supply chains) to effect repairs and

15 rehabilitations at other rural clinics which have not so far been affected by the cholera epidemic but are considered to be at risk. The response teams have liaised with the GoZ water and sanitation structures to identify specific clinics which can benefit from the use of the partners abilities while they are not fully occupied on emergency response. This strategy has resulted in rural health clinics across the country having had their water supply upgraded as an important input into cholera prevention without waiting for the next epidemic to arrive. While working at the unaffected clinics the response teams are simultaneously available for redeployment at short notice to deal with any new outbreak that may be suspected in their geographical area. 30. This aspect of WERU s current work represents a positive step in the direction of LRRD as it uses resources and facilities put in place during the earlier humanitarian crisis to promote a recovery and development strategy with a view to sustainable evolution of the water and sanitation sector. As with the earlier WERU evolution this new shift in strategy is taking place outside of an overall sector strategy addressing the whole LRRD question and without close consideration of and co-operation with the recovering Government structures that are eventually to assume overall responsibility for the long term development of the sector (See Overview of Water and Sanitation Sector in Annex.) It is also noted that this latest stage of WERU evolution is not yet documented and is being co-ordinated unofficially by the DG-ECHO and UN-OCHA offices in Harare. The development of this LRRD strategy is an unofficial recognition of the need for both an exit strategy for the various INGOs that have been hitherto involved in the emergency response to the cholera epidemic as well as the need for a coherent sector strategy for addressing the LRRD issues that are becoming ever more urgent. 5. Evaluation Questions 31. This evaluation is based on a set of key questions which are intended to give a more precise and accessible form to the evaluation criteria and to articulate the key issues. These questions have been developed and refined throughout the evaluation and the final evaluation framework matrix and data collection tools appear in Annex to this report. The evaluation questions address the key OECD/DAC criteria wherever relevant to the specific humanitarian situation and include reference to the cross-cutting issues and the objective of LRRD. 32. While a structured approach has been adopted by the evaluation team it is important to note that the DAC criteria are only guidelines and do not constitute rules that limit the scope and depth of the evaluation. Accordingly other relevant issues are addressed throughout the report and incorporated into the text wherever appropriate. In this way a comprehensive understanding of the reality of the situation existing at the time and in the location of the intervention is achieved rather than a strictly clinical appreciation of specific aspects of the situation. 5.1 Relevance 33. Q1: Relevance. To what extent have the considerations taken into account when establishing the WERU contributed to the achievement of its objectives and the positive impacts on the ground? 34. As explained elsewhere in this report it is now known that the response to the cholera emergency in Zimbabwe was not a carefully planned programme which was established in

16 advance to cater for all the eventualities that could have arisen during a fixed period of implementation. The WERU approach that slowly emerged from the emergency response of several separate agencies and actors in the sector was iterative in nature and organic in its growth and development. Between 2008 and 2010 the WERU programme developed core features which were only properly understood by the members of the WASH cluster and even to this time have not been formulated on paper as a definitive explanation of the essence of WERU. The WASH cluster that was convened under the co-ordinating overview of UNICEF had at its core the four partners who signed FPAs with UNICEF. These four partners assumed the lead roles in the geographic sectors they voluntarily assigned to themselves and they collectively agreed to time-based targets for response to cholera outbreaks and to logistical arrangements such as pre-positioning of relief supplies. At all times it was believed by the partners and the ECHO office in Harare that their response programme was specifically and entirely relevant to the situation that existed at the time and to the progressively developing situation that evolved nationally. This arrangement was referred to by the WASH Cluster coordinator as a coalition of the willing and is based more on personalities within organizations than on formal agreements entered into by the institutions themselves. The drawback with this sort of ad hoc personality based approach to co-ordination is that without the presence of the personalities involved there is little institutional momentum created and the long term sustainability of the arrangement is questionable. 35. The main aspects of the cholera response that contributed to the establishment of the WERU were: The existence of specific funding restrictions occasioned by the application of Article 96 of the Cotonou Agreement. The existence of several INGOs working in the water and sanitation sector in the country prior to the outbreak of cholera. The diverse and adaptable human and logistical resources available within the preexisting WatSan community. The presence of strong and decisive management personnel within the INGOs and donor community who were willing to take important and often difficult decisions. The ability and willingness of the WatSan community to realign their priorities away from their predefined development programmes towards the cholera relief operation. The existence of an operational UNICEF office which was willing to assume the coordinating role for the relief programme. The almost complete absence of a functioning Government structure for delivering water and sanitation services within Zimbabwe. The initial reluctance on the part of the GoZ to admit to the scale and seriousness of the cholera epidemic and the subsequent acceptance by the same GoZ of the need for external assistance without the prerequisite of planning permission and project approval. 36. With this background of urgent need and the absence of external guidance and control the partners in the WERU devised a response strategy that was entirely relevant, realistic and pragmatic at the time. In part it was based on experiences gained in other countries and with other organizations and partly a local initiative to address the specifics of the Zimbabwe situation. This strategy recognised the differences between the various agencies while

17 maximising the strengths of their common features. In this way the six WERU partners were able to apply their individual skills and experiences in the most appropriate way possible depending on the local conditions in their own separate geographical areas of influence. 37. The overwhelming need in 2008 and early 2009 was for emergency relief from the shortage of potable water available at clinics affected by the cholera outbreak. To address this need the WERU partners developed plans to respond to the announcement of new outbreaks within a very short time period (24 hours) so that the specific needs of each clinic could be assessed and subsequently addressed urgently. As the various teams were deployed they became experienced in assessing and predicting the needs and subsequently targeted the establishment of a potable water supply within 48 hours of receiving the alert and often combined the assessment and the response visit into a single activity, enabling the clinic in question to have a clean water supply well within the target time of 48 hours. As all partners gained more experience in the relief operation and got to know their own geographical areas better they became ever more adept at providing water supplies promptly and effectively and almost always were able to complete the entire assessment, response and completion exercise within a 72 hour period. During the course of the evolution of the relief operation the 24 hour, 48 hour and 72 hour target times became the backbone of the WERU approach and were specifically relevant to the reality of the situation pertaining at the time in the cholera affected areas. 38. During the evolution of the response mechanism the pre-positioning of relief supplies in strategically located store centres was adopted as a significant factor in getting to the affected clinics in time to save lives and this development became an additional factor in the strategy of the WERU. It was well known also that the provision of clean water alone would not prevent further cholera outbreaks and the provision of non-food items (NFIs) to the affected communities was added to the range of measures undertaken by the partners. These water related components (water containers, water sterilization chemicals and soap) were distributed free of charge to affected communities along with the health promotion training necessary for their effective use. This secondary response activity was integrated into the establishment of water supplies at the affected clinics with a view to containing the outbreak and adding value to the medical relief provided by the clinic staff. In this way it was intended to propagate the clean water psychology beyond the boundaries of the clinic itself to prevent further outbreaks of the disease and to contain the local outbreak to those inpatients admitted to the clinics and Cholera Treatment Centres (CTCs). 39. While the field work of the relief programme was evolving on the ground the administrative provisions at the co-ordination level were also being fine tuned to adapt to the developing situation. With the active co-operation of the ECHO office a common LogFrame was developed for all the WERU partners in order to promote further convergence of implementation strategies and enhance the adoption of common goals and standards. In this way the evolution of the cholera response mechanism attempted to keep pace with the evolution of the cholera epidemic itself as it progressively migrated from densely populated urban areas to more sparsely populated rural locations. At all times the WERU partners strived to produce the most relevant response mechanism possible in order to enhance and improve their performance throughout the relief programme. 40. Between 2008 and 2009 the WERU approach was always attempting to keep up with the dramatic spread of cholera throughout the country which ultimately affected 55 out of 62 districts in the country. WERU also filled the capacity gap left by health partners who later

18 organized themselves into the Health Emergency Response Unit (HERU) under the leadership of WHO. As the epidemic started to wane in the middle of 2009 and the WERU approach reached its maturity the impact of WERU became less visible as new outbreak reports became less frequent. By the time the cholera was under control and unofficially no longer an epidemic the WERU approach had been fine tuned and finalized to a point where it was clearly understood and well implemented operational modality accepted by all partners and WASH cluster members across the country. 41. The context within which the cholera epidemic developed in Zimbabwe was itself characterised by a rapidly changing (and mostly deteriorating) social, political and economic environment. The catastrophic hyper-inflation and consequential economic melt-down in the country was a serious impediment to any successful financial planning and the inability of the Government to co-ordinate any effective response to the health crisis only compounded the difficulties faced by the affected population. It is therefore considered that the response to the cholera that became known as WERU was well developed and entirely relevant to the dramatic evolution of the cholera epidemic in the country. 42. As the cholera case load dwindled to a trickle during 2010 the cholera public health needs of the general population changed from emergency response to emergency preparedness. At the same time the focus of public health concerns expanded from exclusively cholera oriented to a wider concern about water borne diseases country-wide. The chronic state of the nation s entire water and sanitation infrastructure, including all major cities and rural areas, had not significantly improved despite the numerous clinics which had benefited from the restoration of potable water supplies. The threat of a sudden and rapidly spreading water borne disease outbreak remained a significant factor in the minds of public health practitioners and WatSan service providers alike. 43. During the latter stages of the period in WERU s evolution the emphasis of activity shifted from rapid response to new alerts towards emergency preparedness through the pre-emptive upgrading of rural health clinic water facilities in areas that did not have a known record of cholera outbreaks. The selection of which clinics to upgrade in advance of any cholera outbreak was done in collaboration with the local Government structures including the various Water and Sanitation sub-committees, the Ministry of Local Government and the MoHCW. It is this pre-selection of clinics for upgrading which remains a difficult task when the implementation resources are finite and all clinics cannot be accessed across the entire country, while the threat of cholera and other water borne diseases is not confined to known areas. 44. The new outbreaks of cholera which have been reported towards the end of 2010 and now into 2011 are not statistically disaggregated in a way that would enable their analysis to identify if the new outbreaks are occurring in clinic catchment areas that have previously benefited from upgrading under the WERU programme or not. This important statistical analysis is missing from the data that is being presented to the WASH cluster and yet it could prove critical in assessing the relevance of continuing with the WERU approach in its current pre-emptive phase. 45. In summation it can be said that the core principles of the WERU approach (timely response and flexibility) were entirely relevant to the conditions that pertained during the crisis period when the need for potable water supplies at rural clinics was dire. However the WERU approach was not as obviously relevant to the task of post emergency

19 that followed after the crisis. This is not to say that the WERU approach is inappropriate; however the evidence to prove its appropriateness is not readily available. 5.2 Effectiveness 46. Q2: Effectiveness. To what extent has the WERU concept and its individual projects achieved the stated objectives? 47. The principal objective of the WERU approach as stated in the Logical Framework is to contribute to the reduction of morbidity/mortality rates in urban, peri-urban and rural areas, caused by WASH emergencies. Specifically the WERU programme sought to reduce and eliminate the threat of the spread of water borne disease outbreaks. These are obviously very high targets to set in the context of a cholera epidemic and especially the elimination of the threat of the spread of all water borne diseases. It is entirely reasonable therefore to expect a less than 100% success rate on such ambitious targets. However, as the health statistics illustrate in Annex, the reduction of cholera cases and deaths over time suggests that the coordinated coverage and response as initiated under WERU have largely contributed, together with other national and international efforts, to the prevention and control of cholera in Zimbabwe. 48. At the level of individual projects, the progress made is difficult to document despite partner efforts to develop a common monitoring tool. The WERU tracker is being used to monitor whether the alert and response are carried in a timely manner (24 and 48 hour). However, in its current form, the tool does not provide a comprehensive picture of progress over time. Anecdotal evidence from the current cholera outbreaks in Manicaland province suggests that a timely response is highly dependent on the ability of the health staff to conduct a preliminary epidemiological investigation and to identify the cause and origin/source. As of 2010, the implementation of Rapid Response Teams (RRTs) through the Integrated Surveillance and Response (IDSR) system is intended to improve the timeliness of the outbreak response at district level. It is hoped by partners that this initiative will gradually improve the notification delays. The establishment of RRTs, under the MoHCW leadership, has for the first time provided a common structure for outbreak investigation and response, where information to be collected and reported can also be harmonized. 49. The WERU approach was an evolutionary approach which sought to utilize pre-existing WatSan development expertise in a rapidly evolving situation by being both flexible and prompt in its performance. 50. The innate flexibility of the WERU approach enabled several aspects of the work to be effectively implemented. Firstly the ability to respond immediately in any part of the country through the organization of geographical territories for each partner and their various cooperating organisations (local and INGOs) enabled a structured and organized response system to develop which contributed to the high success rate in terms of assessment and response time limits. Whilst it cannot be statistically or clinically proved that the provision of potable water at any clinic saved lives it is safe to say that the basic requirement of every rural health clinic to have access to clean water was effectively fulfilled in those rural health clinics that reported suspected cholera cases. As the 2010 Vital Medicines Availability and Health Services (VMHAS) survey results demonstrate, 77.3% of rural health clinics (n=1,123) had a source of drinking water available on their premises. Out of the 900 rehabilitated rural health