Bhutan

Supportive Environment

The Convention of the Rights of the Child (CRC) which Bhutan ratified in 1990 provides the international legal framework for children's rights, including access to adequate health services, clean drinking water, protection from malnutrition, and generally the highest standards of life attainable. These rights of the child are guaranteed by the RGoB and a Child's Rights Task Force exists to oversee, advance and protect the rights and welfare of children in the country.

Besides primary health care, the RGoB has in place several programmes and projects in place which are specifically directed at improving child health such as the EPI, Maternal & Child Health, Nutrition, ARI and diarrhoeal disease programmes. These essential child health care services, including supply of medicines and vaccines, are provided free of cost. Services are to be further intensified and coverage levels expanded under the Ninth Five Year Plan.

The implementation of child health programmes are carried out by the Public Health Division which has adopted the Integrated 'Management of Childhood Illness (IMCI) strategy to manage child illnesses. Other positive initiatives that have been undertaken to promote better childcare practices are the development of a national policy on breast-feeding, the designation of baby-friendly hospitals, and the expansion of existing Maternal and Child Health (MCH) facilities including "Well Child" clinics.

      Increasing access to and improving the quality of child care services

      Improving institutional & management capacities at national & local levels

      Supporting ARI and Diarrhoea management programmes

      Supporting the Health Trust Fund for the purchase of vaccines and drugs

      Enhancing awareness and education in communities

Monitoring and Evaluation Environment

GOAL 5: IMPROVE MATERNAL HEALTH

Status and Trends

The maternal mortality rate (MMR) for 2000 was estimated at 255 per 100,000 live births, a dramatic reduction by over half from the high figure of 560 per 100,000 in 1990[1]. Extrapolating this trend and based on the continuation of appropriate interventions, the MDG target of reducing maternal mortality ratio by three-quarters is likely to be achieved by 2015.

The qualitative improvements in and the increased accessibility to reproductive health services, and related information and awareness thereof, have been identified as the reasons for the steep reductions in the MMR. More specifically, the declines in maternal mortality rates were related to the advocacy and implementation of safe motherhood and pregnancy/ delivery practices, ante and post natal clinical examinations, immunization against tetanus, and the widespread distribution of iron and folic acid tablets to reduce anaemia in pregnant women. The distribution of "safe-home delivery kits" was also tried on a pilot basis and replicated nationally from 1998 onwards to help facilitate safe deliveries.

Not withstanding the progress, MMR levels can be reduced even further. Maternal mortality and pregnancy/labour complications have been linked to mother's anaemia and nutritional deficiencies, haemorrhage, puerperal sepsis, malaria, obstructed labour complications, retained placenta, toxaemia, unsafe abortions, malaria and associated hypertensive diseases. Several of these conditional causes of maternal mortality are thought to be easily preventable. Socially, maternal mortality has also been linked to teenage pregnancies and early motherhood which increase the likelihood of high risk pregnancies and deliveries.

The percentage of deliveries attended by skilled health personnel has increased from 15 percent in 1994 to 24 percent in 2000 to 52 in 2005.

Challenges

While maternal mortality rates can be reduced substantially through the presence of skilled health personnel during deliveries, there is a severe constraint due to the dire shortage of health-trained manpower resources and the lack of adequate equipment and facilities in the country. The situation is further compounded by lack of accessibility to health units particularly in the more remote areas.

An important challenge in reducing maternal mortality will depend to a great extent on the RGoB's ability to expand and further strengthen Emergency Obstetric Care (EmOC) facilities and services and their effective utilization by communities. While such initiatives started in 2000 with a significant increase in the number of basic and comprehensive EmOC facilities. There is a need to further strengthen and expand these services, particularly in the context of the widely dispersed and scattered population settlements and difficult terrain.

Some of the other challenges that the country faces in improving maternal health care and reducing MMR are related to cultural and awareness barriers that inhibit widespread contraceptive usage, early motherhood, increasing teenage pregnancies, unsafe illegal abortions, and the lack of information among Bhutanese women on reproductive health and safe motherhood.

Supportive Environment

There is high level and strong political commitment to further reduce the MMR and improve maternal and reproductive health services. Her Majesty Ashi Sangay Choden Wangchuck, in her role as Goodwill ambassador of the United Nations Population Fund (UNFPA), has played a high profile advocacy role in highlighting important reproductive health issues of safe motherhood practices, adolescent health and teenage pregnancies, and family planning.

The Bhutan Vision 2020 document emphasizes the need to reduce maternal mortality and bring it at par with the average of all developing countries by 2007. The Ninth Five Year Plan document also highlights the fact that MMRs are still unacceptably high despite significant achievements, and identifies related issues such as safe pregnancy and motherhood, teenage pregnancies and family planning, as key areas deserving renewed focus.

At the programme level, under a National Plan of Action formulated in 1997, several activities support the goal of improving maternal health and reducing MMR. Among the most important of these is the Maternal and Child Health (MCH) programme with the specific objective to contribute to the reduction of MMR. The Safe Motherhood and Reproductive Health programme also seeks to reduce MMRs through activities focused on making health services and facilities more "woman friendly", increasing access to antenatal and postnatal care, and increasing births attended by skilled attendants.

Priorities for Development Assistance

      Improving access to and quality of Reproductive Health Services, particularly antenatal & postnatal care

      Strengthening capacity building, particularly for health service providers in rural areas Increasing presence of skilled health personnel during deliveries

      Promoting community participation, education & awareness on safe motherhood & reproductive health issues

      Enhancing decentralised, multi-sectoral & integrated approaches

      Strengthening EmOC Services

      Improving advocacy & monitoring

Monitoring and Evaluation Environment

GOAL 6: COMBAT HIV, MALARIA AND OTHER DISEASES

Status and Trends

The first two HIV cases in Bhutan were reported in 1993. By 2002, 38 individuals had been identified as HIV positive, with thirteen cases detected in 2002 alone. The prevalence was highest for the age groups between 20 and 34, all of them urban cases. In all but one case, the identified HIV patients had apparently contracted the infection through sex, though none were reportedly transmitted through homosexual activity. From among these cases, seven have died so far.

In view of the rising trend of HIV infection, even as the total numbers of HIV cases remain small; this has attracted wide public attention. It is seen as a potentially major public health concern, particularly in the context of the relatively common incidence of Sexually Transmitted Diseases (STDs), the emergence of sex workers in border towns and the high prevalence of the HIV/AIDS in neighbouring countries.

The Health Division already had in place a National STD/AIDS programme in 1988, well before the first reported incidences of the disease. In 1990, a three-year Medium Term Plan was formulated that evolved into the Strategic Medium Term Plan II of 1995 to continue addressing the prevention of sexual transmission of HIV.

The programme activities so far have essentially focused on preventive and advocacy measures such as informing, counselling and educating vulnerable groups, including youths and sex workers; promoting widespread condom usage and safe sex; training health care workers and monitoring the situation through sentinel surveillance. It is planned that in addition to making condoms widely available, voluntary counselling and testing units and HIV surveillance systems are to be established by the end of the Ninth Five Year Plan in all districts, though this is likely to be constrained by the availability of trained counsellors.

Challenges

As the prevalence of HIV/AIDS in the country is still relatively low, the challenges of dealing with it relate more to monitoring and surveillance, preventive and Information Education and Communication (IEC) aspects and developing coping strategies in the eventuality of a rise in the spread of the disease.

The potential danger of the disease spreading in the country is a real threat as the country is adjacent to areas in the region that have high HIV/AIDS prevalence. The high mobility of people and open cross border movements therefore pose significant and real risks. Additionally, the risks of the spread of HIV infection are heightened by the common prevalence of sexually transmitted diseases and low condom usage. Further, there is a disconcerting increase of sex workers in border towns. Developing bilateral cooperative strategies and coordination to monitor and contain the spread of HIV/AIDS will therefore prove a significant challenge.

As the experience of many countries indicates, youth are a particularly vulnerable group with high HIV/AIDS prevalence. With over 51 percent of the country's population being under 20, the issue has a potential significance. The country is faced with the important and challenging task to sensitize, inform and educate the youth in the country about the dangers of HIV/ AIDS, and on related issues of safe sex, condom usage, and dangers of drug abuse. In conjunction with the wide dissemination of information and education, an even more important challenge is to ensure that these activities effectively translate into appropriate behavioural change among and utilized by the targeted vulnerable groups. This could comprise the development of youth friendly facilities to promote effective utilization of available sexual health services, particularly condom usage by youths.

Supportive Environment

Bhutan as a member of South Asian Association for Regional Cooperation (SAARC), along with the other South Asian countries, issued a strong declaration at the 11¹" SAARC Summit, acknowledging the debilitating and widespread impact of HIV/AIDS and other transmittable diseases and the imperative to evolve a regional strategy to combat these diseases.

Nationally, the programme enjoys high political support and commitment. Her Majesty the Queen, Ashi Sangay Choden Wangchuck, in her role as the UNFPA Goodwill Ambassador has been campaigning strongly about the control of STDs and HIV/AIDS across all districts. The National Assembly also discussed the issue of HIV/AIDS in 2001 and subsequently passed a resolution to further step up preventive measures and information and awareness to prevent and minimize the impact of the disease. Such high-level advocacy initiatives have had a strong impact. Efforts have been made to include HIV/AIDS awareness into the curricula of schools and teacher training institutes.

The various strategies and activities to combat the disease are implemented through the National STDs/ AIDS Control Programme under the Department of Health. A National AIDS Committee was established in 1994 and is backstopped by a National AIDS Technical Committee. At the district levels, Multi­-Sectoral Task Force Committees and Working Committees have been established in all districts to take preventive measures and create awareness, while being prepared to deal with any outbreak of the disease.

While Bhutan does not presently have an independent Policy Directive for HIV/AIDS prevention, the RGoB broadly adheres to the WHO recommendations articulated in its Global AIDS Strategy document. A Protocol for HIV sentinel surveillance exists, but it is acknowledged to require improvements in order to serve effectively as a tool to contain the spread of HIV.

Priorities for Development Assistance

      Supporting AIDS programme management

      Intensifying prevention activities & measures, particularly at local levels through awareness raising

      Strengthening effective monitoring & sentinel surveillance systems

      Capacity building at national & local levels Strengthening counselling and care facilities

      Integrating HIV/AIDS aspects into national health systems

Monitoring and Evaluation Environment

Status and Trends

Malaria

Malaria has long been a major public health problem for Bhutan, and is endemic to five districts in the sub­tropical regions of southern Bhutan and some of the riverine valleys. Together, the two southern districts of Sarpang and Samdrup Jongkhar account for around 75 percent of all reported malaria cases in Bhutan.

Malaria incidence in the country during the 1990s showed a broad downward trend, though it is sporadic and uneven, indicating periods of small malarial outbreaks and/or resurgences. Reported positive clinical malaria over the decade grew from 22,126 positive cases in 1991 to a high of 38,901 in 1994, but then declined steeply to 6,995 in 1998. In 1999 and 2000, malarial cases were at 12,591 and 5,935 respectively (Annual Health Bulletin, 2001). Malaria ­related mortality/morbidity also broadly follows the caseload trend of overall decline, including the slight resurgence in 1999. While there were 62 malaria caused deaths in 1993, there were only 15 malaria related deaths in 2000. The positive development of a marked reduction in malaria cases between 1995 and 2000 (except for an upsurge in 1999) has largely been attributed to the change in insecticides from DDT to synthetic Pyrethroid.

Of the two varieties of malaria prevalent in the country, P.vivaxand Pfalciparum, there has been a steady overall increase of the latter cases in the last few years from 31.5 percent in 1995 to 53 percent in 2001. The fatality of this most severe form of malaria is well documented in many countries. Additionally, this has serious implications for the future control of malaria, as the Pfalicparumparasite is well known to be resistant to anti-malarial drugs such as Chloroquine and SP.

The MDG target of arresting the spread of malaria appears to be achievable. Reversing it, however, may be more difficult in light of the significant fluctuations and resurgences that have occurred, not only in the 1990s, but also consistently through the last three decades. The disease therefore continues to remain a major public health concern with more than half of the county's total population exposed to the risk of infection. The health authorities in the country are also highly doubtful that the disease can ever be eradicated totally, and hence the appropriate change in strategy to containment and control rather than eradication.

Tuberculosis

The number of reported tuberculosis (TB) cases in the country declined significantly and consistently from 4,323 cases in 1990 to 1,140 in 2000. The most noticeable shift appears to have occurred between 1993 and 1994 after which detected cases dropped from over 4,000 to less than 2000 thereafter. TB related mortality rates for the decade, however, were erratic and fluctuated between 23 and 62 deaths a year with no discernible trend either way.

On average, 58 percent of TB patients are in the age group between 15 and 44 years. Most of the TB cases in the country are of the pulmonary kind, making up around 75 percent of all cases. A perceptible trend is the decline in pulmonary TB while cases of extra pulmonary TB have actually seen a slight increase from 1995 to 2000.

In line with the revised global TB control strategy, DOTS (Directly Observed Treatment Short-Course) was adopted throughout the country in 1997. This has had a noticeable impact on cure rates, which now stand at over 85 percent, a highly positive trend. Improving access to DOTS and enhancing its utilization is now a significant priority for the RGoB. The Cohort Reporting System was introduced in 2000, which is expected to improve reporting quality and enhance information and data reliability.

The considerable reduction of cases for TB strongly indicates that part of the MDG target of halting the incidence of the disease has been achieved and the process of reversing the trend has already started and is likely be achieved by 2015.

Challenges

Tackling malaria in Bhutan is constrained to an extent as malarial areas are for the most part in the southern border areas. Conducting prevention and control related activities such as the spraying of breeding sites require concerted joint coordination and efforts. The free movement of people along the border compounds the difficulties and helps to spread the disease. Sporadic cases are also regularly detected in the non-malarial regions of the mountainous North and central zones, caused through the increasing mobility and migration of people.

Some of the other constraints and challenges faced in battling malaria relate to an increasing tolerance and resistance to insecticides and drugs by mosquitoes; shortage of skilled technicians and researchers; lack of resources and adequately equipped health infrastructures; weak inter-sectoral collaboration and programme management at local levels; and the inaccessibility of large tracts of malaria endemic areas due to dense forests.

Progress towards the MDG target of halting and reversing the trend of malarial incidence in the country will also be largely affected by the availability of financial resources related to the procurement of insecticides and treatment drugs, which form a major expenditure for the programme.

Supportive Environment

The National Malaria Eradication Programme (later renamed as the National Malaria Control Programme, or NMCP) was launched in 1964 and has since spearheaded the various activities to fight the spread of malaria in Bhutan, including conducting research on drug sensitivity and entomological aspects. The programme has gone through various stages of evolution from a vertical strategy to a partial integration to a full fledged integration into the general health care delivery system. Control strategies likewise have changed from Indoor Residual Spraying (IRS) with DDT to IRS with synthetic Pyrethroid, and then to the present day Insecticide Treated Bed Net and bioenvironmental control approaches. The programme envisages the need to further strengthen the facilities, related human resources and other capacities at the, various malaria health centres.

At the district level in malaria endemic areas, the health authorities have begun forming Rapid Response Teams to deal with any potential outbreaks of malaria.

Many of the above programme activities and costs for procurement of insecticides and treatment drugs have been supported actively by a bilateral donor. While Bhutan has broadly followed the strategic intervention guidelines of the global Roll Back Malaria (RBM) strategy, it is not comprehensively engaged in the RBM initiative and process as Bhutan in not included among the RBM areas in the region.

Priorities for Development Assistance

      Procuring insecticides & treatment drugs

      Strengthening of programme management and capacity development for implementation & research

      Enhancing Insecticide Treated Bed Net coverage

      Supporting intensification of malaria awareness campaigns and greater community participation ,

      Continuing drugs sensitivity and insecticide susceptibility research

      Enhancing access to DOTS (Directly Observed Treatment Short-Course)

 Monitoring and Evaluation Environment

GOAL 7: ENSURE ENVIRONMENTAL SUSTAINABILITY

Status and Trends

Bhutan has a rich natural endowment with an extremely abundant forest cover of 73 percent and with 26 percent of its territory established as protected areas to conserve its rich biodiversity. Additional areas constituting 9 of the total land area have also been designated as biological corridors that connect the protected areas.

Environmental conservation has always enjoyed a high priority in the RGoB's vision of holistic development and the cause continues to be an important and integral consideration in the development agenda. The holistic concept and principles of sustainable development closely match the Bhutanese development philosophy and are integrated into the national policies and programmes. The sensitivity towards and prioritisation of environmental conservation is also reflected in the numerous legislations adopted and in the institutional strengthening and capacity building activities during the 1990s.

The National Environment Commission (NEC), formed in 1990, formulated a National Environment Strategy for the country in 1998, known as the Middle Path. This build-up of the institutional and policy framework was accompanied by the passage of critical environmental legislation. The most notable of these relate to the adoption of the Environmental Assessment Act 2000, the Forest and Nature Conservation Act 1995, the Mines and Minerals Act 1995, and the National Plant Quarantine Act 1993.

The RGoB is also in the process of formulating an important piece of legislation, the National Environment Protection Act (NEPA), which is likely to be enacted and enforced within the Ninth Five Year Plan period. At the international level, Bhutan is a signatory to the Convention on Biological Diversity and the UN Framework Convention for Climate Change.

Challenges

While Bhutan's environmental track record has been enviable, there are certain challenges emerging that could seriously compromise the future state of the environment.

Among the key challenges confronting the goal of ensuring environmental sustainability is the rapid population growth that Bhutan is experiencing. While the growth level has come down from 3.1 percent, the present growth rate of 2.5 percent still poses a serious threat to the country's environmental resources.

With increasing pressures on grazing land, agriculture, and forest resources, the protection of forest lands and conservation of biological diversity are expected to become ever more difficult. Bhutan's fuel wood consumption per capita is particularly high. Overgrazing by domestic livestock has further been identified as a serious environmental threat with great potential to impact forest regeneration and effect changes in natural vegetation. Recently, air and water pollution near industrialised and urban areas have been of concern.

The modernization and economic development of the country invariably require the establishment of extensive road infrastructure. This is an important priority for the RGoB and regarded as vital for alleviating rural poverty. Given the high vulnerability and fragility of mountain eco-systems and the lack of advanced construction techniques and expertise, the building of an extensive network of mountain highways and feeder roads in an environment-friendly manner will prove to be a major challenge. This would similarly apply to urban and development associated infrastructure building.

Incorporating Environmental Impact Assessment (EIA) and relevant environmental friendly practices in development and industrial projects results in increased associated investment and maintenance costs. The sacrifices of foregoing immediate economic gains to further protect natural resources, and the costs for maintaining and managing environmental conservation, collectively create an enormous burden on scarce resources. Viewed within the context of declining international donor assistance for core environmental management activities, the financial implications form a key challenge and debilitating constraint, which could have severe implications for the future state of the environment.

There are also several capacity related constraints pertaining to the management, monitoring and evaluation of the state of the environment such as the:

      lack of a nationwide inventory of eco­systems;

      paucity of environmental data & research • information;

      absence of a set of appropriate environmental indicators; and

      shortage of qualified & trained environmental practitioners.

Supportive Environment

There is full and strong national support for ensuring environment sustainability in the country. This is best exemplified by the mandate of the National Assembly and the pledged commitment of the Royal Government to maintain at least 60 percent of the country under forest cover in perpetuity. The development vision of the country as articulated _.in the Bhutan Vision 2020 document further places a very high accord to the principles of environmental conservation and sustainable development.

The various policy, institutional, legislative and regulatory developments already outlined in the status and situational context, serve as the important supportive framework for achieving the MDG target. Additionally, the NEC introduced mandatory EIAs for all large-scale projects and is in the process of applying this requirement for all physical infrastructure projects, to be monitored by the EIA unit in the Commission. EIAs are therefore being effectively integrated into the development planning and the environmental management process. Watershed management has also been identified as an important tool through which environmental conservation can be furthered. The Wang Watershed Management Project is already under implementation and there are plans to undertake similar projects for the four other major watersheds. Processes to develop a national watershed management strategy are also underway.

The RGoB developed some innovative funding mechanisms such as the Bhutan Trust Fund for Environmental Conservation (BTF) (see box above) and the unique multi-partnership of countries under the Sustainable Development Agreement, which have greatly enhanced the financial and long-term sustainability of environmental conservation activities.

Priorities for Development Assistance

      Strengthening capacities in information systems and research; institutional development & popular participation; policies & legislation; training & education; and monitoring and evaluation & enforcement at all levels

      Strengthening institutional capacities to undertake EIAs

      Improving environment databases and mitigation options for all sectors towards implementing effective and appropriate responses to climate change

      Formulating & implementing the National Environment Action Plan to implement recommendations of the National Environment Strategy

      Preparing and implementing watershed

      Management plans

      Developing a nationwide inventory of eco-systems Supporting the BTF

      Participating at international conferences and implementing activities and enforcing the provisions of these conventions

Monitoring and Evaluation Environment

Status and Trends

78 percent of Bhutan's population had access to safe drinking water in 2000 as compared to 45 percent in 1990. In the urban areas, access to safe drinking water as of 2000 is at 97.5 percent, while in the rural areas it is estimated to be around 75 percent. However, while coverage in rural areas has increased significantly, many people still have to walk long distances to fetch water from streams and springs, thus limiting water use.

The Rural Water Supply and Sanitation (RWSS) Programme was initiated in 1974 to improve the health of the rural population by reducing the incidence of water-borne and related diseases. Under the programme, 2,300 water supply schemes, mostly of the gravity fed type, have been constructed to provide safe drinking water to about three fourths of the rural population. The notable improvements in the health standards of people in rural areas can be attributed, to a certain extent, to this programme, which has greatly reduced water and sanitation related diseases.

The RGoB's target is that by the end of the Ninth Five Year Plan in 2007, 100 percent of the population will enjoy access to safe drinking water. This will require the annual construction of 130 new schemes, in addition to rehabilitating and maintaining numerous old schemes.

The six major towns in the country have been provided with proper and modern water supply schemes, and the issues are more related to qualitative and quantitative supplies of water than access. In order to enhance conservation and the awareness of the cost and value of water supplies, nominal charges were levied to urban water consumers after the completion of the urban water supply schemes.

As the overall percentage of people without access to safe drinking water decreased from 55 percent in 1990 to 22 percent in 2000, the MDG target has already been achieved.

Challenges

Increasing and maintaining access to safe drinking water is a more pressing issue in rural than in urban areas. A critical challenge in maintaining and further enhancing safe and improved water coverage to rural populations will depend greatly on the maintenance and rehabilitation of older water supply schemes. It is estimated that around 800, or roughly one third of existing schemes, must be repaired to avoid contamination and total dilapidation of the structures. Meeting the goal of attaining complete safe water coverage will not only require the annual construction of many more new schemes, but the rehabilitation of at least 150 older schemes every year until the end of the Ninth Five Year Plan.

There is a need to identify and use alternative technologies for areas where water sources are scarce, and to develop simple treatment facilities that can be operated and maintained by communities without clean water sources. Given the significant costs and community inputs required for maintaining and repairing rural water supply schemes, the durability, lifespan and simplicity of the appropriate technology would be a prime concern in considering such alternatives.

Enhancing community participation in building, monitoring and maintaining rural water supply schemes is integral to the success of the RWSS programme. However, this is constrained by the lack of capacity and a feeble sense of ownership of the schemes that is further compounded by communal disputes over water rights. The burdens of cost sharing for communities through labour contributions are also increasingly felt as development activities increase, and are exacerbated by the steady migration of young people from villages to towns.

While the Royal Government continues its commitment to build water and sanitation infrastructure in rural institutions such as schools, basic health units and religious institutions, their coverage level remains lower than the national average. Attaining universal coverage for institutional water supply will thus prove a significant challenge.

Supportive Environment

A royal decree was issued in 1992 that stressed the great importance of access to and use of safe drinking water and sanitation facilities as an integral component of sustainable development. This has greatly spurred on the initiatives to improve the water supply and sanitation situation in the country.

While no administrative policies or legislative framework on water supply and related rights exists as yet, the Bhutan Water Vision, Water Act and Water Policy are being formulated to create an enabling environment for the integrated and efficient management of water resources. Processes to develop a national watershed management strategy are also underway.

In 1997, the first pilot National Baseline Water Survey was conducted to estimate national water quality standards. Reflecting the growing concerns of water pollution near urban and industrial centres and mines that were found in the survey, water monitoring programmes are to be undertaken on a periodic basis.

Institutionally, the Public Health Engineering section of the Department of Health now implements the activities relating to rural water supply. At the community level, water management committees have been formed and water caretakers trained to oversee the operation and maintenance of the water schemes. This, however, has not proved to be very successful, judging by the many schemes that are poorly maintained and in dilapidated condition, with water quality monitoring aspects largely ignored.

The ultimate objective would involve the full transfer of the implementation and management of the RWSS schemes to the communities themselves, with relevant technical backstopping and resources. However, this is currently seen as impractical given the lack of appropriate capacities in communities and the absence of a legal and policy framework.

Priorities for Development Assistance

      Increasing clean & improved water supply coverage in rural areas through the RWSS programme

      Rehabilitating existing water supply schemes

      Strengthening community participation & capacity building to plan, manage & maintain rural water supply infrastructure

      Developing & implementing alternative clean water source technologies

      Planning & implementing urban water supply for remaining urban & satellite towns

      Establishing & monitoring water quality standards through surveys and programmes

      Formulating & subsequently implementing the mandate of the Water Act/Policy.

Monitoring and Evaluation Environment

LIST OF ACRONYMS AND ABBREVIATIONS