Process evaluation and assessment of use of a large scale water filter and cookstove program in Rwanda.

BACKGROUND: In an effort to reduce the disease burden in rural Rwanda, decrease poverty associated with expenditures for fuel, and minimize the environmental impact on forests and greenhouse gases from inefficient combustion of biomass, the Rwanda Ministry of Health (MOH) partnered with DelAgua Health (DelAgua), a private social enterprise, to distribute and promote the use of improved cookstoves and advanced water filters to the poorest quarter of households (Ubudehe 1 and 2) nationally, beginning in Western Province under a program branded Tubeho Neza ("Live Well"). The project is privately financed and earns revenue from carbon credits under the United Nations Clean Development Mechanism. METHODS: During a 3-month period in late 2014, over 470,000 people living in over 101,000 households were provided free water filters and cookstoves. Following the distribution, community health workers visited nearly 98 % of households to perform household level education and training activities. Over 87 % of households were visited again within 6 months with a basic survey conducted. Detailed adoption surveys were conducted among a sample of households, 1000 in the first round, 187 in the second. RESULTS: Approximately a year after distribution, reported water filter use was above 90 % (+/-4 % CI) and water present in filter was observed in over 76 % (+/-6 % CI) of households, while the reported primary stove was nearly 90 % (+/-4.4 % CI) and of households cooking at the time of the visit, over 83 % (+/-5.3 % CI) were on the improved stove. There was no observed association between household size and stove stacking behavior. CONCLUSIONS: This program suggests that free distribution is not a determinant of low adoption. It is plausible that continued engagement in households, enabled by Ministry of Health support and carbon financed revenue, contributed to high adoption rates. Overall, the program was able to demonstrate a privately financed, public health intervention can achieve high levels of initial adoption and usage of household level water filtration and improved cookstoves at a large scale.