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This volume highlights some of the challenges in delivering effective environmental health interventions, and presents examples of emergent theories and case studies that can help close the gap between intent and impact. These include impact crediting systems, objective evidence gathering tools, and social businesses that service environmental health. The case studies presented cross disciplines, scales, organizational and national boundaries and can defy easy categorization. A water project may be designed for a health impact, but financed with a climate change tool, and leverage high tech cell phone sensors. A cookstove program may be primarily concerned with employment and capacity building, but balance environmental and health concerns.

Presently, the impact of interventions may not always be aligned to the intent sought. In this book, readers will discover alternative ways to move the mindset of funders and implementers toward pay-for-performance models of humanitarian and environmental interventions. Undergraduate and graduate students taking courses in social enterprise, social entrepreneurship, global health, appropriate technology, international development and development engineering would benefit from these increasingly non-traditional case studies that challenge commonly accepted presentations of poverty reduction and social enterprise.



Chapter 1. Introduction

Global environmental health efforts are motivated by a sense of common responsibility and opportunity. These programs take forms large and small, from community groups to the World Bank. The methods likewise take varying, and sometimes competing forms, from watershed restoration to road building to community engagement, with funding provided by charities, loans, microfinance and big business. Once these projects are installed, typically the implementers are their own evaluators. When resources allow, some may invite external experts to visit the projects. Under the best of circumstances, funding is available to run a randomized controlled trial to rigorously evaluate if the projects are improving the intended environmental, health or other outcomes. But, usually sooner rather than later, the funding runs out for that particular project, and often organizations move on. This has resulted in sad statistics. For example, half of the water pumps installed in some African countries are broken a few years after they’re installed. We propose an alternative – moving the mindset of funders toward pay-for-performance models of humanitarian and environmental interventions, backed by objective measurement tools and metrics. Instead of pushing money toward projects based on promises, pay interventions for successfully demonstrating impact that meets a stated intent.
Evan A. Thomas

Chapter 2. Performance Over Promises

Globally, stories of environmental health efforts are filled with good intentions and broken promises. Linking payments directly to long term social and environmental change can in some cases provide a solution. Pay for performance is now being used in a wide range of interventions and programs, but the potential of this approach is only beginning to be understood in the social sector. We explore theories that underlie pay for performance and lay the groundwork for understanding why and how this approach works. We then describe our Intent-to-Impact cycle—a four-stage model of Intent, Interventions, Evidence, and Pay for Performance that closes the loop between good intentions and impacts delivered. The challenge now is to use knowledge from this cycle to identify, explore, and learn from funding approaches that have and have not worked in important fields within the sector.
Kristi Yuthas, Evan A. Thomas

Chapter 3. Trade-Offs and Risks in Results-Based Approaches

The growth in results-based approaches (RBA) to development financing is motivated by the underlying assumption that these approaches will incentivize implementing agencies to more closely align their actions and exert more focused effort on achieving the objectives of the program that have been agreed upon by the recipient and donor. At the same time RBAs strengthen accountability of both recipient and donor, by generating objective evidence that the agreed upon results have been achieved. But it should not necessarily be taken for granted that they are a more efficient approach to development just because payments are tied to results. If donor and government objectives are misaligned, RBA can help focus government actions towards a clear target that they may not otherwise focus on, but this comes with a shift in the risk burden towards the government agency, which is likely to come with an implicit risk premium.
Claire Chase, Aidan Coville

Chapter 4. How Feedback Loops Can Improve Aid and Governance

If private markets can produce the iPhone, why can’t aid organizations create and implement development initiatives that are equally innovative and sought after by people around the world? The key difference is feedback loops. Well functioning private markets excel at providing consumers with a constantly improving stream of high-quality products and services. Why? Because consumers give companies constant feedback on what they like and what they don’t. Companies that listen to their consumers by modifying existing products and launching new ones have a chance of increasing their revenues and profits; companies that don’t are at risk of going out of business. Is it possible to create analogous mechanisms that require aid organizations to listen to what regular citizens want – and then act on what they hear? Recently, many examples have emerged in which direct feedback from citizens has been solicited as input into both the selection and implementation of development initiatives. Not all have been successful, but some have led to significant improvements to outcomes. Being successful – having a closed feedback loop – requires not only that citizens be listened to, but that their voices be acted upon in the form of changes to aid programs. The chapter provides a set of principles that can be used by practitioners to design feedback loops that have a higher probability of success. It also provides a set of key conceptual issues that remain to be explored in depth by researchers, as well as a potential implementation roadmap for leaders of aid agencies.
Dennis B. Whittle

Chapter 5. Intent to Impact – Diluted Safe Water Monitoring

In early 2012, the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) made an important announcement: “The world has met the Millennium Development Goal (MDG) target of halving the proportion of people without sustainable access to safe drinking water, well in advance of the MDG 2015 deadline” (WHO/UNICEF, Millennium development goal drinking water target World Health Organization. United Nations Children’s Fund, Geneva, 2012a). Major news organizations heralded the accomplishment. The editors of The Lancet used the occasion to draw attention to underachievement other MDG targets but still acknowledged the water announcement as “some good news to celebrate” (The Lancet, Lancet 379(9820):978. doi:10.​1016/​S0140-6736(12)60412-7, 2012). There was little celebrating, however, among many who work at the intersection of water and health. This is because the way progress is measured on the MDG water target—by counting those that have access to “improved water supplies”—does not fully address water quality, quantity and sustainable access—key components of the target that are fundamental to human health. Overly simplistic metrics used to monitor progress on important health and development goals can be misleading. Monitoring that relies on poor indicators can exaggerate progress. Even worse, however, inadequate assessments of environmental health interventions can undermine the proper allocation of scarce resources to where they can best advance the intended goals. This chapter describes how existing monitoring of water supplies in low-income settings fails to address the key health-based conditions that the MDG water targets sought to encourage. Its aim is to use the inadequacy of international water monitoring as a case study to demonstrate the critical need to carefully align targets with conditions that are most likely to advance the overall goals, and the potential consequences of failing to do so.
Thomas F. Clasen

Chapter 6. Mobilizing Payments for Water Service Sustainability

The current model of rural water service delivery is broken. Money flows down from donors and governments to install infrastructure but little reliable information on performance flows back. Increased use of handpump mapping exercises by survey teams may usefully identify handpumps working one day of the year but this leaves the remaining 99.7 % of any year unknown. The continuous monitoring of services is increasingly important if we are to know the real level of water services being enjoyed by rural communities, with the growing consensus on the Human Right to Water adding further impetus. For governments and donors, knowing whether investments deliver verifiable impacts over time rather than simply knowing that budgets have been spent, is transforming established thinking. Mobile networks provide an inclusive architecture to reduce the information asymmetry between investments and outcomes. Information alone is insufficient to make progress but it is necessary to track and improve accountable service delivery. Information can improve institutional performance and help define appropriate roles and responsibilities between communities, governments and donors to close the loop between well-meaning investments and quantifiable outcomes. Donors can demonstrate value-for-money, government and water service regulators can align performance with measureable outcomes, and communities can contribute to financial sustainability through user payments that are contingent upon service delivery. Using unique observational data from monitoring handpump usage in rural Kenya, we evaluate how dramatic improvements in maintenance services influence payment preferences across institutional, operational and geographic factors. Public goods theory is applied to examine new institutional forms of handpump management. Results reveal steps to enhance rural water supply sustainability by pooling maintenance and financial risks at scale supported by advances in monitoring and payment technologies.
Johanna Koehler, Patrick Thomson, Robert Hope

Chapter 7. Enabling Ecological Restoration Through Quantification

The Freshwater Trust, a conservation non-for-profit headquartered in Portland, Oregon, has been working since 1983 on solutions to address river impairment in ways that are replicable and scalable to meet the today’s environmental challenges. The methods and tools that The Freshwater Trust uses to return degraded waters to healthy waters are founded on the principles of measuring, or quantifying, environmental outcomes and tracking effectiveness to maximize ecological uplift. Current restoration actions include planting streamside, or riparian, forests to provide shade to streams and stabilize banks; placing large wood structures instream to provide habitat for spawning and rearing habitat; restoring flow to dewatered streams; and reconnecting streams to closed floodplains.
Alex H. Johnson, Joe S. Whitworth

Chapter 8. Incentivizing Impact – Privately Financed Public Health in Rwanda

There is effectively universal agreement that clean air and clean water are human rights. Yet there is not universal agreement on effective ways of ensuring these rights. In environmental health interventions addressing water and indoor air quality, multiple determinants contribute to adoption. These may include technology selection, technology distribution and education methods, community engagement with behavior change, and duration and magnitude of implementer engagement. In Rwanda, while the country has the fastest annual reduction in child mortality in the world, the population is still exposed to a disease burden associated with environmental health challenges. Rwanda relies both on direct donor funding and coordination of programs managed by international non-profits and health sector businesses working on these challenges. In this chapter, a program in Rwanda illustrates the potential of public-private partnerships, combined with objective measurement tools and metrics, to deliver a sustained impact in poor households.
Evan A. Thomas, Christina Barstow, Thomas Clasen

Chapter 9. A Critical Review of Carbon Credits for Household Water Treatment

Household water treatment (HWT) provides a means for vulnerable populations to take charge of their own drinking water quality as they patiently wait for the pipe to finally reach them. In many low-income countries, however, promoters have not succeeded in scaling up the intervention among the target population or securing its consistent and sustained use. Carbon financing can provide the funding for reaching targeted populations with effective HWT solutions and the incentives to ensure their long-term uptake. Nevertheless, programs have been criticized because they do not actually reduce carbon emissions. We summarize the background and operation of carbon financing of HWT interventions, including the controversial construct of “suppressed demand”. We agree that these programs have limited potential to reduce greenhouse gas emissions and that their characterization of trading “carbon for water” is misleading. Nevertheless, we show that the Kyoto Protocol expressly encouraged the use of suppressed demand as a means of allowing low-income countries to benefit from carbon financing provided it is used to advance development priorities such as health. We conclude by recommending changes to existing criteria for eligible HWT programs that will help ensure that they meet the conditions of microbiological effectiveness and actual use that will improve their potential for health gains.
James M. Hodge, Thomas F. Clasen

Chapter 10. HAPIT, the Household Air Pollution Intervention Tool, to Evaluate the Health Benefits and Cost-Effectiveness of Clean Cooking Interventions

There is a growing focus on interventions seeking to reduce the burden of disease associated with household air pollution. HAPIT provides policy-makers and program implementers an easy-to-use tool by which to compare the relative merits of programs both within and between countries, helping assist with optimization of limited resources. Although a number of uncertainties remain, HAPIT represents the ‘state of the science’ and relies on the best available knowledge – and is built to easily integrate new knowledge and findings to better hone estimates.
Ajay Pillarisetti, Sumi Mehta, Kirk R. Smith

Chapter 11. Innovations in Payments for Health Benefits of Improved Cookstoves

This chapter presents two brief overviews of entrepreneurs demonstrating recent advances in monitoring and marketing the health impacts of improved cookstoves in developing countries. CQuest Capital proposes commoditizing and marketing Averted Disability Adjusted Life Years (ADALYs) associated with demonstrated reduced particulate exposure. Nexleaf Analytics leverages sensor technology and carbon credit markets to pay cookstove users for demonstrated use of stoves. Both efforts are innovations in the cookstove sector, and may over time contribute to improved cookstove program models.
Ken Newcombe, Tara Ramanathan, Nithya Ramanathan, Erin Ross

Chapter 12. The Role of Mobile in Delivering Sanitation Services

Lack of access to adequate sanitation has a considerable impact on public health, leading to mortality from diarrhea to stunting and malnutrition for children, directly affecting their school attendance. Open defecation, in addition to highly impacting privacy and dignity of individuals, is unsafe, especially for women, who are far more vulnerable to the risk of physical and sexual assault. Governments have the responsibility to improve sanitation capacity, but have often failed to provide service supply chain for operation and maintenance. Most practitioners also recognize that building a toilet cannot ensure that it will be used. In rural locations, sustainable access to sanitation is challenged by poor distribution networks, low availability to local sanitation solutions and open defecation behaviors. Growing mobile and data connectivity and use of mobile monitoring tools (SMS or applications), can improve understanding of community sanitation behaviors, while allowing service providers to develop more efficient supply chain and customer relationship management.
Michael Ronan Nique, Helene Smertnik

Chapter 13. Combining Sensors and Ethnography to Evaluate Latrine Use in India

This chapter presents recent research in latrine use measurements—a challenging element of sanitation service delivery. The research used quantitative and qualitative methods to contribute to new understanding of sanitation practices and meanings in rural India. We estimated latrine usage behavior through ethnographic interviews and sensor monitoring, specifically the latest generation of infrared toilet sensors. Two hundred and fifty-eight rural households in West Bengal (WB) and Himachal Pradesh, India, participated in the study by allowing PLUMs to be installed in their houses for a minimum of 6 days. Six hundred interviews were taken in these households, and in others, where sensors had not been installed. Ethnographic and observational methods were used to capture the different defecation habits and their meanings in the two study sites. Those data framed the analysis of the PLUM raw data for each location. PLUMs provided reliable, quantitative verification. Interviews elicited unique information and proved essential to understanding and maximizing the PLUM data set. The combined methodological approach produced key findings that latrines in rural WB were used only for defecation, and that low cost, pit latrines were being used sustainably in both study areas.
Kathleen O’Reilly, Elizabeth Louis, Evan A. Thomas, Antara Sinha

Chapter 14. Sustainable Sanitation Provision in Urban Slums – The Sanergy Case Study

Sanergy, a Nairobi-based social enterprise, tackles the sanitation crisis in urban informal settlements in Africa. We take an innovative, systems-based approach that addresses the entire sanitation value chain. We build high-quality, low-cost sanitation units, known as Fresh Life Toilets, which we franchise to community members, who run them as businesses. We collect the waste on a regular basis, removing it from the community. We then convert the waste into valuable by-products, including organic fertilizer and insect-based animal feed, which we sell to regional farmers. Through this model, we are making it profitable – and thus sustainable – to provide hygienic sanitation in urban slums.
David Auerbach

Chapter 15. Pay for Performance Energy Access Markets

Few examples of pay-for-performance service delivery models have been as successful, particularly in the development context, as the “Energy Access” market. Originally the domain of non-governmental organizations and government rural electrification programs in developing countries, the energy access sector has transitioned to a vibrant marketplace with potential for continued scaling. The market has developed to the point, enabled by rapid reductions in solar PV and lighting prices, expanded telecom coverage, innovation in machine-to-machine technology development, and “last-mile” business models, that traditional aid now is seen as a threat to further market growth. This article examines the trends that enabled the rapid deployment of off-grid solar markets based on pay-as-you-go electricity service that is yielding significant health and economic benefits for those living in many of the most remote communities in developing countries.
Dexter Gauntlett, Michael Ronan Nique, Helene Smertnik

Chapter 16. Mobilizing Commercial Investment for Social Good: The Social Success Note

In this chapter, we present a new pay-for-success investment model, which we call the “Social Success Note”. This approach may offer an innovative solution to crowd-in commercial investment at scale to organizations that seek to achieve both financial sustainability and measurable positive social and environmental outcomes. While initially designed for investment into social enterprises, this pay-for-success financing solution has application wherever there is the potential to incentivize greater positive social and environmental impact through an outcome payment linked to investment.
In the Social Success Note model, a private investor agrees to make capital available to a social enterprise at a below-market rate. The investee has to repay the investment or loan, but if it achieves a predetermined social outcome, a philanthropic outcome payer provides the investor an additional “impact payment” corresponding to a market-rate return.
The Social Success Note is being developed and piloted by Yunus Social Business, a global incubator of social businesses, and The Rockefeller Foundation as part of its Zero Gap portfolio, focused on developing innovative financing solutions to address the world’s most critical challenges.
Lorenzo Bernasconi Kohn, Saskia Bruysten


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