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Dispatches from Rwanda
Dispatches from Rwanda

By Jonathan Fink

PSU Professor Evan Thomas  has been in the tiny, central African nation of Rwanda working on an ambitious program, locally called Tubeho Neza ("Live well"), to help reduce childhood diarrhea and pneumonia in Rwanda by distributing water filters and clean-burning cook stoves to the poorest third of this UN designated Least Developed Country (LDC). The project is run by DelAgua Health, of which Evan is the Chief Operating Officer, in partnership with the Rwandan Ministry of Health (

Much of the funding for the project comes from the sale of United Nations issued carbon credits, made possible because the filters and stoves reduce the villagers' need for firewood, thus lessening the pressure on Rwanda's mostly-depleted forests. Receiving carbon credit funding requires careful monitoring of the use of the stoves and filters, which is done by independent auditing organizations, as well as through a robust research program run out of PSU in collaboration with the Oregon Health and Science University (OHSU), the London School of Hygiene and Tropical Medicine, Emory University, the University of Colorado at Boulder, the University of California at Berkeley, and the University of Rwanda.

Tracking the performance and usage of stoves and filters is accomplished in part through the use of wireless transmitters that Evan and his co-workers at PSU have developed, which are embedded in approximately 1% of the deployed filters and stoves. The transmitters send usage data over the ubiquitous cell-phone network to the research and programmatic teams. These sensors are also deployed in 14 other countries by PSU, and allow philanthropic, public and private funders of public health programs to know whether their investments are being used and having impact.

The deployment we observed on October 2, 2014 is part of the second of Tubeho Neza's three phases. Phase I, which was completed in 2012, reached 10,000 people in 15 villages. Phase II, which began in September 2014 and is scheduled to be completed by the end of 2014, should reach 500,000 people in 2600 villages. Phase III in 2015 aims to serve at least 2M people in 13,000 villages. DelAgua, which is a social enterprise, hopes that the less poor 2/3 of the population, seeing the health benefits received by their neighbors, will choose to purchase stoves and filters for themselves, helping the company recover their costs and allowing them to continue to receive payments for carbon credits.

Each deployment is a complex, well-choreographed operation. Filters and stoves are picked up at DelAgua's warehouses in Kigali and delivered to the villages by the Rwandan National Police, contingent on the roads being passable, which is not always the case, especially during the two rainy seasons. Coordination is done ahead of time with the village leaders, who confirm the identities of each community member that will be receiving filters and stoves. Local Community Health Workers (CHW), who are employees of the national government and get trained by DelAgua staff, assist with the distribution.

The actual deployment kicks off with speeches by a village leader and a DelAgua project manager, who outline what will be taking place over the following few hours. Next, the CHWs put on a humorous play, depicting the health effects of contaminated drinking water and dirty indoor air from cooking. This is followed by more speeches telling the villagers about how the filters and pumps work, and the nature of the program, including warnings to not steal or try to sell the devices. Each recipient then gets checked off a list by a village leader, gets their stove and filter, along with a poster that shows how they’re used, and heads back to their home. CHWs then go to every home to explain again how the devices work, using a picture book as well as the poster. They also conduct a survey about the family, which provides baseline information about demographics and helps in calculating carbon credits. GPS locations and photos of the homes are recorded, along with bar codes for the filters and stoves. Before the end of the day, after the families have had an opportunity to try their devices, the CHWs and/or DelAgua managers return to make sure everything is working properly. All of these programmatic activities are designed to be robust implementations of well-established health behavior change methodology.

The community members seemed grateful and intrigued by the whole process. The scale is ramping up rapidly, and the basic public private partnership model for aid distribution is not well established. Success requires the cooperation of the community, the National Police, the Ministry of Public Health, the CHWs, DelAgua’s leadership, the manufacturers of the stoves and filters, the organizations providing the carbon credits, and the weather. I found the ambition and scale of the program to be mind-boggling. If they succeed, it could radically change the way global assistance is done.

As if the humanitarian aspects of Tubeho Neza were not impactful enough, DelAgua’s work in Rwanda is also the subject of a major scientific research program encompassing mechanical and electrical engineering, tropical medicine, epidemiology, statistics, and climate change. The PSU-led team of researchers described above are participating in a large-scale randomized controlled trial (RCT) to evaluate the health impacts of the filter and stove deployments. DelAgua is the primary funder of this research effort, with some additional support from the United States Agency for International Development (USAID).

Comparison with 40,000 households in the control areas is used to help evaluate the 100,000 households in the program areas. The team is measuring villagers’ behavior and device use through a combination of the PSU sensors, self-reported health conditions, blood samples, blood pressure, and in situ air and water quality monitoring. This information is then compared with clinically reported pneumonia and diarrhea cases among children under 5. This is one of the largest environmental health RCTs ever run.

In addition to the DelAgua program, PSU leads a separate research project, funded by the British Department for International Development, to put sensors on 200 hand pumps across Rwanda to assess the relative efficacy of three different operation and maintenance models with the goal of seeing if sensors can improve the cost-effectiveness of water service delivery in developing countries ( This is a critical issue because worldwide, roughly half of the water pumps installed by governments and aid programs are broken at any given time, and estimates of compliance with international metrics such as the Millennium Development Goals are likely over estimating progress.

These projects are expected to result in a large number of scientific publications in the next few years, and will open the door to many additional funding opportunities for comparable programs in several other developing world settings. In addition to the social and economic benefits in the targeted countries, this work can demonstrate the beneficial role of cutting-edge engineering technology in international development, expand the market for carbon credits, extend the global reach of Oregon companies and institutions, form part of the foundation for the new joint OHSU-PSU School of Public Health, and provide unique training opportunities for students from the US, UK, Rwanda, and other LDCs.