ACTIVITY REPORT
No. 103
Midterm Evaluation of the
USAID/El Salvador Public Service Improvement Project
(Project No. 519-0320)
Water and Sanitation for Health Program
(PROSAGUAS)
September 2000
by
Eduardo Perez
Patricia Martin
Harold Lockwood
Morris Israel
Prepared for the USAID Mission to El Salvador
under EHP Project No. 26568/Other.SV1.WSSEVAL
Environmental Health Project
Contract No. HRN-I-00-99-00011-00
is sponsored by the Bureau for Global Programs, Field Support and Research
Office of Health and Nutrition
U.S. Agency for International Development
Washington, DC 20523
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TABLE OF CONTENTS
ABOUT THE AUTHORS..........................................................................................................iii
ACKNOWLEDGMENTS..........................................................................................................iv
ACRONYMS..............................................................................................................................v
EXECUTIVE SUMMARY .......................................................................................................vii
1 INTRODUCTION AND EVALUATION METHODOLOGY...............................................1
1.1 Purpose of the Evaluation ...............................................................................................1
1.2 The Evaluation Team......................................................................................................1
1.3 Evaluation Methodology.................................................................................................2
1.4 Organization of the Report..............................................................................................3
2 BACKGROUND...................................................................................................................4
2.1 Country Overview ..........................................................................................................4
2.2 Health Status ..................................................................................................................4
2.3 Status of Current Water Sector and WS&S Sector ..........................................................5
2.4 Status of Reform Efforts for WS&S Sector.....................................................................6
2.5 Status of Public Sector Reform.......................................................................................6
2.6 Purpose of PROSAGUAS...............................................................................................7
3 ASSESSMENT OF PHASE I RURAL WS&S PROGRAMS................................................9
3.1 Introduction....................................................................................................................9
3.2 Diagnostic Study of Phase I Results................................................................................9
3.3 Phase I Evaluation by the EHP Team............................................................................10
3.3.1 Overall Findings ..................................................................................................11
3.3.2 Critical Issues Arising from Phase I .....................................................................14
3.3.3 Lessons Learned from Phase I Experiences..........................................................14
3.3.4 Conclusions .........................................................................................................15
4 EVALUATION OF PROSAGUAS: FINDINGS, CONCLUSIONS, 
AND RECOMMENDATIONS......................................................................................16
4.1 Program Management and Administration....................................................................16
4.1.1 Introduction and Definition..................................................................................16
4.1.2 Progress in Meeting Overall Program Objectives.................................................16
4.1.3 Findings...............................................................................................................18
4.1.4 Conclusions and Recommendations .....................................................................21
4.2 Community-Level Project Implementation ...................................................................22
4.2.1 Introduction and Definition..................................................................................22
4.2.2 Objectives and Indicators.....................................................................................23
4.2.3 Findings...............................................................................................................23
4.2.4 Conclusions and Recommentstions ......................................................................25
4.3 Community Organization..............................................................................................26
4.3.1 Introduction and Definition..................................................................................26
4.3.2 Objectives and Indicators.....................................................................................27
4.3.3 Findings...............................................................................................................28
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4.3.4 Conclusions and Recommendations .....................................................................33
4.4 Health Education ..........................................................................................................34
4.4.1 Introduction and Definition..................................................................................34
4.4.2 Objectives and Indicators.....................................................................................35
4.4.3 Findings...............................................................................................................36
4.4.4 Conclusions and Recommendations .....................................................................38
4.5 Water Supply and Sanitation Infrastructure...................................................................40
4.5.1 Introduction and Definition..................................................................................40
4.5.2 Objectives and Indicators.....................................................................................40
4.5.3 Findings...............................................................................................................41
4.5.4 Conclusions and Recommendations .....................................................................44
4.6 Environment and Source Water Protection....................................................................46
4.6.1 Introduction and Definition...................................................................................46
4.6.2 Objectives and Indicators.....................................................................................46
4.6.3 Findings...............................................................................................................47
4.6.4 Conclusions and Recommendations .....................................................................47
5 SUMMARY OF CONCLUSIONS......................................................................................49
5.1 Major Accomplishments...............................................................................................49
5.2 Areas of Concern..........................................................................................................51
6 RECOMMENDATIONS.....................................................................................................54
6.1 Recommendations for CARE.........................................................................................54
6.2 Specific Recommendations for USAID in the Second Half of PROSAGUAS ...............57
6.3 Broader Issues for USAID to Consider with regard to PROSAGUAS...........................58
6.4 Opportunities for Use of “Surplus” Funds.....................................................................58
6.5 Recommendations for Future USAID/El Salvador Strategy ..........................................59
APPENDICES .................................................................................................................1
(Following the colored sheet, page numbers begin again with 1.)
A Scope of Work.................................................................................................................3
B Persons Interviewed ......................................................................................................12
C Question Guide for Previous Phase WS&S Projects.......................................................13
D Question Guide for Current PROSAGUAS Projects......................................................15
E Documents Reviewed ....................................................................................................20
F Project Sites Visited.......................................................................................................23
G PROSAGUAS Indicators by Objectives.........................................................................24
H EHP Diarrheal Disease Prevention Indicators................................................................30
I World Bank Utility Benchmark Indicators....................................................................33
TABLES
1 Communities Visited by EHP Team ..............................................................................11
2 Assessment of PROSAGUAS Program Progress, as of July 2000 ..................................17
3 Composition of Community Organizations, by Gender..................................................31
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ABOUT THE AUTHORS
Eduardo A. Perez is an environmental engineer with a graduate degree in engineering and 
public policy. Mr. Perez has over 25 years of international work experience in WS&S 
and housing programs in Latin America, Africa, and Asia. Mr. Perez is currently a senior 
project manager and urban environmental sanitation specialist with the USAID-funded 
Environmental Heath Project (EHP) based in Washington, D.C. Prior to the EHP project, 
Mr. Perez was the Technical Director for Engineering and WS&S specialist on the 
WASH Project. As part of his responsibilities with WASH and EHP, Mr. Perez has been 
involved in the design, management and evaluation of multiple rural and urban water 
supply and sanitation projects including a rural WS&S reconstruction program in 
Nicaragua. Before joining WASH, Mr. Perez was the country director for the 
Cooperative Housing Foundation (CHF) in Honduras and implemented a large-scale 
home improvement loan program.
Harold Lockwood is an independent consultant specializing in water supply and 
sanitation based in England, and has over nine years of international work experience in 
providing technical assistance to projects in Central America, Asia, and Africa. He has 
been a long-term advisor to the Nicaraguan Water Supply and Sanitation Authority and 
has working experience with the British and Dutch governments as well as UN agencies, 
international NGOs, and the private sector. His particular area of expertise is in post￾project institutional support for operation and administration; he has worked on other 
EHP technical teams, most notably in Central America. 
 
Patricia Martin is a specialist in community development, health, and gender issues with 
over 20 years’ experience in Latin America and the Caribbean. She is an independent 
consultant who has participated in design, evaluation, and provision of technical 
assistance for numerous USAID-supported activities, including many in health and water 
and sanitation. She has previous experience with WASH, and served as Gender Advisor 
for the Bureau for Latin America and the Caribbean (USAID/Washington) for five years.
Morris Israel is an Environmental Advisor in USAID’s Bureau for Latin America and the 
Caribbean. He has a broad background in environmental policy and institutional issues 
with emphasis on water resources planning and management. Mr. Israel has over 10 
years of experience in water supply and sanitation, watershed management, and 
institutional and management aspects of water resources. Organizations for which he has 
provided consulting services in those areas include the Inter-American Development 
Bank, the UN Economic Commission for Latin America and the Caribbean, and the 
Ministry of Public Works in Chile. Mr. Israel received a Ph.D. in Water Resources 
Planning and Management from the University of California-Davis, he worked for 
several years as a design engineer with a major engineering consulting firm.
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ACKNOWLEDGMENTS
The members of the evaluation team greatly appreciate the collaboration and support 
provided by USAID/El Salvador and CARE/El Salvador. Staff members were very 
helpful in providing information and logistical support. 
In particular, we would like to thank Jose Antonio Ramos Chorro from the USAID/El 
Salvador Health Strategic Objective team (SO3) for providing clear guidance on the 
needs and perspectives of the Mission. Jose Antonio also participated in many of the 
field visits and provided valuable insights. We also want to thank Ricardo Mancia and 
Jonathan Claros, PROSAGUAS director and deputy director respectively, for their role in 
organizing and facilitating many details of our itinerary in the three regions of El 
Salvador to which we traveled. It would have been much more difficult to visit the 
communities and have meaningful discussions without their support and introductions. 
In addition, the PROSAGUAS regional directors and their staffs were also extremely 
helpful in answering questions and bringing us together with their communities. Not 
only do we thank all of the above for their support but we also commend them for their 
strong personal dedication and commitment to the well-being of the communities with 
which they are working. 
The evaluation team would also like to acknowledge the contributions of Carlos Linares 
for providing valuable background information, much of which is included in the 
background section of this document. 
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ACRONYMS
ADESCO Asociaciones de Desarrollo Comunal (Community Development 
Associations)
AGUA Acceso, Gestion, y Uso de Agua (Access, Management and Water 
Use—USAID SO4 Program)
ANDA Administracion Nacional de Acueductos y Alcantarillados (National 
Water and Sewage Administration)
ANDA/GSR Gerencia de Sistemas Rurales—ANDA (Rural Division of ANDA)
BID Banco Interamericano de Desarrollo (Interamerican Development 
Bank)
Barriles Barrels of water used as common measurement for purchase from 
private water vendor. One barrel is reportedly roughly equivalent to 
200 liters.
BEO USAID Bureau Environmental Officer
CALMA Centro de Apoyo de la Lactancia Materna (Nicaraguan PVO: Center 
for Support of Maternal Breastfeeding)
Cantaro Traditional household water storage container 
Cantarero Community standpipe
CARE Cooperation for American Relief Everywhere—international NGO 
that has Cooperative Agreements with USAID/El Salvador to 
implement the PROSAGUAS, MAS and AGUA projects. 
CENTA Centro Nacional de Tecnologia Agricola (MAG) (National Center 
for Agricultural Technology)
Colones Salvadoran currency (about 8.75 colones = US$1.00)
COMURES Corporacion Municipal de la Republica de El Salvador (association 
of mayors)
CREA Creative Associates International Inc
DASAGUAS CARE engineering design office
EA Environmental assessment
EHP Environmental Health Project
EU European Union
FISDL Fondo de Inversion Social para el Desarollo Local—GOES (Social 
Investment Fund for Local Development)
FIS-SCALA Financial Information System for CARE International
FUNDEMUNI Fundacion para el Desarrollo Municipal (Municipal Development 
Foundation)
GOES Government of El Salvador
h/h Household
IR Intermediate Result (USAID)
IRC International Reference Center for Water Supply and Sanitation
KAP Knowledge, attitudes, and practices
LAC USAID Bureau for Latin American and the Caribbean 
M&E Monitoring and evaluation
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MAG Ministerio de Agricultura (Ministry of Agriculture)
MAS Mitch Agua y Saneamiento (USAID Hurricane Mitch Reconstruction 
Program)
MOH Ministry of Health
MSPAS Ministerio de Salud Publica y Asistencia Social
Ministry of Health
NGO Nongovernmental organization
O&M Operation and maintenance
PAHO Pan American Health Organization
PCI Project Concern, International
PLANSABAR Plan de Saniamiento Basico Rural (Rural Sanitation Program)
PROSAGUAS Programa de Agua y Saniamiento para la Salud (Water and Sanitation 
for Health Program)
PROSEGUIR CARE land titling program
PVO Private voluntary organization (usually refers to U.S.-based NGOs 
such as CARE)
RFA Request for Assistance (a USAID term)
RAS ES Red de Agua y Saneamiento de El Salvador (National WS&S 
Network)
RTI Research Triangle Institute – contractors for USAID Municipal 
Development Project
RWSS Rural water supply and sanitation
SALSA Salvadorenos Saludables (Healthy Salvadorans—USAID SO3 
Health Program)
SARAR Self-esteem, Association with others, Reacting with ingenuity to 
problems, Actualization and Responsibility for sustainable solutions 
to problems; a participatory training methodology 
SO Strategic Objective (USAID)
UME Unidad de Monitoreo y Evaluacion (CARE’s monitoring and 
evaluation unit)
UNICEF United Nations Children’s Fund
USAID United States Agency for International Development
VIP Ventilated improved pit latrine
WASH Water and Sanitation for Health Project
WS&S Water supply and sanitation
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Executive Summary 
Background
The USAID/El Salvador Health Strategy for the period 1997-2002 states that the lack of 
access to water and sanitation is a major constraint to the improvement of health in rural 
areas, and that the large difference in infant and child mortality rates between urban and 
rural areas is closely connected to this lack of water and sanitation infrastructure. The 
primary causes of child mortality (for children1 to 5 years of age) are acute respiratory 
infections (28%),dehydration from diarrhea (24%), and measles (13%). In rural areas, 
30% of infant deaths are reportedly due to dehydration from diarrhea, as compared to 
22% in the urban areas. 
It is estimated that only 57% of El Salvador’s total population has access to clean water: 
78% in urban areas and 25% in rural areas. El Salvador has the lowest figure for overall 
water coverage in Central America. In the area of sanitation, some 60% of those living in 
urban areas nationwide have access to sewerage systems. Approximately 52% of the 
rural population has access to sanitation systems, predominantly latrines
In response of those figures and as part of its Health Strategic Objective (SO3), 
USAID/El Salvador signed a cooperative agreement with CARE/El Salvador to 
implement the Water and Sanitation for Health Program (in Spanish, Programa de Agua 
y Saniamiento para la Salud, generally called by the acronym, PROSAGUAS).
Purpose of PROSAGUAS
The purpose of the PROSAGUAS program is to reduce the incidence of diarrheal 
diseases in children under five years by providing access to potable water supply and 
sanitation systems to the communities where the activities are carried out. The program 
was funded in the spring of 1998 for a five-year period.
Beside the water and sanitation facilities to be provided, USAID requested that 
promotion, organization, and health education activities be developed in the beneficiary 
communities. In addition, a participatory methodology approach was to be used to make 
community individuals and local government authorities active participants in the 
construction, operation, utilization, maintenance, and administration of the potable water 
and sanitation facilities installed under this program.
The PROSAGUAS program is now at its midpoint, and USAID/El Salvador requested 
that the Environmental Heath Project (EHP), a technical assistance project funded by 
USAID/Washington, carry out an evaluation of the program in July 2000. 
viii
Scope of Work for the Evaluation
The purpose of the midterm evaluation and assessment of the PROSAGUAS program 
was to undertake the following:
· Assess the current status and sustainability of benefits of earlier (pre-PROSAGUAS) 
USAID-funded rural water supply and sanitation (WS&S) programs. (These were 
implemented by CARE, Creative Associates International Inc., and Project Concern 
International in a previous phase of USAID Project no. 519-0320.)
· Evaluate the current PROSAGUAS program and assess progress to date in achieving 
the expected results.
· Identify lessons learned from both past and current programs.
· Recommend improvements for the second half of the PROSAGUAS program.
· Identify possible inputs for future USAID strategic objectives and WS&S and Health 
programs in the short- to medium-term.
This evaluation reviews the results to date and effectiveness of the overall PROSAGUAS 
program and each of its major components. The various components are community 
organization, health education and hygiene behavior change, water supply and sanitation 
infrastructure, environment and source water protection, program management and 
administration, monitoring and evaluation, operation and maintenance, and coordination 
with other USAID Strategic Objective teams and programs.
Findings and Conclusions
1. Phase I Program 
The overall conclusion of the Evaluation Team is that the Phase I WS&S program 
represents a major success story with regard to sustaining the benefits of the original 
projects over a relatively long time period. It is apparent that communities have been very 
resourceful, and in most cases successful, in resolving a range of problems related to 
system operation, repair, administration and financing, including the direct contracting of 
goods and services from the private sector. The team viewed the impact of the program 
on general sanitary and hygiene conditions at household and community levels as 
relatively positive, given the fact that the original program did not have an explicit health 
focus.
Regarding incorporation of positive lessons learned from the first phase, PROSAGUAS 
staff have made sincere and vigorous efforts to include new approaches and to modify 
existing elements of the program design. These modifications include adding an 
environmental education component to the program; extending the post-construction 
program presence in communities to six months; urging increased involvement of women 
ix
in project management; monetizing work on health and environment committees; 
creating a paid position for health promoters; and requiring universal installation of water 
meters.
2. The Current PROSAGUAS Program: Overall Progress
As noted, the overarching purpose of PROSAGUAS is the reduction of diarrheal disease 
in children under five year. The quantitative data for diarrheal rates presented by 
PROSAGUAS to the Evaluation Team was limited to the nine projects constructed to 
date, with a comparison being possible in only three of the cases, where prevalence has 
been reduced by 81.2%, 68.5% and 39% respectively, over the course of one year. This 
is significantly higher than the 26% target. In the absence of comparisons with control 
groups or other evidence that this is not simply a single year-to-year variation, the 
Evaluation Team cannot state with absolute certainty that this reduction is attributable to 
the interventions under the PROSAGUAS program. However, this scale of impact is 
consistent with what would be expected, given the quality and integrated nature of this 
WS&S and hygiene behavior change intervention.
The overall conclusion of the Evaluation Team is that the PROSAGUAS program is 
being successfully implemented and is meeting most of the targets set out for each 
objective. More specifically, PROSAGUAS is ahead of schedule in reaching the planned 
number of beneficiaries with installation of both water supply and sanitation 
infrastructure. Equally important, significant progress has been made in establishing 
viable and effective community management structures, including an increase in the 
participation of women, to ensure the sustainable operation and administration of water 
supply systems.
Considerable progress has been made in the overall health component, both in numeric terms and in 
qualitative impact on awareness, improved hygiene practices and changes in behavior among the 
target population. There has been slower progress in meeting targets of the environmental 
component, and it is unlikely that PROSAGUAS will meet its tree-planting goal. Limited progress 
has been made in providing technical assistance to communities following the construction phase. 
The objective of developing designs for future water supply and sanitation systems has not yet been 
addressed, as of the time of the evaluation. 
Other points noted by the Evaluation Team include lack of attention to environmental 
impact mitigation during construction; the presence of graywater around households 
resulting from increased water use, especially in more urbanized areas; limited success in 
achieving synergy with other USAID SOs; ineffective use of the program monitoring 
system; and lack of support mechanisms for long-term technical assistance for 
community water systems. 
Overall, the team found that PROSAGUAS has for the most part been successful in terms 
of achieving an appropriate balance between meeting physical outputs and investment in 
the qualitative, or “software,” aspects of project implementation. It is premature to draw 
any conclusions about the sustainability of community projects initiated under 
x
PROSAGUAS. However, based on the strong performance of Phase I community￾managed systems and the improvements since made in the program approach of 
PROSAGUAS, the team is confident that the current projects will be viable in the long 
term. 
2.1 Summary Recommendations
The team considers PROSAGUAS, overall, a success. Nonetheless, there are a number 
of areas where weaknesses were identified and the program could be improved still 
further. The recommendations summarized below are based on the detailed findings and 
conclusions presented in the body of the report.
2.2 Recommendations for CARE
PROSAGUAS Program Management
· Improve program monitoring to analyze and disseminate the data in a timely manner 
and use the results to inform management decisions. Ensure feedback of monitoring 
data to both the field staff at regional level and the communities and individual 
households in a timely manner
· Improve horizontal lines of communication and provide mechanisms to share lessons 
learned across regional teams.
· Systematize, document and disseminate PROSAGUAS program methodology for a 
wider audience both nationally and regionally. 
· Include the integration of relevant health, rural WS&S coverage and poverty 
indicators in community selection criteria.
Community Development and Health Education
· Strengthen involvement by water committees in project design and construction so 
that communities are more fully appraised of design decisions and strategies.
· Refocus the health monitoring and evaluation system to include greater analysis of 
health results and ensure feedback to the community and individual households.
· Revise the KAP surveys to identify the most important, highest-risk behaviors related 
to diarrhea incidence and focus educational interventions on those key behaviors.
· Assess the impact of the educational materials for different target populations (urban 
and rural) and adapt the materials as necessary to increase their effectiveness. 
xi
Water Supply and Sanitation Infrastructure
· Broaden the current PROSAGUAS menu of sanitation options to include 
technologies that are more appropriate for semi-urban areas.
· Begin to assess the financial and management impact of provision of wastewater 
services in more semi-urbanized locations (an inevitable offshoot of the program). 
· Develop and promote the use of performance benchmarks for small-scale community￾run utilities.
· Calculate and document the full costs for both the water and sanitation systems by 
specific project system and per beneficiary. 
· Reduce the household subsidy for latrines; make household subsidies of water supply 
dependent on household income level. 
Environment and Source Water Protection
· Retarget environmental activities, so that they reflect priority issues in the watershed, 
including graywater discharge. 
2.3 Specific Recommendations for USAID for the Second Half 
of PROSAGUAS
· Consider amending the contract to significantly reduce or revise the results for the 
environmental objective. (Even if PROSAGUAS were able to meet the targets 
(number of trees planted), that would not notably contribute to the overall purpose of 
improving health--or source water protection, either.) 
· Enforce compliance with USAID environmental regulations and work with 
PROSAGUAS to develop a specific checklist for all construction sites and 
beneficiary communities. 
2.4 Broader Issues for USAID to Consider with regard to PROSAGUAS
· Review program goals related to relieving rural poverty. The majority of projects 
implemented under the first two years of the PROSAGUAS program are serving 
populations in what can best be described as small towns or “semi-urban” areas rather 
than truly rural. USAID should consider the consequences of selection of such 
project areas as it relates more generally to the goal of addressing (and reducing) rural 
poverty. 
· Engage in policy dialogue with the Government of El Salvador. At present there is 
no coherent engagement by USAID of the GOES and other stakeholders regarding 
the reform of the rural WS&S sector as part of the broader water sector reform 
xii
process underway in El Salvador. USAID is one of the most important donors in the 
rural sector and CARE is probably the biggest single implementing agency, and 
certainly has some of the best experience (in terms of both engineering and software) 
in the country. By participating in the development of a sound rural WS&S sector, 
USAID will also be able to replicate and scale up the PROSAGUAS approach.
2.5 Opportunities for the Second Half of PROSAGUAS Using “Surplus” 
Funds
In its first two years of operation, PROSAGUAS has made rapid progress toward meeting 
the targets for WS&S service provision. Thus, there is a good chance that a considerable 
amount of funds will remain in the budget after all the targets have been met. The 
evaluation team has identified the following possible options for re-programming this 
surplus; the list is not exhaustive and these suggestions are not presented in any order of 
priority: 
· Continue working with the PROSAGUAS approach and increase the number of 
WS&S projects and beneficiaries served under this current cooperative agreement. 
· Use resources from the PROSAGUAS program (human, logistical and material) to 
provide a sanitation and hygiene complement to the AGUA project under SO4. 
· Work together with ANDA and the Water Supply and Sanitation Network (“Red 
Nacional”) to develop coherent and viable guidelines and norms for rural WS&S that 
could then be used by other donors, NGOs, and municipalities.
· Provide technical assistance to local municipalities, ANDA, the MOH and possibly 
others to begin to develop a national technical support program for community￾managed or small municipal water systems.
2.6 Recommendations for Future USAID/El Salvador Strategy
In light of the success of the PROSAGUAS program, the Evaluation Team unequivocally 
recommends that the Mission continue to support water supply, sanitation, and health 
programs in its future five-year strategy. In addition, the team makes the following final 
suggestions: 
· USAID programs should continue to use an integrated approach which combines 
water, sanitation and hygiene/health, particularly if the Mission chooses to implement 
future water programs through a Strategic Objective team other than the Health SO 
team. 
· The Mission should seek to improve integration with other health SO3 programs and 
to look for synergy in achieving health impacts and preventing disease.
xiii
1
1 INTRODUCTION AND 
EVALUATION METHODOLOGY 
1.1 Purpose of the Evaluation
The midterm evaluation and assessment of the El Salvador Rural Water and Sanitation 
for Health Program (PROSAGUAS) was carried out by a team from the Environmental 
Health Project (EHP), a USAID-funded technical assistance project, at the request of 
USAID/San Salvador. The purpose of the evaluation was to:
· Assess the current status and sustainability of benefits of earlier (pre-PROSAGUAS) 
USAID-funded rural water supply and sanitation (WS&S) projects;
· Evaluate current PROSAGUAS projects and assess progress to date in achieving 
expected results;
· Identify lessons learned from both past and current projects;
· Recommend improvements for the second half of the program;
· Identify possible inputs for future USAID strategic objectives and WS&S and health 
projects.
The evaluation addresses each issue and question contained in the Scope of Work (see 
Appendix A) and analyzes inputs, results, and effectiveness of each of the following 
major project components:
· Community organization
· Health and hygiene behavior change
· Water supply and sanitation infrastructure development
· Environment and source water protection
· Program management and administration
· Monitoring and evaluation
· Operations and maintenance (O&M)
· Coordination with other USAID strategic objectives
1.2 The Evaluation Team
The evaluation team was composed of a senior EHP staff member, two EHP consultants, 
and a USAID/Washington staff member. Together, the team represented a wide range of 
2
disciplines relevant to water supply, sanitation, and health programs with significant 
experience with USAID-funded and NGO-implemented WS&S programs. All team 
members are fluent in Spanish and have lived or worked in Central America. The 
members of the team were as follows:
Eduardo A. Perez: team leader, engineer, project management – EHP staff
Morris Israel: engineer, environmental specialist – USAID/Washington
Patricia Martin: gender, community organization, and health specialist – EHP consultant
Harold Lockwood: rural WS&S specialist, O&M, sector reform – EHP consultant
1.3 Evaluation Methodology
The team used the following methods for collecting and assessing project-related 
information:
a. Interviewed CARE personnel at the national, regional, and project level (see list 
of persons interviewed, Appendix B, and guides for questions, Appendix C and 
D).
b. Reviewed project-related documents (see Appendix E).
c. Interviewed USAID personnel from the health strategic objective team as well as 
from the environment and democracy strategic objective teams. 
d. Interviewed personnel from other institutional stakeholders, including agencies of 
the Government of El Salvador (GOES) and external donors.
e. Made field trips to 11 project sites from the previous project; also visited 8 project 
sites from the current PROSAGUAS program in various stages of completion in 
the three geographic regions of the country (see Appendix F, list of projects 
visited). Field trip activities included:
- Interviewing various stakeholders (see Question Guide for previous-phase 
projects, Appendix C, and Question Guide for Current PROSAGUAS Projects, 
Appendix D):
· members of the water management boards (junta administrativa),
· staff of the water users’ associations (administrators, plumbers, 
health promoters, meter readers, etc.)
· health committees 
· environment committees 
3
· water committees 
· Ministry of Health/ health clinic personnel
· municipal officials
- visiting households to interview project beneficiaries; inspecting the water 
supply and sanitation infrastructure; observing household environmental health 
conditions (general cleanliness of house and yard, household water storage 
containers, handwashing stations, etc.)
- inspecting community infrastructure such as water storage tanks, wells, pumps, 
etc.
Selection of Phase I project sites to visit was based on communities geographically near 
to each other to maximize the number visited, representative examples of systems built 
by the three implementing NGOs, and representative samples of different types of 
communities and water system technologies. All communities participating in the current 
PROSAGUAS project at the time of this midterm evaluation were visited. 
1.4 Organization of the Report
The report follows the proposed outline in the scope of work, with a specific focus on 
answering the questions contained in it. Following this introductory chapter, a 
background chapter provides the context for the project, including health, water and 
sanitation sector, and governmental reform of the public sector. The following chapter 
assesses the status of projects that were built with USAID funding prior to the 
PROSAGUAS program with an eye toward capturing lessons that may be applied to
PROSAGUAS. The next chapter documents the findings of the PROSAGUAS program 
by key components. The last two chapters are overall conclusions/lessons learned and, 
the final one, recommendations. 
4
2 BACKGROUND
2.1 Country Overview
El Salvador is the smallest and most densely populated country in the Western 
Hemisphere. It has a population of approximately 5.7 million in an area about 21,000 
square kilometers, roughly the size of Rhode Island. The population is about evenly 
divided--50% living in urban settings, and 50% in rural areas. Population growth trends 
show El Salvador becoming even more urbanized in the next few years, with 25% of the 
country’s population living in the Metropolitan Area of San Salvador, which comprises 
14 municipalities. These highly urban municipalities have an average population 
distribution of 80% urban/20% rural. 
El Salvador's Gross Domestic Product (GDP) showed positive signs of growth in the 
post-war period of 1988 to 1997, increasing at an average rate of 2.2% per year. GDP in 
1997 was US$7,663 million (in 1990 US$). Measured in constant 1990 US$, GDP per 
capita in 1997 was US$1,293, only slightly higher than the 1988 value (US$1,274) due to 
a slow-down in economic growth, reported in 1996 and 1997. El Salvador has one of the 
lowest GDPs per capita in Latin America. There is great inequality in income in both 
urban and rural areas. However, the incidence of poverty is much greater in rural areas 
than urban.
2.2 Health Status
The USAID/El Salvador Strategy for 1997 to 2002 states that lack of access to water and 
sanitation is a major constraint to the improvement of health in rural areas, and that the 
large difference in infant and child mortality rates between urban and rural areas is 
closely connected to this lack of water and sanitation infrastructure. 
The primary causes of child deaths (1- to 5-year-olds) are acute respiratory infections 
(28%), dehydration from diarrhea (24%), and measles (13%). In rural areas, 30% of 
infant deaths are due to dehydration from diarrhea; the comparable figure for urban areas 
is 22%. Respiratory infections and diarrheal diseases are the main infant and child health 
problems. In 1990, the reasons given for 80% of outpatient visits for children under five 
were acute respiratory infections (ARIs), intestinal infections, and intestinal parasites. 
Lack of access to potable water, inadequate disposal of sewage and garbage, and other 
contamination (of both in food and water) contribute to the spread of infectious and 
parasitic diseases. In a 1992 study in 80 sentinel locations, the prevailing diagnosis was 
diarrheal disease. The Metropolitan and Eastern areas had rates around 30%, while the 
other regions (Central, Paracentral, and Oriental) had rates between 40% and 42%. 
2.3 Status of Current Water Sector and WS&S Sector 
5
The primary source of water for El Salvador is the Lempa River. It is used to generate 
electric power, irrigate farmland, and supply drinking water. The principal user of water 
resources, although not the main consumer, is the electricity sector; hydrogenerating 
plants produce over 60% of the country's electricity. Irrigation of some 46,000 hectares 
of farmland consumes the largest proportion of water. Of the total water resources 
available to El Salvador, it is estimated that 63% comes from the Lempa River basin, 
while the remainder is drawn from other surface and underground sources. Human 
consumption of water is relatively low, averaging 120 liters/person/day in San Salvador 
and even less in the smaller municipalities and rural areas, due to reduced production 
capacity.
The dumping of untreated wastewater into bodies of water has seriously compromised 
water quality. Only 2% of all municipal and industrial discharges receive any kind of 
treatment before reaching a receiving body of water. Various studies indicate that some 
90% of the country’s rivers and streams are contaminated and are unsafe for human 
consumption without treatment. Water shortages are widespread, yet El Salvador does 
not have an agency responsible for overall management of water resources. What exists 
instead is the disjointed and unsustainable use of the resource within each sector.
It is estimated that only 57% of El Salvador's total population has access to clean water: 
78% in urban areas and 25% in rural areas (El Salvador has the lowest figure for overall 
water coverage in Central America.) For those with access to piped water, there is a great 
deal of variation in level of service. Very few, if any, cities in El Salvador have water 
service 24 hours a day. Higher-income families, certain institutions, and private 
enterprises compensate for fluctuating service by using water storage tanks with 
automatic pumping systems. In the area of sanitation, some 60% of those living in urban 
areas nationwide have access to sewerage systems. In rural areas, the use of sewage 
systems is practically nonexistent, but the use of latrines accounts for a total 52% of the 
population. These factors have a direct impact on the serious public health and 
environmental sanitation problems that confront the country.
The problems of the WS&S subsector can be traced primarily to its management 
structure. The National Water and Sewage Administration (ANDA), which was created 
in 1961 as an autonomous public service agency reporting to the Ministry of Public 
Works, is responsible for providing services throughout the country. According to the 
original legislation, ANDA is the only institution authorized to regulate, standardize, 
plan, set tariff rates, and operate water and sewage services. Provision of water and 
sewage services, up to now, can thus be described as a centralized public monopoly. 
Operating in parallel, there are a growing number of private, informal operators not 
subject to any kind of regulation, along with various independent water systems in urban 
and rural communities, supported by external donations and lending programs. The 
Ministry of Health is responsible for sanitation services; latrine construction programs, 
for example, do not fall under the aegis of ANDA. 
6
Neighborhood associations (Juntas Vecinales de Agua) in rural communities manage 
their own systems, usually built with external funding and without ANDA participation. 
A regulatory entity to oversee such WS&S operations, provide technical assistance, or 
monitor compliance with norms and standards does not exist in El Salvador. 
ANDA operates 150 water and sewage systems in 181 of El Salvador's 262 
municipalities, ranging from the country's largest, the Greater Metropolitan Area of San 
Salvador with 300,000 connections, to some of its smallest, towns with less than 200 
connections. There are 78 municipalities that operate their own (urban area) systems, 
without ANDA participation. 72 of these are managed—de facto—by the municipal 
government directly, and 6 others are managed by other indirect means, such as an NGO, 
private concession, or mixed-economy model. 
Two important characteristics of El Salvador with relevance to the WS&S sector are: a) a 
highly fragmented municipal administrative structure (in a small country with 262 
municipalities with an average area of 80 square kilometers each); and b) a large number 
of small towns with populations under10,000 (89% of all urban areas fall into this 
category). 
2.4 Status of Reform Efforts for WS&S Sector
A draft of a Water Law has been prepared, covering broad water resource issues. 
According to informal discussions with Salvadoran sector professionals, this law 
provides for the establishment of a water authority that will regulate the use of water 
resources and the allocation of water rights. Thus promoting a private market-oriented 
approach to the management of water resources.
The law to regulate the water supply and sanitation sector, a subsector of the larger water 
sector, is still being drafted. It is too early to tell what the nature of this law will be. 
However, according to Salvadoran sector professionals, there appears to be widespread 
agreement that the basic thrust of the reform will be decentralization using a variety of 
models of private, semi-private, indirect municipal administration and community based 
administration of WS&S systems. These models are based on present day experiences, 
including autonomous municipal companies, mixed economy companies, and other 
community-based associations, NGO’s, and concession contracts to private companies.
2.5 Status of Public Sector Reform
The GOES has made significant strides in modernizing and reforming the country's 
public sector. Reform programs introduced by the government have redefined the 
concept of public service and are bringing about changes in areas were the government 
operated centralized state monopolies. Positive and profound changes have already 
occurred in such areas as energy, telecommunications, transport, ports, and financial 
services, limiting the state’s role to regulation, policy making, and promotion. 
7
Efforts to reform both the water resources sector and the WS&S subsector began early in 
1995 with the creation by executive decree of the Coordinating Committee for 
Restructuring of the Water Resource Sector (COSERHI). The purpose of this new body 
was coordination of studies and activities to initiate the modernization of the water sector. 
COSERHI, through its technical arm—the Coordinating Unit on Modernization 
(UCM)— and with special support from the Office of the Chairman of ANDA, worked 
closely with the Inter-American Development Bank (IDB) during 1997 and 1998 to 
prepare a loan proposal for US$60 million to launch a Reform Program for the water 
sector and the water supply and sanitation subsector. In mid-1998, the IDB approved this 
sectoral reform loan (the total amount of US$60 million includes a $43.7 million loan, 
donations, non-reimbursable technical assistance funds, and local counterpart funds). 
Disbursement of funds, however, is contingent upon the presentation of two laws to the 
Salvadoran Congress. The first is a General Water Law to provide a framework for 
managing water resources, and the second, a law to provide the regulatory framework for 
the WS&S subsector. The GOES, through ANDA and with support from the President's 
Technical Secretariat (STP), has been actively involved in the process of preparing these 
two laws. (Two IDB-financed consultants have also provided assistance.) 
The election of President Francisco Flores in the spring of 1999 brought about a dramatic 
change in the importance of the water sector. President Flores gave top priority to reform 
of the water sector and the decentralization of WS&S systems in small towns. This gave 
renewed impetus to reform efforts. 
2.6 Purpose of PROSAGUAS
The purpose of the PROSAGUAS project, as described in the original USAID Request 
for Assistance (RFA), is to reduce the incidence of diarrheal diseases in children under 
five years by providing communities with access to potable water supply and sanitation 
systems. The project, funded for a five-year period, was to be undertaken in 
municipalities meeting the USAID Mission Poverty Focus criteria, specifically those in 
the Model Municipalities category as determined by USAID i.e., San Francisco 
Menendez in the Department of Ahuachapan; Corinto, Department of Morazan; and 
Berlin and Jiquilisco, Department of Usulutan. 
In addition to provision of water and sanitation facilities, USAID requested that 
promotion, organization, and health education activities be developed in the beneficiary 
communities. The project was to use a participatory approach to bring in community 
members and local government authorities as active participants in the construction, 
operation, utilization, maintenance, and administration of the new water and sanitation 
facilities.
8
The USAID RFA also recognized that other USAID/El Salvador activities designed to 
increase municipal government capacity often included construction of water systems but 
did not include community organization and health education activities. Therefore, 
USAID mandated that, where feasible, these activities should be added as part of the 
PROSAGUAS project to enhance the sustainability of the systems and the health impact 
for those communities.
9
3 ASSESSMENT OF PHASE I RURAL WS&S 
PROGRAMS
3.1 Introduction
From 1993 to 1997, USAID-funded a rural water supply and sanitation program which 
developed 80 rural systems, benefiting a total of 130,400 persons. (The program 
operated under USAID project numbers 519-0320 and 519-0394.) This overall program 
was implemented by three PVOs: Project Concern International (PCI), Creative 
Associates International Inc. (CREA), and CARE International/El Salvador. The 
experience gained in implementation of that first phase was instrumental in refining the 
design and implementation of the follow-up program, PROSAGUAS.
3.2 Diagnostic Study of Phase I Results
One of the tasks identified in the Scope of Work for EHP for the midterm evaluation of 
PROSAGUAS was to determine the lessons learned and sustainability issues related to 
water and sanitation systems constructed under the earlier phase. Beginning in 1998, as 
part of the PROSAGUAS program, CARE conducted a diagnostic study of 55 systems 
developed under the first phase. The results are presented in the document, Agua 
Potable–Una Experiencia Para Compartir (Potable Water and Sanitation–An Experience 
to Share), published in 1999. In that document, a number of findings and 
recommendations were made with respect to key issues and project sustainability. By 
identifying a short list of systems with specific needs, the diagnostic study served as the 
baseline document for objective 8 of the PROSAGUAS program, the objective which 
focuses on technical assistance to Phase I projects. The main findings of the study are as 
follows:
· On the whole, communities have been successful in managing and sustaining their 
water supply systems. Household latrines have been used and maintained since the 
project implementation phase—good sustainability in that regard.
· Legalization of community management structures was a key factor for sustaining 
services in the medium-term.
· There has been an overall positive impact on the health status of communities 
benefiting from RWSS systems, with improved personal and household hygiene 
conditions.
The most notable weaknesses or deficiencies common to many of the systems are as 
follows:
· Few women participated in management of the systems; if they did have a role, they 
were generally in very low-level positions. 
10
· Health committees formed during the project did not receive follow-up support on a 
permanent basis.
· There was no environmental component to oversee the protection of the water source.
· Technical knowledge and skills in design, operation, and repair of the water supply 
systems were not transferred successfully to communities.
· The managerial and administrative capacities of communities were weak; they were 
not able to improve overall operation of their systems and ensure financial 
sustainability.
· The program lacked long-term external support, or a back-up mechanism, to provide 
communities with the necessary assistance and guidance for a range of technical and 
social issues that would inevitably arise.
Based on these findings from Phase I, USAID and CARE applied some of the key lessons 
in the design of the current phase, both in terms of general program design or focus as 
well as quite specific operational elements. For example, the program design included 
installation of household water meters in all systems, an increased number of women on 
various committees, and an environmental component for long-term protection of the 
water source.
3.3 Phase I Evaluation by the EHP Team
The Phase I portion of the PROSAGUAS midterm evaluation was set up to complement 
the findings of the diagnostic study mentioned above and to validate the conclusions, 
given the benefit of two additional years of water system operations. Due to the limited
time available to the EHP team in the field, the observations and findings presented in 
this chapter represent an assessment and analysis of specific community projects from the 
previous phase, not a qualitative judgment of the project as a whole. In general, the 
assessment of Phase I systems provides a rare opportunity to review water systems that 
have been functioning for six or seven years. The communities visited by the Evaluation 
Team are summarized in the following table:
11
Table 1. Communities Visited by EHP Team
COVERAGE OF SERVED 
POPULATION AS % OF TOTAL 
COMMUNITY
Community Municipality/
Department
Executing
Agency
Year
AT COMPLETION JULY 2000
El Señor Quetzaltepeque/
La Libertad
CREA 1994 100 60
Pandeadura Tacuba/
Ahuachapan
CREA 1995 100 97
El Sincuyo Tacuba/
Ahuachapan
CREA 1996 100 72
La Puebla San Matías/
La Libertad
CREA 1995 57 58
Rosario Tablón Tenancingo/
Cuscatlan
PCI 1997 81 69
Conquista Suchitoto/
Cuscatlan
PCI 1998 100 100*
Montepeque** Suchitoto/
Cuscatlan
PCI 1996 N/A N/A
El Palón Lolotique/
San Miguel
CARE 1996 97 94
El Jalacatal San Miguel/
San Miguel
CARE 1998 86 86
San Matías Ciudad Barrios/
San Miguel
CARE 1996 100 100
Teponahuaste Ciudad Barrios/
San Miguel
CARE 1997 95 N/A
* There was a 25% reduction in community size due to security concerns.
** Standpipe system
3.3.1 Overall Findings
The overall conclusion of the Evaluation Team is that the Phase I WS&S program 
represents a major success story with regard to sustaining the benefits of the original 
projects over a relatively long time period. It is apparent that communities have been very 
resourceful, and in most cases successful, in resolving a range of issues such as system 
operation, repair, administration, and financing—including drawing up contracts with 
private vendors for goods and services. This conclusion is particularly noteworthy as 
some of the technologies for water supply (e.g., electrical pumps) and sanitation (e.g., 
composting latrines) are relatively complex and costly to sustain. 
Equally important, the Evaluation Team agrees in general with the findings, analysis, and 
recommendations of the PROSAGUAS diagnostic study. The team is of the opinion that 
by undertaking that study, CARE was successful, with a few exceptions, in identifying 
the most critical issues and shortcomings of the initial program phase. With the benefit 
of another two years of operational history, the Evaluation Team now found that most of 
12
the conclusions reached in 1998/9 still hold true today, with only a relatively small 
number of changes.
Technical Issues
In terms of technical performance of systems, a majority of the communities have been 
able to maintain water supply benefits at end-of-project levels for the original beneficiary 
population. Almost every community organization has been successful in carrying out 
some type of repair to its system, mainly without assistance from CARE. In a minority of 
cases, the water supply schemes have partially failed due to poor construction (El 
Jalacatal) or a lack of understanding of the system design and inappropriate technology 
choice (El Señor), or failed completely, due to external factors such as Hurricane Mitch 
(San Matías). 
Population Growth
The diagnostic study did not examine the issue of whether or not community 
organizations have been able to expand to keep up with population growth. The 
Evaluation Team looked into this question. In general, while new connections have been 
made in almost all cases, the overall coverage levels as a proportion of total community 
population have not kept pace with community growth (from natural population growth 
and migration).
Household Benefits
Benefits to individual households from correct use and up-keep of latrines (both VIP and 
composting types) have generally been maintained at, or near, end-of-project levels for 
the original beneficiary population. Unfortunately, sanitation benefits have not been 
extended to all new households as population grows, except in certain localities where 
progress was made due to other donor interventions (i.e., the E.U. latrine construction 
program in Pandeadura). 
Given the overall ability of communities to maintain WS&S services in the medium term, 
the Evaluation Team considers the technologies employed appropriate for the context of
rural and peri-urban El Salvador. The areas served typically have high population 
densities, generally well developed physical infrastructure (road access, electrification), 
and a significant proportion of the population engaged in, or having access to, the formal 
cash economy.
Community Organization Structure
The water management boards, which are responsible for management of systems, have 
been able to continue operating at end-of-project levels in most communities visited by 
the Evaluation Team. In several cases, membership of these community organizations 
has changed through a democratic process, and the majority of the water management 
boards are functioning now as effectively as when first formed. The Evaluation Team is 
13
of the opinion that the establishment of formal, legalized organizations, with title to the 
physical infrastructure and clear operational guidelines (estatutos), are critical factors in 
ensuring project sustainability. In those cases where legal title has not been clearly 
established, the lack of documentation could pose a threat. In La Puebla, for example, 
having legal papers establishing community ownership of the assets successfully stopped 
a threat by the local mayor to take over the system infrastructure. 
Finance Issues
In most Phase I communities visited by the Evaluation Team, the tariff collection system 
has been well administered, resulting in a surplus income which has been put into savings 
accounts for repairs and maintenance in the future. Several communities have made 
substantial investments in their systems (El Señor, El Sincuyo, Pandeadura). In some 
cases the total savings built up over time have been very substantial, running into the 
hundreds of thousands of Colones (Pandeadura, El Señor, El Palón). A smaller number 
of communities have been less successful in building up capital reserves (San Matías, 
Teponahuaste, La Conquista). These communities generally have smaller total 
populations, are more rural in nature, are not fully integrated into the formal cash 
economy, and usually consist of systems that do not rely on electricity. Typical tariff 
rates in those communities are substantially lower than in the larger, more complex 
systems (5 or 10 Colones per month as compared to 45 or 50). Other factors that limit the 
capacity to save money include less continuity of service, absence of household water 
meters, and less willingness on the part of the water management board to collect tariffs.
Health Results and Health Committees
In the majority of Phase I communities visited by the Evaluation Team, there were no 
health committees as such established after the project execution phase. Surprisingly in 
two of the smaller, more rural communities (San Matías and Teponahuaste), the health 
committees are still active after four and five years respectively. This is explained by the 
fact that the both the water management boards and health committees were incorporated 
into a pre-existing legal community structure (Asociación de Desarollo Comunal –
ADESCO). 
There have been mixed results in maintaining the health and hygiene behavior benefits 
provided during the initial period of project implementation. The main benefit has been 
adoption and use of household latrines. The most critical hygiene practices observed by 
the team included poor handling and storage of household drinking water, lack of 
drainage for household greywater, and unsafe disposal (or absence of disposal) of 
children’s excreta. Having highlighted these concerns, it should also be stated that the 
Phase I program appears to have had an overall positive impact on health conditions 
which is especially remarkable considering that the focus of the program was on 
increasing access to WS&S facilities and not specifically improvement of health, in 
contrast to the current phase which does specifically target health benefits. 
14
3.3.2 Critical Issues Arising from Phase I 
Most of the findings are in agreement with and validate the main conclusions of the 
PROSAGUAS diagnostic study. However, there are a number of important issues that 
were not emphasized in the study or have become relatively more important in the last 
two years. These issues have implications for modification of the remainder of the 
PROSAGUAS program (due to end in 2002) as well as for USAID’s longer view of rural 
WS&S provision in El Salvador and regionally: 
· Increased fees for electricity have forced many communities with electro-mechanical 
pumps to increase their monthly tariffs; that situation was anticipated in the 
diagnostic study. Recently, however, the central government has threatened to end 
subsidies for electricity in rural areas. That would be a potentially disastrous 
development and could push many economically fragile systems over the edge, 
especially in communities that cannot afford a significant increase in tariffs.
· The lack of general technical information, know-how, and skills flagged in the 
diagnostic study seems to be an even more pressing concern for Phase I communities 
today (a year later). Indeed, this lack of involvement of water management boards is 
already causing problems for community management of current PROSAGUAS 
systems (see Section 4.3 in the next chapter.) There seems to have been a reluctance 
on the part of the NGO technical staff in the earlier projects to involve communities 
in a meaningful way from the outset of the activities, thereby allowing them to act as 
“co-managers” of the whole process. The lack of understanding of system design, 
procurement channels, construction, and maintenance was repeatedly stated as a 
constraint to sustainable management (in Pandeadura, El Señor, El Sincuyo, El Palón, 
El Jalacatal, and Montepeque).
· Following on the previous observation, there is an overwhelming and unequivocal 
demand for long-term external support, or a back-up mechanism, to give communities 
assistance and guidance in a range of technical, administrative, legal, and social 
issues. This point was raised in the diagnostic study, and USAID/CARE developed a 
limited response in the form of technical assistance for about 18 to 20 communities of 
the previous phase (Objective 8). However, given the scale of the demand (i.e., all 
rural WS&S projects regardless of implementing agency) and the need to 
institutionalize this type of support over the long term, a much more comprehensive 
solution is required at the national level. 
3.3.3 Lessons Learned from Phase I Experiences
PROSAGUAS program planners and implementers have incorporated lessons learned 
from the first phase in the current program. They have made sincere and vigorous efforts 
to include new approaches and modify existing elements of the program design. The 
diagnostic study was very useful in identifying key problems from Phase I, and 
implementers of PROSAGUAS have also shown a great willingness to continue to 
15
modify its approach on the basis of experiences from the earliest communities in the 
current program. 
It is clear from visits to communities in the current phase that the PROSAGUAS program 
has incorporated many positive aspects both in program design and operational activities. 
These changes include the environmental educational component, extending the post￾construction project presence to six months, increased involvement of women in project 
management, monetizing work on health and environment committees, creating a paid 
position for health promoters, and installing household water meters in all project 
communities.
3.3.4 Conclusions
All of the examples of lessons from Phase I and design modifications mentioned above 
are signs of positive progress. PROSAGUAS should be encouraged to continue on the 
same path for the duration of the current program. Particular attention should be paid to 
the three critical issues listed in Section 3.3.2. Indeed, the single most pressing need is 
long-term back-up for rural communities, as mentioned in the third bullet. 
There is a clear need to establish some type of support mechanism or clearinghouse 
through which communities can get access to reliable sources of information or referral 
to other organizations. Several possibilities to explore with regard to such a support 
mechanism include ANDA, the MOH, municipal governments, NGOs and the private 
sector, or some combination of these organizations and institutions working together in 
combination. Dealing with this issue of long-term support or back-up is an important 
factor for sustaining benefits USAID has achieved through expenditure of tens of 
millions of dollars in the rural sub-sector to date. The solutions are long-term, but both 
USAID and CARE need to begin thinking through the issue now. The rich and varied 
operational experience gained in both program phases is a good place to start. 
16
4 EVALUATION OF PROSAGUAS:
FINDINGS, CONCLUSIONS AND 
RECOMMENDATIONS
This chapter provides the detailed findings, conclusions, and, recommendations of the 
PROSAGUAS project at midterm. It is broken down into sections dealing with overall 
project management, implementation at the community level, community organization, 
health programs, water supply and sanitation infrastructure, and environmental 
management at the local level.
4.1 Program Management and Administration
4.1.1 Introduction and Definition
The Evaluation Team looked at CARE’s technical capacity to manage the PROSAGUAS 
program in the most efficient and effective manner possible. The team also looked at the 
broader issues relating to coordination of PROSAGUAS with external agencies and 
programs. This section discusses the overall progress of the program in reaching its 
targets (by objective) as well as presenting a qualitative assessment of outputs to date. 
4.1.2 Progress in Meeting Overall Program Objectives
To assess overall progress the team reviewed quarterly and annual reports prepared for 
USAID, as well as up-dated information presented by the PROSAGUAS team at the 
beginning of the team’s assignment. 
PROSAGUAS’s program purpose is the reduction of diarrheal disease in children under 
five years of age, with particular reference to (a) the incidence, (b) the prevalence, and (c) 
the mortality rates attributable to diarrheal diseases in the target population. Quantitative 
data for diarrheal rates presented by PROSAGUAS was limited to the nine projects 
constructed to date, with a pre- and post-project comparison being possible in only three 
project communities, where prevalence has been reduced by 81.2%, 68.5%, and 39% 
respectively, over the course of one year. This is a significantly higher reduction than the 
26% target figure. In the absence of control groups or other evidence that this is not 
simply a one-year variation, it is not possible to state with absolute certainty that this 
reduction is attributable to the effect of the PROSAGUAS program. However, the 
impact is consistent with what would be expected given the quality and integrated nature 
of the WS&S and hygiene behavior change intervention. The Evaluation Team fully 
expects the PROSAGUAS program to achieve these major results in other communities.
Progress to date (half-way through the five-year program) with regard to the 12 main 
program objectives is presented in the table below; it should be noted that progress here 
17
is identified by major objective and does not include all the relevant sub-indicators, 
which are given in Appendix F. 
Table 2. Assessment of PROSAGUAS Program Progress, as of July 2000
OBJECTIVE UNIT OF 
MEASURE
PROGRESS
TO JULY 2000
TOTAL 
PROGRAM 
TARGET
OBSERVATION/DESCRIPTION
1. Increase access to water 
supply
Person 30,775 45,000 68% of target in 9 systems 
2. Sustainable water supply System 4 (18 – 20 
current 
estimate)
9 communities completed to date –
most are newly on-line
3. Sustainable water sources System 4 (18 – 20 
current 
estimate)
Physical tree-planting program 
objective is behind schedule (24%)
4. Increase access to h/h 
latrines
House￾hold
4,032 4,700 86% of target in 9 systems (new 
objective is to reach up to 11,000 h/h)
5. Adoption of improved 
hygiene practices 
House￾hold
4,077 9,000 45.% of target achieved – multiple 
areas addressed
6. Provide assistance to 
Health Promoters
Person 12 48 25% of target achieved
7. Promote adoption of other 
health practices
House￾hold
3,660 9,000 41% of target achieved – wide range 
of practices to address and measure
8. TA to previous USAID 
projects
System 17 48 35% of target achieved--this 
objective has been slower to start up 
than anticipated
9. TA to other communities System 0 Maximum of 5 Objective not clearly defined; 
independent role of DASAGUAS
10. Measure program impact 
on diarrhea
Communi￾ty
23 No pre￾defined 
number.
To date 9 systems constructed 
serving 35 distinct communities or 
barrios
11. Design of futureWS&S 
systems
System 0 4 Limited importance for 
PROSAGUAS management
12. Program monitoring, 
evaluation and reporting
Reports 9 18 100% compliance in reporting 
progress to USAID.
Note: System is used to describe the physical water supply infrastructure, which can often include multiple 
communities (up to as many as 10 in the largest), hence the discrepancy between no of systems and number 
of communities. 
It was not possible (and was beyond the scope of work) for the Evaluation Team to 
review and assess the indicators and sub-indicators related to each objective. The 
following findings do relate, however, to one or more of these principal objectives of the 
program. It was also not possible to draw any quantitative conclusions, and thus the 
team’s observations are for the most part qualitative, drawing where possible on hard data 
provided by CARE.
The Evaluation Team’s overall conclusion is that the PROSAGUAS program is being 
successfully implemented and is meeting most of the stated targets by objective. More 
specifically, in terms of physical infrastructure, PROSAGUAS is ahead of schedule in 
reaching the planned number of beneficiaries, 45,000 for water supply and 4,700 for 
sanitation. Equally, it is clear that significant progress has been made in establishing 
viable and effective community management structures, including increased participation 
18
of women, to ensure the sustainable operation and administration of water supply 
systems. 
In general the Evaluation Team found that considerable progress has been made in the 
health areas (Objectives 5, 6, and 7), both in numerical terms (numbers of committees 
formed and promoters trained) as well as qualitative effect. The Evaluation Team noted 
that these interventions are having an impact on the level of awareness and hygiene 
practices among the target population. In contrast, progress has been slower than 
expected in reaching the targets in the environmental component. It is clear that 
PROSAGUAS will not meet the tree-planting goal (Objective 3). And even where trees 
have been planted , the desired impact—source water protection—is rarely occurring.
Progress to date on Objectives 8 and 9—technical assistance to Phase I project 
communities and to other communities with USAID funding—has been very limited. No 
progress has been achieved in Objective 11, developing designs for future water supply 
and sanitation systems. 
A monitoring and reporting system (Objective 12) has been established by 
PROSAGUAS; information and data have been gathered and fed into quarterly and 
annual progress reports for USAID. 
While program progress is considered positive overall, the Evaluation Team has some 
concerns about certain aspects of project implementation and the appropriateness of the 
some of the original objectives. These issues are addressed in the findings and 
recommendations sections which follow and in the conclusions and recommendations, 
the last two chapters of the report.
Evidence from the midterm evaluation suggests that PROSAGUAS has been successful 
in achieving an appropriate balance between meeting targets for physical outputs under 
the agreement and meeting the qualitative, or software, goals as well. Obviously it is 
premature to draw any definitive conclusions with regard to the sustainability of Phase II 
projects. The Evaluation Team feels optimistic in that regard, however, given the 
generally strong performance of community-managed systems that were implemented 
under Phase I of the program. 
4.1.3 Findings
Financial Management 
Comprehensive and professional accounting and financial tracking systems have been put 
in place by CARE. These systems are largely based on financial accounting programs 
developed by CARE International for use globally; they are designed to satisfy the 
stringent demands of an external audit. Currently the San Salvador office is in the 
process of upgrading its main financial information management software system. The 
existing system is very good at collecting and tracking large volumes of data, but it is not 
19
flexible enough to provide senior management with meaningful analytical models; for 
example, the total program cost per community or cost per beneficiary. 
As part of the financial tracking system, the PROSAGUAS management team is also able 
to account for matching fund contributions on the part of the community beneficiaries. 
Contributions in the form of cash, labor, and in-kind services or materials are recorded at 
project level; and that information is reported to the central office and entered into the 
computerized system. Contributions are tracked both for the community as a whole, in 
the case of the water supply system; and for each individual household, in the case of 
latrines. Equally, PROSAGUAS is able to track and separately account for counterpart 
funding from other national and international agencies (e.g., E.U., municipalities, Rotary 
Club, etc.).
Personnel Management and Communication
With respect to personnel management and administration, the team was equally impressed 
by the professionalism of both the central office in San Salvador and the regional offices. 
There is a clear understanding of roles and task-sharing between the two senior managers 
(program manager and deputy manager). Management team meetings are held monthly in 
San Salvador with all regional coordinators to monitor overall progress. Regional team 
meetings are held every week, with contact- and information-sharing facilitated via e-mail 
between San Salvador and all three regions. 
Vertical communication between senior management and field-based teams appears to be 
good; however, horizontal information sharing and communication among the three field￾based teams is more problematic. It is apparent that field promoters from one office are not
regularly informed as to how their colleagues are implementing projects in other regions. 
This limits cross-fertilization of ideas or sharing of innovative approaches, such as the 
household level diarrheal monitoring activity in Múltiple La Loma. 
Program Reporting and Monitoring
According to the latest benchmark updates from CARE, the reporting and planning 
systems of the PROSAGUAS program are fully established and producing the anticipated 
outputs in terms of data collection (17 communities until March 2000), as well as 
providing USAID with regular progress reports. There is some concern over the slow 
start-up of the KAP studies:only two have been completed to date. (Information from 
KAP studies is key to targeting health education messages.) There is also concern about 
the time lag in making baseline and evaluation data available. 
The Evaluation Team found that CARE has developed relatively sophisticated systems 
for collecting large quantities of data in the PROSAGUAS program, mainly relying on 
the Monitoring and Evaluation Unit of the central CARE office. However, the data 
collection mechanisms do not allow for timely feedback to field-based project staff, much 
less to beneficiaries. The focus of this monitoring system seems to be geared toward
reporting on indicators to satisfy the donor’s requirements. There was little evidence that 
20
this bank of raw data was being analyzed systematically for the purpose of informing 
senior managers about the strengths and weakness of the program processes and impacts. 
Management Absorption Capacity 
Although the team was primarily engaged in an evaluation of the PROSAGUAS 
program, it was possible to discuss the implications of activities carried out by CARE 
under other USAID-funded programs (e.g., MAS, AGUA) and to see first hand how the 
organization has scaled up its management and field activities in response to this 
increased workload. In general, the EHP team was very impressed by CARE’s capacity 
to expand its operations and to bring on new staff. It is noteworthy that despite this 
relatively recent expansion of programs, CARE has continued to recruit high-quality 
staff, demanding exacting standards of professionalism and commitment, and has 
continued to provide them with the necessary orientation and training. This capacity has 
undoubtedly been a key factor in CARE’s ability to expand operationally without 
compromising the quality of outputs. The Evaluation Team is not in a position to predict 
whether CARE could expand further beyond its current workload.
Liaison and Coordination
CARE has been very effective at leveraging funds for project-specific operations from 
other organizations (e.g., European Union, Rotary Club, municipalities). Insofar as this 
was one of the key community selection criteria set by USAID in the RFA, the 
PROSAGUAS program has been very successful. It has also been successful in forging 
local-level alliances, particularly with municipalities and the MOH promoters at the local 
level, with numerous specific examples of fruitful collaboration during the project 
execution phase.
However, the Evaluation Team feels that PROSAGUAS has been less effective in 
forging strategic relations with other externally funded programs and even some 
internally funded, i.e., with other USAID-funded programs within CARE. For example, 
coordination and synergy with the USAID-funded environment project (SO4), “AGUA”, 
also managed by CARE, has been much more limited to date than was originally 
anticipated by the Mission. In addition, very limited integration or even communication 
was noted between PROSAGUAS and the Mission’s urban development project (SO2) 
being managed by RTI. That represents a lost opportunity, especially since many 
PROSAGUAS project experiences are quite relevant for small towns.
It appears that from the start, the PROSAGUAS program has had a more conciliatory 
position about working with ANDA, both at the operational level and with senior 
management. The EHP team feels that this is very beneficial and encourages further 
engagement with that key agency. 
Apart from the close working relation with CALMA, a key PROSAGUAS sub￾contractor, the Evaluation Team observed very limited involvement by local NGOs. The 
inclusion of local NGOs in project execution appeared to be based on existing relations 
21
between the community and those particular agencies, with PROSAGUAS taking advantage 
of such pre-existing linkages (e.g., ACID in El Palón, AGAPE and CARITAS in San 
Matías). Based on the EHP team’s field visits, PROSAGUAS does not appear to be actively 
or systematically engaging local NGOs in order to strengthen institutional capacity or with a 
view to replicating the project’s approach elsewhere.
Relations with ANDA – Gerencia de Sistemas Rurales (GSR)
The team was impressed by the generally positive, open, and mutually supportive 
relations between PROSAGUAS and the GSR (the rural division of ANDA), both at 
operational and managerial levels. It is clear that wherever possible PROSAGUAS 
consults with the director of GSR on key decisions and consciously adheres to the 
agency’s norms and procedures, where these are clearly established. The GSR, like 
ANDA as a whole, is going through a period of great uncertainty while the various legal 
reforms are in progress, GSR also has limited technical and human resource capacity. 
Despite these limitations it is particularly positive to note that PROSAGUAS has made 
efforts to include the GSR as a partner of the program and is building a solid basis for 
future relations. 
It is clear that GSR is in general agreement with the PROSAGUAS project 
implementation methodology and its approach to service provision (i.e., level of service), 
even going as far as to cite the project as an exemplary model in terms of community 
participation and management. 
4.1.4 Conclusions and Recommendations
On the basis of the findings as presented above, the Evaluation Team concludes that in 
general the PROSAGUAS program is being well managed and administered, with high￾quality and dedicated professional staff at both central and field level. CARE has 
successfully put into place sound financial, accounting, and reporting systems which 
make it possible to monitor program activities closely and measure progress. 
Furthermore, CARE successfully managed to scale up operations to include two new 
USAID cooperative agreements last year (MAS and AGUA), without having significant 
negative impact on the PROSAGUAS program.
However, the team did observe certain specific weaknesses within the overall program 
management of PROSAGUAS which, if addressed, would contribute to improving the 
performance in the remaining time period of the cooperative agreement. To this end the 
EHP team has the following recommendations for improving overall management and 
administration:
· Financial Tracking. The new FIS-SCALA financial information management 
system should be used for greater flexibility in tracking and analysis of financial data. 
Specifically, the Evaluation Team recommends that PROSAGUAS configure the new 
system in such a way that it will allow calculation of costs per system and costs per 
beneficiary by system or latrine type. The calculation should make it possible to 
22
distinguish between direct and indirect program costs, other cash contributions, and 
in-kind (materials and labor) inputs. Reaching that level of detail is critical if CARE 
is to engage in the sector policy reform process with ANDA or other international 
agencies. Transparent and credible financial data will be an important part of 
informing that debate at the national level. 
· Internal Communications. PROSAGUAS management should make an effort to 
improve horizontal lines of communication and develop mechanisms for field-level 
staff from the three regional offices to share experiences. That would provide support 
among the regional staff and might bring a greater degree of creative innovation and 
consistency of approach within the program. The team recommends that regular 
meetings be held for the exchange of information and ideas among the three regions.
· Program Monitoring. Given the quantity of data available to PROSAGUAS, the 
team strongly recommends that greater efforts be made to analyze this data bank and 
use the results to inform management decisions and adjust program direction and 
focus as necessary. The analysis of data should concentrate on qualitative aspects of 
program performance as well as numerical progress. 
In terms of the relations between PROSAGUAS and ANDA/GSR, the Evaluation Team 
believes that significant progress has been made to involve the state institution in a 
meaningful way as a partner in the program. Moreover it is clear that PROSAGUAS has 
been able to establish the necessary degree of trust and communication between the two 
institutions, which bodes well for the future of the sub-sector. As one of the principal 
nongovernmental actors in rural water and sanitation, CARE is in a good position to play 
a critical role in discussions, as is USAID. Together they will be able to participate 
knowledgeably in discussions and have an influence over aspects of the reform process. 
· Engagement with ANDA. The Evaluation Team recommends that PROSAGUAS 
continue this positive engagement with ANDA and become active in the policy 
debate with regard to sector reform as far as possible within the existing program 
terms of reference set out by USAID. 
4.2 Community-Level Project Implementation
4.2.1 Introduction and Definition
In the context of the PROSAGUAS program, community-level implementation is taken 
to mean the combined approach, or methodology, which is applied at the individual 
project level, referring to one water supply system; in most cases, a single system serves 
more than one community. As such, “project implementation” consists of a series of 
activities and inputs which, when applied in a particular community or group of 
communities, determines the end products contained in a project, including the physical 
water supply and sanitation infrastructure, health benefits, and social and organizational 
23
outputs. The project implementation process has a diverse range of considerations, 
including the following: 
· Material and physical inputs
· Project selection criteria
· Implementation duration and time management
· Quality and quantity of human resources
· Implementation approaches
· Coordination at the local level, participation and ownership
· Training and transfer of knowledge and skills
· Monitoring and modification of methodology
An assessment of some of the particular components is taken up in other sections of this 
chapter (i.e., health, community organization, and WS&S systems), however this 
particular section presents the findings of the Evaluation Team with respect to some of 
the more qualitative issues in community-level project implementation.
4.2.2 Objectives and Indicators 
In general, no individual objectives, indicators, or benchmarks were established in the 
program design to measure the quality of these aspects of project-level implementation. 
As such, the most relevant program objectives are those most directly concerned with 
project implementation and sustainability and include:
Objective No. 1: to increase access to potable water supplies;
Objective No. 4: to increase access to latrines;
Objective No. 2: to ensure sustainable water supplies via adequate operation, 
maintenance, and administration;
Objective No. 5: to ensure the adoption of proper hygiene practices and proper 
latrine use and maintenance practices.
4.2.3 Findings
Project Implementation Cycle
The average project cycle has been a period of 18 months. The Evaluation Team felt that 
this is a reasonable period, given the magnitude and complexity of some of the individual 
projects. The rhythm of project implementation is usually dictated by progress (or delays) 
in the physical construction, which in several cases was caused by the lead-time 
necessary to import specialized equipment from the United States (for example, in El 
Jalacatal, El Señor). 
The current practice of extending the post-construction project presence for up to six 
months is a very positive modification in the overall PROSAGUAS program. It was also 
24
observed that in a number of cases, CARE was flexible in terms of extending this period 
where communities required additional and targeted assistance. 
Project Implementation Teams
The Evaluation Team was consistently impressed by CARE field personnel’s level of 
professionalism and dedication to the job. Staff often go well beyond the normal call of 
duty in terms of hours worked and making visits to communities on weekends. The 
strong performance and genuine dedication of CARE staff was repeatedly mentioned 
during the course of meetings with the water management boards and is obviously greatly 
appreciated. 
The practice of assigning one fully integrated field team to a particular project for most of 
the implementation phase is a very positive factor in the community development 
process, especially in terms of continuity. Associated with this is the CARE approach of 
using a four-person implementation team in every project. The implementation team 
includes an environmental promoter, health promoter, social organizer, and project 
engineer. 
Community Selection Criteria
At the regional level, PROSAGUAS staff has been consistent in applying criteria in the 
selection of communities for inclusion in pre-feasibility studies. The field staff has also 
been rigorous in assessing community requests for assistance based on the selection 
criteria as defined in the program documentation. As the overall PROSAGUAS goal is to 
improve health, it is surprising that the community selection criteria do not include health 
conditions or poverty indicators. 
Documentation of Project Methodology 
In the course of visits to the regional offices and discussions with program field staff, the 
Evaluation Team found that PROSAGUAS has been successful in documenting most of 
the project implementation methodology and approaches. The team was generally 
impressed by the scope and quality of the various training and extension modules 
developed for both PROSAGUAS staff and community promoters. These are discussed at 
greater length in Sections 4.3 and 4.4. CARE has made efforts to capture and 
systematically record the various elements of project implementation in a document 
entitled, “Estrategias Operativas para la Implementación de PROSAGUAS.” That 
document is the nearest approximation to an official implementation guide which 
explains the “PROSAGUAS approach”, and it appears that most field staff use it 
regularly as a reference tool. 
Community Agreements
The Evaluation Team was generally impressed by the quality and level of detail of the 
agreements drawn up between CARE and the community. More often than not these 
25
contracts are multi-institutional documents that include agencies such as ANDA, 
MSPAS, the Ministry of Education, and local municipalities. The contracts are very 
inclusive and detailed with respect to the execution of projects, clearly setting out expected 
activities, obligations and inputs of all parties, including formation of committees, tariff 
systems, and health and environmental concerns. Details of post-project arrangements are 
less explicit; they tend to be much more open-ended, partly due to uncertainty about which 
mechanism or institutions will be involved in long-term support to communities. 
Community-Level Monitoring
The PROSAGUAS program has put into place systems to monitor activities and impacts 
at field level. These systems have been successful in assessing the physical progress of 
individual projects, as well in the collection of data for reporting purposes. Overall the 
Evaluation Team noted that this monitoring process is mainly designed for reporting to 
USAID; its use for program or project adjustment is limited, or at least not carried out in 
any systematic way. Of even greater concern is that there appears to be little or no 
feedback of monitoring results to the communities or households involved. One example 
is the diarrheal data, collected by CARE’s Monitoring and Evaluation Unit (UME) but 
not reported back to either project staff or communities. The positive exceptions to this 
are in La Loma and Cara Sucia, where health promoters have introduced a very 
innovative household-level diarrheal monitoring system. 
4.2.4 Conclusions and Recommendations
On the basis of the field visits and discussions with community members and 
PROSAGUAS field staff, the Evaluation Team concludes that the program has developed 
a very effective implementation methodology. The approach adopted by PROSAGUAS 
is progressive, allows for a high degree of community participation, and is effective in 
ensuring the integration of both social and technical components during the project 
execution phase. The team is also of the opinion that the quality and dedication of 
PROSAGUAS field staff have been key factors in the success of the projects to date. 
Regarding the selection process, however, the Evaluation Team concluded that the final 
community selection process in the first two years of PROSAGUAS has been 
consistently geared towards larger, generally more resource-rich, semi-urban 
communities. Although providing services to these communities is not without merit, 
their selection represents a distancing from the original target population of the 
program—defined as areas of rural poverty with communities of generally less than 
2,000 inhabitants. 
Two areas where the performance of the PROSAGUAS program could be improved still 
further are as follows:
· Documentation and Dissemination of Methodology. The strategic objective 
document developed by PROSAGUAS is clearly composed of disparate parts, 
26
patched together; it does not address all issues in a systematic way. PROSAGUAS 
should be encouraged to complete this important document since it would be useful in 
assuring a consistent approach within the program and would also make it easier to 
disseminate information about PROSAGUAS’s experience to a wider audience—
nationally and regionally. 
· Community-Level Monitoring. The Evaluation Team strongly suggests that the 
monitoring data currently collected by PROSAGUAS be made available to both the 
field staff at the regional level and the communities and individual households, so that 
community residents can be active participants in resolving their own problems, and 
regional staff can replicate successful interventions. Much innovative work has been 
done on community-based monitoring and corrective actions by the International 
Reference Centre for Water Supply and Sanitation (IRC) in The Netherlands, 
generally available in Spanish.
4.3 Community Organization
4.3.1 Introduction and Definition
According to PROSAGUAS strategy guidelines, communities should participate in: 
· selecting water service levels and latrine types
· determining the administrative model for the water system (community, municipal, 
ANDA, or mixed)
· developing the system design
· protecting water sources
· providing labor and local materials, and material storage and control
· providing cash payments for a portion of the costs
· legalizing titles to water sources and land
· forming organizational structures, which include both men and women, to achieve 
and maintain health, water, and environmental objectives.
The initial organizational structures promoted by PROSAGUAS include water, health, 
and environmental committees, to be formed and trained once a community project has 
been deemed feasible; finally, a water management board is formed to administer the 
system, if the community administrative model has been selected. According to 
PROSAGUAS guidelines, members of the water management board should be drawn 
predominantly from the various committees. The PROSAGUAS social promoter, in 
coordination with the health and environmental promoters, discusses the functions of 
these committees and requirements; members are chosen or approved by community 
assemblies. PROSAGUAS guidelines emphasize the importance of trying to achieve the 
best possible gender balance in committee membership. They set a goal of at least 33% 
women on water committees and water management boards, they also seek similar 
representation of men on health committees, where women tend to predominate.
27
The water, health, and environmental committees generally stand for the 18-month 
project implementation period. After that, the functions of the water committee are 
usually assumed by the water management board, which is responsible for 
administration, operation, and maintenance of the system once it becomes operational. 
The health and environmental committees are not required to continue past the 18-month 
commitment of their members (though they may do so voluntarily), but according to the 
guidelines, efforts are made to ensure that the functions of these committees continue 
through local promoters paid by the water system, Ministry of Health (MOH) promoters, 
or other actors such as other environmental projects or NGOs.
The water committee organizes human, material, and financial resources during project 
implementation, and is also responsible for coordinating activities with the other 
committees. The health committee is responsible for educating community members in 
basic sanitation and measures to promote child health and reduce diarrheal disease. The 
environmental committee promotes protection of water sources through education, tree 
planting, and soil-conservation activities. 
All committee members receive technical training related to their committees’ area of 
responsibility, as well as leadership skills; all the program’s training also incorporates 
sensitivity to gender. Committee members are trained in community participation and 
organization, leadership development, teamwork, and group facilitation, using the 
participatory SARAR methodology to empower committee members and promote 
replication of this empowerment throughout the community. The SARAR methodology 
emphasizes development of capacity to resolve problems, use resources effectively, and 
generally develop greater control by people over their own lives and environment. The 
five basic qualities promoted through the SARAR method are: Self-esteem, Association 
with others, Reacting with ingenuity to problems, Actualization, and Responsibility for 
sustainable solutions to problems. Training materials for all program components 
incorporate these elements.
Community work groups are organized during the construction period, and accounts are 
kept of the labor contributed by each beneficiary family. Service on committees during 
the entire project period counts as the membership contribution for the family (if two or 
more family members serve on committees, only one membership contribution can be 
claimed). It should be noted that at least one community, Los Conacastes, did not count 
service on the environment committee as the membership contribution, though most 
others apparently did.
4.3.2 Objectives and Indicators
Community organization and capacity-building are not independent objectives of 
PROSAGUAS; rather, they are the principal means for achieving and sustaining activities 
to reduce the incidence of diarrheal diseases in children under age five by providing 
access to potable water and sanitation. Thus community organization and capacity￾building contribute to many of the 12 program objectives and their respective indicators, 
although they are not measured directly since indicators measure the results of 
28
community actions, not the organizational process itself. The objectives to which 
community organization contributes most directly are several:
Objective 1: Increased access to potable water
Objective 2: Ensuring the supply of potable water through adequate management, 
maintenance, and administration
Objective 3: Ensuring the sustainability of water resources through management of 
micro-watersheds
Objective 4: Increased access to latrines
Objective 5: Ensuring the adoption of adequate hygiene practices and use and 
maintenance of latrines
Objective 7: Ensuring the adoption of other health practices which directly or indirectly 
impact the incidence, prevalence and mortality from diarrhea in children 
under age 5
While PROSAGUAS indicators appropriately focus on results rather than process, there 
are indeed a few benchmarks to track the organizational process. The following are 
benchmarks that mark progress related to community organization, through March 2000, 
as reported by PROSAGUAS:
· Number of water committees formed: 15. (Large projects have more than one 
committee, accounting for the difference between the 9 communities selected as of 
March 2000 and the number of committees.)
· In beneficiary communities, the number of women working in organizations 
responsible for water and sanitation systems is at least 33% of the total number of 
people who comprise these entities: 3 communities. (Six are programmed.)
· Number of health committees formed: 23. (See note for water committees above.)
4.3.3 Findings
Based on field visits and a review of documented results to date, PROSAGUAS has been 
very successful in promoting effective community organization and community capacity 
to manage water systems. It has also been successful in promoting improved sanitation, 
health, and environmental protection.
Community Management Structures
Water, health, and environmental committees as well as water management boards have 
been established as planned, largely following the program’s strategic guidelines. The 
guidelines clearly indicate that community participation is understood to mean 
participation in decision-making and assumption of management responsibility, along 
with the contribution of labor and other resources. While this type of involvement has 
generally been achieved, there are some programmatic areas in which community 
involvement could be further strengthened. A major area where community involvement 
has been weak was mentioned to the Evaluation Team by people in several communities: 
they cited lack of adequate involvement in water system design and execution, such as 
29
knowing the costs of materials and details of the design, equipment, and functioning of 
the system. Not being involved in the design and execution phase created a problem 
when they were faced with repairs, replacements, or expansion of their systems. (This 
comment was particularly frequent in interviews with those representing Phase I 
communities which had been in operation longer. The same issue may also pertain to the 
current implementation phase of PROSAGUAS.) Some community representatives also 
said they did not really have a voice in choosing the technology, a comment heard most 
often in reference to latrines.
Technical Assistance Needs
Another issue more evident in Phase I communities is the community water boards’ need 
for a trustworthy source of technical, administrative and legal support. While the 
PROSAGUAS communities have received more training and greater support than those 
in Phase I, it is likely that with time they too will encounter problems which they may not 
be able to solve on their own. The degree to which legal issues have cropped up is 
noteworthy, particularly those relating to obtaining clear title to land and water sources. 
Water management boards have also faced technical and administrative problems which 
threaten the survival of their water systems, including problems stemming from inability 
to communicate effectively with their communities, particularly with regard to delayed or 
non-payment of fees. Inadequate tariffs and technical problems in maintaining water 
systems are also common among the older systems.
Working with Local Structures
To its credit, PROSAGUAS has made use of and built on existing organizational 
structures in the communities, primarily the Community Development Associations 
(Asociaciones de Desarrollo Comunal, ADESCO), which are legally constituted and 
recognized entities existing in most communities. Most have a history of trying to 
improve community conditions, and have been active in obtaining services such as 
electricity, improved roads, and water. In some Phase I communities the water system is 
legally owned by the ADESCO and is administered by a committee under the ADESCO, 
rather than functioning as an independent water users’ association. Under 
PROSAGUAS, the water users’ association generally has legal recognition and the 
system is owned by the association and administered by the water management board, 
independent of the ADESCO. This system of governance generally facilitates a more 
“entrepreneurial” focus, contributing to water system sustainability as a non-profit, but 
business-like, operation, apart from the broader community concerns of the ADESCOs. 
However, there is often significant collaboration between the ADESCO and the water 
management board. In Cara Sucia, for example, the ADESCO (which had owned and 
managed the old, now-defunct water system) donated the site of the old well to the new 
system, as well as the site for a new well; the ADESCO also collaborated in the 
construction of the office and storage facility for the new system. At a minimum, the
ADESCO, when it exists, is usually the first point of contact with community leaders and 
constitutes the community assembly which selects and approves committee members, 
promoting strong community roots for the system. 
30
The relationship between the water users’ associations and municipal authorities varies. 
There has been an effort by PROSAGUAS to involve municipal governments, and there 
appears to be significantly more involvement than was evident in most Phase I 
communities. Among the PROSAGUAS communities visited, one was administered 
directly by the municipality (Conchagua), which had used and repaid CARE/COMURES 
loan funds to build the water system for Nueva Esperanza. The community is repaying 
the loan to the municipality over a much longer period, and will take over administration 
of the system when the loan is repaid. In Los Conacastes, the mayor of the San Francisco 
Menendez municipality has donated land for the water tank. He has also given support 
for construction of the well and water tank for Cara Sucia and has provided auditing 
services and advice on candidates for the water management boards for these 
communities. Relations are less close in some communities, however. In Corinto, the 
citizens living in the municipal seat voted to have no municipal government involvement 
in the management of their water system.
Relationships with local NGOs are limited. The only ones mentioned to the Evaluation 
Team were CALMA, which has been sub-contracted by CARE to support health 
materials development and training as well as monitoring/evaluation of health status, and 
Agape, a health NGO which collaborates informally in areas where it is working. Some 
health promoters belonging to other NGOs are also collaborating with PROSAGUAS 
communities. However, there does not appear to be any systematic effort to seek out and 
involve local NGOs.
Gender Balance
Gender balance is considerably better under PROSAGUAS than in the Phase I projects. 
The following table summarizes participation by gender on committees, as reported by 
community members, for the communities visited by the Evaluation Team for both the 
current phase and Phase I.
31
Table 3. Composition of Community Organizations, by Gender
Water Mgt. 
Boards
Health 
Committees
Environmental 
Committees
Current Phase 
(Community/ 
Munic./Dept.) male female male female Male Female
Istagua/S. Pedro 
Perulapan/Cuscatlan
1 3 16 15 6 2
Cara Sucia/S. Fco 
Menendez/Ahuachapan
6 5 5 37 7 0
Conacastes/S. Fco 
Menendez/Ahuachapan
5 4 7 9 2 3
La Loma/S. Pedro 
Perulapan/Cuscatlan****
21 16 82 35 2 14
3H/Moncagua/San 
Miguel****
6 6 34 57 14 20
Analco/Erequayquin/
Usulutan
8 4 5*** 24
Esperanza/Conchagua/
La Union
3** 2 2 3 2 3
Corinto/Corinto/Morazan 6 6 2 3
Phase I
(Community/Mun./
Dept.)
El Señor/Quetzaltepeque/
La Libertad
3 3 * *
Pandeadura/Tacuba/
Ahuachapan
25 0 * *
Sincuyo/Tacuba/Ahuach. 18 0 * *
La Puebla/San Matías/La 
Libertad
10 1 * *
Rosario Tablón/Tenan￾cingo/Cuscatlan
5 2 * *
Conquista/Suchitoto/
Cuscatlan
6 1 * *
Montepeque/Suchitoto/
Cuscatlan
1 1 * *
El Palón/Lolotique/San 
Miguel
6 0 * *
Jalacatal/S. Miguel/S. 
Miguel
11 1 * *
San Matías/Ciudad 
Barrios/S. Miguel
4 1 2 5 *
Teponahuaste/Ciudad 
Barrios/S. Miguel
5 1 ? ? *
*No committee established. 
**Water system administered by municipality; water committee helped organize work during the 
construction phase, then disbanded.
***Health and environment committee are combined into one.
****Data from PROSAGUAS July-September Quarterly Report for all committees (there are multiple 
water, health and environment committees); EHP team unable to get data for all committees during visit.
32
Based on these figures for projects visited by the team, participation in water 
management boards or water committees by women in Phase I projects averaged 28%, 
while women’s participation averaged 47.5% for the “current phase” communities 
visited, nearly equal to men’s and well above the 33% target. Conversely, male 
participation in health committees for the current phase communities averaged 39%.
While these numbers are impressive, they do not tell the whole story, particularly with 
regard to the level and quality of participation by gender. PROSAGUAS guidelines 
stress the need to seek active participation by both women and men as well as greater 
balance in numbers; therefore, measures of the level of participation (such as men and 
women who are presidents and vice-presidents) and reporting, even if anecdotal, on the 
extent to which decisions are influenced by both women and men, give a more accurate 
picture of participation and of the impact of PROSAGUAS’ community organization 
efforts than the numerical indicators alone. Based on the communities visited, there are 
still many more men than women in leadership positions (there are no women serving as 
presidents of administrative committees or water boards, for example), but there are 
women serving as vice-presidents. The Evaluation Team encountered one ADESCO 
with a female president. The team also observed very active and informed participation 
in discussions by a number of women in its meetings with communities. 
PROSAGUAS requirements for labor contributions do not appear to be a strong barrier to 
participation by women-headed households. But as the program proceeds, it should be 
kept in mind that the requirement for a labor contribution could create a barrier to such 
households, and poor households generally, because of their inability to contribute labor 
or pay someone else to do so. There are large numbers of women-headed households—
judging by the team’s visits, up to 75% in some peri-urban communities—and such 
households are not uncommon even in very rural communities. The provision for 
counting committee service as the membership contribution is innovative and valuable in 
this context, providing an alternative to facilitate participation. Many women also 
reported contributing manual labor during the construction process.
There has been less apparent emphasis on participation by other socio-economic 
variables beyond gender, although there is some focus on involving young people and 
students, especially through working with schools. The local promoter in Istagua, for 
example, indicated that she is trying to form youth committees, especially for 
environmental activities.
Process Documentation
The lack of emphasis in PROSAGUAS documentation of the qualitative aspects of 
community organization and decision-making is also an issue. Current monitoring 
systems focus on quantitative data rather than qualitative information about the process of 
developing community capabilities and participation. For example, topics which would 
be of use are the types of issues and problems faced in local management of systems, 
constraints overcome, level and type of participation by gender and any other significant 
33
variables, and the time taken to develop local management capacity. Such information 
would be useful in replicating the experience.
Follow-on Provisions
The fact that all committees except the water management board are viewed as temporary 
structures, functioning only during the 18-month implementation period, has resulted in 
the creation of different vehicles to carry on essential follow-up for health/sanitation 
promotion and environmental protection functions. In some cases, such as Istagua, the 
water management board has contracted a local promoter to maintain these functions, 
calling on community volunteers as needed. Other communities have relied on Ministry 
of Health promoters to continue health/sanitation and water quality monitoring, or plan to 
continue their health and environmental committees at a less intensive level of activity, 
with committee terms concurrent with the water management board. It will be important 
to monitor and evaluate these various means of follow-up as the program progresses to 
determine their effectiveness.
4.3.4 Conclusions and Recommendations
In general terms, the community organization process, methodology, and structures used 
are all working effectively. Members of water management boards and health and 
environment committees clearly recognize their responsibilities and are carrying out their 
functions. They consider their training useful and effective. Participation by women (as 
measured by the number of women on committees) has improved markedly, surpassing 
target levels and reaching nearly equal levels with men, on average, in the communities 
visited. PROSAGUAS staff training and staff capabilities are excellent, judging from the 
results achieved.
Nonetheless, there are a few areas in which performance could be improved even further, 
contributing to the sustainability of the current program and to replication by others in the 
future.
· Greater Involvement by Water Committees. Involvement of water committees in 
project design and implementation should be strengthened, so that the committees and 
water management boards are fully involved in decisions and are familiar with the 
equipment used, the reasons for project design and technology choices, and cost and 
source of equipment and materials, to facilitate maintenance, repair and system 
expansion. Such intensive involvement at the start constitutes on-the-job training for 
these bodies. It may slow things down a bit at the beginning, but it may also shorten 
the six-month post-project period and reduce the number of problems arising. It is 
also important to seek out people with appropriate skills to serve on water committees 
and water management boards. In urban and semi-urban areas, for example, there 
may be skilled engineering students, accountants, and construction managers. The 
purpose of this recommendation is to ensure that the committees and boards gain 
experience in procurement, construction management, resolution of legal issues, and 
34
dealing effectively with the private sector with regard to system maintenance and 
repair.
· Permanent Technical Assistance. As noted in the recommendations for Section 
3.3.3, a permanent source of technical, administrative, and legal assistance for 
community water systems is crucial to the long-term sustainability of community 
management, as well as the sustainability of the water and sanitation systems 
themselves. USAID and CARE should examine possible means of creating such an 
entity, on a non-profit but self-sustaining basis, to serve community and small 
municipal systems.
· Process Documentation. Improved documentation of the community 
organization/participation process, including participation by gender, would 
contribute greatly to replicability of the program. Documentation should describe and 
analyze the process of organization, including identifying constraints to participation 
by gender and other factors, especially poverty, and also participation by young 
people; describing how such constraints have been addressed; describing how 
communities participate (by gender) in the decision-making process throughout the 
project, and how their level of participation may change during the implementation 
period; tracking levels of participation after the implementation period has been 
completed, and the effectiveness of provisions for follow-up on health and 
environmental conditions and water system management.
· Provisions for Poor/Female-Headed Households. While the Evaluation Team was 
unable to ascertain the degree to which women-headed households and poor 
households in general are left unserved because they cannot contribute labor or 
otherwise pay membership costs, PROSAGUAS staff should assess this situation 
carefully. If warranted, program staff should encourage water users’ associations to 
institute flexible credit systems so that such households can pay membership 
contributions over an extended period of time.
4.4 Health Education
4.4.1 Introduction and Definition
The PROSAGUAS health education strategy seeks to generate awareness within 
communities of their health practices and situation, and thus promote improvement in 
health conditions in order to achieve the project goal of reducing diarrhea in children 
under age five. 
The program uses a participatory methodology to train health committee members, using 
the SARAR approach to empower community members to take action (see Section 
4.3.1). The health committee members, in turn, repeat this training with families in the 
community. The objectives of this educational process are to promote change in health 
35
behavior and to facilitate community organization and formation of leaders to promote 
improved health. A gender focus is also included, stipulating that at least 35% of health 
committee members should be men, that training should be given at times that are 
convenient for women and men, and that community training should not focus solely on 
women (and especially mothers) as the parties responsible for family health, but should 
include all members of the family, male and female.
The major elements of the health education process are as follows:
· A diagnosis and baseline study which document health conditions at the beginning of 
each project (and community).
· A KAP study, prior to training health committee members, to identify major 
problems; this study serves as a basis to plan educational interventions.
· Selection by the community of a health committee which includes both men and 
women, based on a profile provided by the PROSAGUAS health educator. The 
membership will vary according to the population size; optimally, each committee 
member will cover no more than 20 families.
· Training for health committee members, incorporating group process and leadership 
and facilitation skills as well as basic sanitation and child health information.
· Training Ministry of Health (MOH) and NGO health promoters (under the terms of 
an agreement with the departmental director of the Ministry) according to their 
training needs, using the same participatory methodology.
· Replication by health committee members, each training his or her assigned group of 
families. The first phase of training focuses on basic sanitation; the second phase 
incorporates immunization, breastfeeding, diarrhea and use of oral rehydration.
· Monitoring and evaluation, including semi-annual collection of data to measure 
change in health indicators against those in the baseline study. Evaluation focuses on 
progress in improving health and sanitation indicators.
· Development of a follow-up plan for the post-project phase, by the health committee, 
health promoters and water management board.
As noted in the community organization section above, service on the health committee is 
the equivalent of the manual labor required for membership for the member’s household.
4.4.2 Objectives and Indicators
As with community organization, health education is not an end in itself, but a means to 
achieve the health results which are the purpose of the PROSAGUAS program: reduction 
of diarrhea among children under age five. Therefore, program indicators do not measure 
progress in health education, rather they measure the results of health education, together 
with other interventions which contribute to these results. The objectives to which health 
education contributes directly include:
Objective 5: Ensuring the adoption of adequate hygiene practices, and appropriate use 
and maintenance of latrines.
Objective 6: Providing assistance to health promoters.
36
Objective 7: Ensuring the adoption of other improved health practices that impact 
directly or indirectly to reducing the incidence, prevalence, and mortality 
from diarrhea in children under five.
Objective 10: Measuring the impact of the program in reducing the incidence, 
prevalence, and mortality from diarrhea in children under five.
The benchmarks used to track progress in the health education component follow, 
indicating levels attained as of March 2000, as reported by PROSAGUAS:
· Number of health committees formed: 23.
· Hygiene and latrine use and maintenance practices (population trained): 20,133.
· Number of health promoters who have been assisted: 10.
· Number of households with other improved health practices (households trained): 
2,660
· Number of communities in which (diarrhea reduction) data was collected: 17.
4.4.3 Findings
PROSAGUAS has achieved substantial health and sanitation benefits, as evidenced by 
the decrease in diarrhea in program communities. 
Health Committees
The selection process for community health committees works well, and the committee 
members have demonstrated their commitment and effectiveness in replicating the 
training they themselves received in their communities. The committee members that the 
Evaluation Team talked with took their responsibilities seriously, visited their assigned 
families weekly, checked hygiene conditions and disseminated hygiene and health 
education. Another achievement of the program is the extent to which men have been 
incorporated into the health committees, since health has been considered a traditionally 
female concern. For the communities the team visited, 39% of all health committee 
members were men.
Health Education Methodologies and Materials and KAP Surveys
The training methodologies and modules are very good. They use a participatory 
approach to help trainees internalize the learning. It is evident that adaptations are being 
made, based on experience as well as on the results of KAP studies in the two 
communities where they have been conducted. These studies are conducted by 
PROSAGUAS staff, with guidance and participation by CALMA, a local health NGO 
contracted by CARE to provide training and technical assistance to program staff. The 
KAP studies cover a range of topics, reporting responses by focus groups of mothers, 
fathers, grandmothers, and community leaders regarding health knowledge and practices. 
The studies include conclusions and recommendations, which are discussed with the 
health committee and health promoters in order to refine the education strategy. This 
37
approach appears to be promising, and compensates for some of the problems with the 
monitoring and evaluation system discussed below, since the information is discussed 
and used at the community level. Nonetheless, as PROSAGUAS staff members have 
noted, the KAP studies need to be more tightly focused to identify the highest-risk 
behaviors related to diarrheal disease and the reasons for them, and to prioritize and tailor 
health education toward changing these behaviors. Reducing the number of messages 
and frequently reinforcing the learning process around these behaviors is important in 
promoting behavior changes. As has been noted previously, the delay in beginning KAP 
studies has meant that they were not done for the earliest project communities.
Using existing health education materials certainly saves money, but if the materials are 
not appropriate, achievement of ultimate health objectives may be thwarted, and 
sustainability of gains made thus far not assured. Some of the materials used in the 
program (e.g., materials produced by UNICEF) are oriented to rural settings and may not 
be effective in the urbanized areas of some of the PROSAGUAS projects. Investing in 
developing the most appropriate materials and methodologies for urban and semi-urban 
areas is likely to be a wise use of funds and could save money, in the long run, by helping 
communities reach their targets sooner than originally expected.
Focus on High-Risk Behaviors
The need for increased focus on high-risk behaviors was reinforced for the Evaluation 
Team by examples seen during its field visits. While latrine use and maintenance 
appeared to be generally very good, there were some issues around maintenance, 
especially of compost latrines (especially reluctance to stir contents and, in a couple of 
instances, lack of drying material). Disposal of children’s feces was generally good, but 
the team did observe some examples of excreta around latrines and failure to put soiled 
paper in latrines. Handwashing after latrine use was flagged as a problem by 
PROSAGUAS staff, and the team did not observe any handwashing facilities adjacent to 
latrines. Other problems observed were standing graywater puddles or open run-off (of 
particular concern given the current rapid spread of dengue) and potential contamination 
of drinking water by grasping the pouring lip of water jugs with the hands (observed in 
seven of nine communities, which were both current and Phase I sites).
Monitoring and Evaluation Issues
Baseline and evaluation studies of health and sanitation conditions are conducted by 
CARE’s central monitoring and evaluation unit, using contracted personnel rather than by 
health committee members and health promoters, as originally envisioned. This 
arrangement has the advantage of producing credible data efficiently and freeing the time 
of local staff and volunteers. It also takes into account that local staff and volunteers are 
usually not available for post-project evaluations. However, it also means that there is no 
local involvement or ownership of the information produced, and the information is not 
fed back to the community, i.e., to the water management board, local or MOH 
promoters, or other follow-up mechanisms. The studies produced contain an array of 
data, but there has been almost no analysis of reasons for positive or negative changes in 
38
the data, which is especially important for changes that do not fit the expected pattern. 
Further, as noted in the management section, these studies do not appear to be used to 
make program adjustments; they are mainly used for reporting to USAID. While the 
KAP studies (limited to two to date) provide another source of information which does 
appear to be used in program decisions, they should not constitute a system parallel to the 
formal M&E system; rather, the M&E system should be refocused to serve program 
management and community needs. 
Follow-on Provisions
In most of the communities visited, the MOH (or NGO) health promoters are active 
participants in supporting hygiene and health education and follow-up, and also in testing 
water chlorine levels. In urban areas such as Cara Sucia, promoters are not used; the 
health center nursing/auxiliary staff collaborate in training and education efforts. At least 
one rural community, Nueva Esperanza, has no health promoter, although residents do 
use the health unit in Conchagua.
The role of MOH and NGO health promoters is important for maintaining and improving 
program achievements in health and hygiene, as health committees usually become 
inactive once the 18-month project implementation period is completed. Some water 
users’ associations have been able to hire a local promoter to provide follow-up. This 
model appears to be very effective, since in addition to promoting continued attention to 
health, hygiene, and environmental activities, it gives value to health and other follow-up 
functions as something worth paying for, and provides employment to a community 
resident (in the case of Istagua, a former health committee member). However, other 
communities are considering other follow-up mechanisms, including using current (or 
requesting new) MOH health promoters or continuing the health committees. In the latter 
case, they are encouraging turnover to avoid overburdening volunteers, i.e., having 
members serve for the same fixed term as the water management board.
4.4.4 Conclusions and Recommendations
The health education methodology, use of health committees, and incorporation of MOH 
and NGO health promoters have been successful and have contributed to the decrease in 
diarrhea in children, particularly with regard to hygiene and latrine use. There is a need 
to focus KAP studies and hygiene/health education on the highest-risk behaviors in each 
community. Monitoring and evaluation of health conditions need improvement. It is 
wasteful and ineffective to have a system that is used only for reporting. If would be far 
better to use the information produced to make improvements in the program and to share 
it with the community so that people can take action to make improvements themselves. 
There is also some question about the efficacy of rural-focused training materials in an 
increasingly urban environment. So far, adequate follow-up is being provided, but that 
situation should be evaluated carefully over the remainder of the project to assess 
effectiveness. 
39
In light of these conclusions, the following actions are recommended to improve this 
already strong program component:
· Monitoring and Evaluation. Refocus the health monitoring and evaluation system 
to include greater analysis of health results and investigate reasons for unexpected 
results. The information should be processed and disseminated in a more timely 
manner, taking into account the 18-month project implementation period. It should 
also be synthesized in an easily accessible manner with feed back to the community 
promoter, if there is one, and to the MOH promoter and water management board, as 
well as to CARE staff for possible follow-up if there are situations requiring further 
intervention. It would also be useful if the monitoring/evaluation system could be 
adapted to track changes in key behaviors identified in the KAP surveys. Limited use 
of longitudinal studies may be helpful in determining program impact on health￾related behaviors.
· KAP Surveys. Revise the KAP surveys to identify the most important, highest-risk 
behaviors related to diarrhea incidence, prevalence, and mortality; use them to 
prioritize a few key behaviors, and focus educational interventions on changing these 
behaviors, with frequent reinforcement (see Appendix H for a list of indicators for 
diarrheal disease prevention).
· Educational Methodologies and Materials. Carefully assess the effectiveness of 
the current rural-focused educational methodologies and materials in urban and semi￾urban areas; adapt and revise the methodologies and materials as necessary to 
increase their effectiveness. Investment in such “software” materials is as important 
to program success as “hardware” investments. It is also important to document any 
methodological changes and to make the revised materials available for replication 
for future urban projects.
40
4.5 Water Supply and Sanitation Infrastructure
4.5.1 Introduction and Definition 
The major portion (83%) of the budget for PROSAGUAS is designated for the design 
and construction of water supply and sanitation infrastructure for the beneficiary 
population. The water supply systems proposed for this project cover a wide range of 
technologies and service levels. Water sources are, for the most part, either capped 
springs or deep underground aquifers. Construction of new systems is the norm, but in 
some cases, rehabilitation of very deficient existing water supply systems has been 
undertaken. Water delivery is piped, either through a gravity-fed system or from a 
storage tank to which water has been pumped using an electric motor. Water supply 
systems may consist of household connections, public tap connections, or, less 
frequently, hand pumps. The PROSAGUAS design standard for level of service is 
metered household water connections with water available 24 hours a day, 7 days a week 
(actual availability varies depending on community decisions regarding how long to run 
the pumps). The amount of water consumed per household varies according to user 
preference and willingness to pay; all household connections are metered, and tariff rates 
are based on the level of consumption, with increased unit cost as volume goes up (i.e., 
the more water consumed, the more expensive it becomes per cubic meter). The 
sanitation technology proposed to for this project is household latrine. The construction 
can be either a ventilated improved pit (VIP) latrine or dry compost latrine (letrinas 
aboneras). 
To assure long-term sustainability of the water supply systems, this component includes 
(1) training of water committees before, during, and after the construction phase and (2) 
the creation and legalization of a formal water users’ association with its own board of 
directors (also known as “the water management board”). Training related to 
construction, operations, utilization, maintenance, tariff setting, collection and 
administration of the systems is provided. 
4.5.2 Objectives and Indicators
The following program objectives, presented in the PROSAGUAS proposal, relate to 
water supply and sanitation infrastructure:
Objective 1: To increase access to potable water supplies. The target is to provide 
access to potable water to approximately 45,000 persons.
Objective 2: To ensure sustainable water supplies via adequate operation, 
maintenance, and administration. This objective is measured by the number of water 
management boards that have been created and are functioning in a sound and effective 
manner. 
41
Objective 4: To increase access to latrines. The target is to provide access to 
improved latrines to the 45,000 persons who will be gain access to water through 
objective 1. 
4.5.3 Findings
Based on data provided to the Evaluation Team, PROSAGUAS is on track to achieve all 
of the expected results for these objectives. According to staff members (and supported 
by their quarterly reports to USAID), PROSAGUAS is ahead of schedule in reaching the 
planned 45,000 beneficiaries for both water supply and sanitation. The program may 
indeed be able to surpass its targets within the project period. As of July 2000 (when 
60% of the project period had elapsed), PROSAGUAS had achieved 86% of its goal for 
latrine construction and 68% of its goal for water supply access. In addition only spent 
61% of the $9.05 million grant funds from USAID and 51% of the CARE and 
counterpart matching funds had been spent as of that date. 
Water Users’ Associations and Water Management Boards
The water users’ associations and their respective water management boards for all 
constructed water systems have been formed and are in appropriate stages of 
development, consistent with the time when construction of each system was completed. 
Water users’ associations from the first projects completed through PROSAGUAS have 
been formalized and legalized; members have been trained; and the boards are fully 
operational and largely independent of CARE. An important and surprising finding of 
the Evaluation Team is that beyond the traditional concept of creating rural water 
management committees, the PROSAGUAS program is effectively creating private, 
small-scale community-run utilities that are being operated based on sound business 
principles. Most of the “utilities” visited had full-time staff, including between one and 
three plumbers, meter readers, health promoters, computer operators , and even 
administrators. Many of the “utilities” are making long-term investments in land (for 
future well sites, for example) and in the construction of offices and community meeting 
centers. Even in communities with systems in operation for only a year, significant 
savings have already been accumulated. For example, the Moncagua “utility” already 
had over 140,000 colones in savings after little more than a year of operation. It is clear 
that the water management boards understand that they need to set adequate tariff rates 
and objectively enforce payment of water bills in order to ensure that they will be able to 
operate, maintain, and repair the systems as needed. In addition, many of the water 
management boards have set significant connection fees that help capitalize the “utility” 
and strengthen their capacity to expand the system to new users/consumers. It is telling 
that the one exception to this that the Evaluation Team observed was in the Nueva 
Esperanza community where the municipality is managing the water system and has 
lowered the tariff rates from those originally set and has not enforced monthly payments 
of water bills. The result is that the system is running at a financial loss. 
42
Technology Choice for Water Supply
At first glance, the water supply technologies incorporated in the PROSAGUAS program 
tend to be more sophisticated than might be considered appropriate for rural areas. Two 
out of the nine systems built to date use capped springs as a source of water; the other 
seven tap deep aquifers (200 to 300 feet) with electric-powered pumps. However, several 
factors affect the choice of water supply technologies in El Salvador, Regional water 
scarcity and extensive contamination of surface waters, limited availability of shallow 
aquifers, households’ willingness and ability to pay for water connections, high 
population density, and high coverage of rural electrification often make deep wells with 
electric pumps or long-distance piping of water feasible alternatives. Given those 
conditions, it does appear that the choice of technology and level of service under the 
PROSAGUAS program is, by and large, appropriate and sustainable, especially when 
packaged with training for operations and maintenance and where the water management 
boards understand the importance of appropriate tariff rates and metering. Completed 
community water systems, such as those found in Istagua and Moncagua, are relatively 
sophisticated, yet the water management boards and their staff seem perfectly capable, 
both financially and technically, of operating, maintaining and, when needed, repairing 
their systems. This operational capacity also includes knowledge and willingness to 
contract with the private sector for engineering services, supplies, and replacement parts 
when needed. The team noted, however, that in some communities, there is lingering 
suspicion of the private sector. 
The technologies chosen by the PROSAGUAS engineering staff, although suitable given 
the prevailing hydrological and physical conditions, may nonetheless be a bit too 
sophisticated for the intended target group of poor rural communities to operate and 
manage. Of particular concern is the occasional use of imported equipment and 
materials, reliance on grid electricity, and the high cost per beneficiary. In these 
situations, the communities may need more outside assistance in the long term. An 
example of this would be El Señor (built under the Phase I programs) where the water 
management board was not aware that the electric pump had been imported because of 
special design features.
PROSAGUAS has a fairly explicit norm that the level of service is determined to a large 
extent by water source availability. In addition, early in an intervention, PROSAGUAS 
staff carry out a technical and social feasibility study to determine level of service and 
community and household willingness and ability to pay. To date, PROSAGUAS studies 
have shown that in all communities, the target beneficiaries want household connections 
and are willing and able to pay for them. Thus, all nine of the systems built by 
PROSAGUAS to date provide household level connections 
In the more “urbanized” rural communities, the studies found that before the program 
was introduced, the general practice was for households to buy water by the barrel from 
private vendors, paying significantly higher costs than the newly established tariffs under 
the PROSAGUAS program. An approximate calculation of the pre-project average 
monthly household water bill was 45 to 65 colones for about 15 cubic meters of water (75 
43
barrels). Most of the families reported buying a minimum of 2 barrels per day, with 
costs ranging from 5 to 20 colones per barrel. Even at the low end of the scale, a family 
that bought 2 barrels per day for 30 days at 5 colones/barrel would need to pay 10 
colones per day or 300 colones over a 1-month period. It is clear that both poor rural and 
urban Salvadorans have accepted the principle that water is an economic good and are 
more than willing to pay a fair tariff for it as long as they are getting the service. 
Along with household connections, all PROSAGUAS systems include household meters, 
and, where possible, CARE will try to retrofit meters into Phase I systems. Although 
worldwide experience suggests that the use of household meters can cause problems with 
long-term sustainability and reliability (e.g., frequent breakdown of meters, false readings 
of water consumption as air goes through the system when there is not a steady flow of 
water 24 hours a day), their use in PROSAGUAS appears to be effective. It provides an 
increasing block tariff structure which fosters efficiency and equity of water use and 
assures the financial health of the water users’ association.
For water systems that involve pumping (either from wells or to storage tanks), project 
sustainability is highly dependent on relatively low-priced (i.e., subsidized) electricity. If 
electric subsidies cease, as is rumored, many communities will find it increasingly 
difficult to pay for continued operation of their systems. Tariffs may need to be increased 
to levels that are beyond the communities’ ability to pay. The Evaluation Team felt that 
this is a vulnerable area for the long-term health of these systems. 
Most systems have been designed for systemwide disinfection (chlorination), with no 
disinfection at the household level. Normally, piped systems that are disinfected at the 
point of distribution and have household connections provide a significant level of 
protection against contamination. Unfortunately, much of this protection may be at risk 
due to the widespread practices of storing water in large potentially unprotected 
household storage tanks as well as storing drinking water in unprotected drinking water 
containers. 
Technology Choice for Sanitation
PROSAGUAS systems support only VIP or compost latrines. No sewered systems, 
septic tanks, or the like are considered. The team concluded that both the VIP and 
compost latrines are appropriate for the rural sites. PROSAGUAS’s gaining user 
acceptance of the compost latrines is particularly notable, given negative history of that 
option in El Salvador and other countries. (Most of the “compost” latrines observed by 
the Evaluation Team, however, were being used simply as elevated pit latrines, with 
households making no use of the composted material.) Nevertheless, the program’s 
limitation on sanitation options is somewhat inconsistent with the more urbanized 
strategy of providing household water connections, since provisions of such connections 
results in relatively high levels of water consumption and generation of graywater and, 
increasingly, wastewater. 
44
PROSAGUAS staff note that households and communities typically do not demand 
improved sanitation. It is not a high priority to them. To assure improved sanitation, the 
program makes construction or improvement of latrines a pre-condition for construction 
of the water system. While the Evaluation Team recognizes that sanitation may not be a 
perceived as a high priority need by many households, it also feels that the 
PROSAGUAS strategy of providing close to a 100% subsidy and actually building 
latrines for the beneficiary families is not the most appropriate or effective use of 
program funds—it represents too high a level of subsidy and is a paternalistic approach. 
Operation and Maintenance: System Management and Administration
Water management boards appear to be very aware of their roles and responsibilities with 
respect to water system management and generally take their duties very seriously. 
Essentially, these boards are administering small, unregulated water utilities. With the 
exception of municipal audits (in theory at least) and MOH monitoring of chlorine 
residual, there is no oversight or reporting requirement. Water management boards are 
free to set and modify tariffs, subject only to community approval; they can cut off 
service to consumers in arrears, are under no obligation to expand service, and can decide 
the level of service and who can become new members. As the population of 
communities with such community-run water utilities increases, there may be obvious 
inequities/disparities in tariff structure for adjacent communities. This may seem 
immaterial at the moment, but could cause problems in the future. In Corinto, for 
example, one of the five communities in the municipal seat is not part of the 
PROSAGUAS program and pays different fees and has a different relationship with the 
municipal government from the other four.
4.5.4 Conclusions and Recommendations
The overall conclusion regarding the PROSAGUAS water supply and sanitation systems 
is that the program is successfully reaching its numerical targets with technologies that 
are, for the most part, appropriate, well designed, and well constructed. Given the rural￾urban range of program sites, however, PROSAGUAS water technologies are more 
appropriate for more urbanized areas, and the sanitation technologies are more 
appropriate for the rural areas. The Evaluation Team also concluded that the 
PROSAGUAS strategy of installing household meters, setting appropriate tariff rates, and 
training the water management board members has been extremely effective in creating 
small-scale utilities with an entrepreneurial vision. These boards are likely to be able to 
operate, maintain, and even expand their systems into the future. 
Specific recommendations are given below:
· Sanitation Options. Broaden the PROSAGUAS menu of sanitation options to 
include technologies that are more appropriate for urbanized and urbanizing areas and 
for households with water connections where consumption increases significantly. 
Part of the process for broadening the technical options should include an assessment 
45
of the hardware and software costs of the current latrine choices so they can be 
compared to other options such as flush toilets, small-bore sewer systems, and 
primary wastewater treatment plants. Another aspect that should be investigated is 
the collection and handling of the sludge produced by VIP latrines or the compost 
produced by the compost latrines, if use as fertilizer is not a viable option. When 
these types of latrines are used in urban areas, a plan must be in place, with costs 
calculated, for sludge removal and management. It is also recommended that CARE 
investigate the information available on alternative systems for wastewater collection 
and treatment. Much of that information is being collected by EHP in Washington 
and is available free. It is also recommended that CARE explore the potential use of 
the WAWTTAR software program (Water and Wastewater Treatment Technologies 
Appropriate for Reuse) developed by EHP. (CARE engineering staff in DASAGUAS 
have a copy of this material.)
· Wastewater. A related recommendation is that CARE staff begin to assess the 
financial and management impact of the need in the foreseeable future to introduce 
wastewater services. A wastewater or graywater collection and treatment system will 
have to be managed by either the water users’ associations created by PROSAGUAS, 
the municipality, or ANDA. The management options will need to be compatible 
with the operations and management of the water systems, as it may be difficult to 
separate the two. Costs for operation and management of collection and treatment 
systems and additional tariffs will also need to be assessed by the PROSAGUAS 
communities as they move forward. Given the limited experience in the country with 
this issue (as opposed to O&M of water systems), dealing with graywater and 
wastewater will be breaking new grounds. 
· Small Utility Benchmarks. Develop and promote the use of benchmarks that reflect 
the health of small-scale community-run utilities (as opposed the more traditional 
benchmarks used for rural water management boards). Examples of such benchmarks 
include percent of water leakage or loss (which becomes feasible for PROSAGUAS 
projects with macro and household water meters and sophisticated accounting 
software), number of utility employees per household connection, number of 
consumer complaints per month, number of new connections per month or year, 
billing status, etc. A list of utility benchmarks (in Spanish) developed by the World 
Bank is included as Appendix I. The benchmarks could be used by the water 
management board to measure how well they are doing as well as by PROSAGUAS, 
local municipalities, or ANDA to monitor progress and provide overall technical 
assistance. This process should be initiated in all PROSAGUAS projects as soon as 
possible . 
· Costs per Beneficiary. PROSAGUAS staff should be more rigorous in calculating 
and documenting the full costs for both the water and sanitation systems by specific 
project sites. This information will be useful for better understanding the costs per 
beneficiary under different conditions (i.e., in areas of disbursed rural populations, 
deep aquifers, and dense urban settings, etc.).
46
· Subsidies. PROSAGUAS should take a more careful look at the subsidies that are 
currently being provided equally to all project beneficiaries. It might be possible to 
reduce subsidy levels in the more urbanized areas. 
4.6 Environment and Source Water Protection
4.6.1 Introduction and Definition
Protection of the source of drinking water is a major element for the long-term 
sustainability of a water system. Sound management of the micro-watershed can help 
ensure continued quantity and quality of water for the future. In a country such as El 
Salvador, where over 90% of the surface water sources are highly contaminated and 
water shortages are frequent, source water protection programs are even more critical. 
The types of activities being implemented under this PROSAGUAS objective include 
formation of an environmental committee in each community, training and capacity￾building for the environmental committee as well as the water management board, 
reforestation (including the establishment of nurseries), environmental education in 
schools, and programs for soil conservation and reduction in sources of water 
contamination.
4.6.2 Objectives and Indicators
The program objective for the environment component is:
Objective 3: to ensure the sustainability of water sources via micro-watershed 
management.
Five indicators track the progress of activities under Objective 3:
· Percentage of committees and water management boards receiving 
training/information in watershed protection.
· Training in soil and water conservation measures for small-scale farmers working in 
the watershed.
· Number of trees planted in reforestation programs.
· Statutes include provisions discouraging deforestation, soil erosion, and 
contamination.
· Training in watershed management provided for at least three environment committee
members in the project area.
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4.6.3 Findings
The major focus of this component is reforestation, with some element of improved 
agricultural practices. Environmental committees are established in the PROSAGUAS 
communities and seem to be functioning relatively well. Environmental education and 
other demonstration activities are increasing awareness among residents of environmental 
issues and the need to protect water sources. Istagua has established a nursery as a 
revenue-generating enterprise.
Appropriateness of Environmental Activities
Given that many of the PROSAGUAS projects are tapping deep aquifers (i.e., over 150 
feet), the original concept of adding an environmental objective to protect the project’s 
water supply source water does not appear to be effective. The environmental portion of 
the program was aimed at protecting surface water sources. Trees are being planted 
around peoples’ homes, by the community water storage tanks, or above the well site. 
While this is helpful in a general way, it does not appear to be significantly contributing 
to the objective of protecting the water source aquifers.
Even if the objective were feasible as applied, CARE recognizes that the target set for 
reforestation (835,000 trees) is unrealistic and it is not likely that it will be met.
The most pressing/immediate environmental issue actually may be the consistently poor 
handling of household drainage water from laundry basins and showers (also drainage 
and solid waste handling from backyard livestock operations). Not only do these waters 
directly contaminate receiving surface waters, but they can pose significant health 
problems at the household and community level.
4.6.4 Conclusions and Recommendations
In light of the above, the following recommendations are suggested.
· Environmental Education. PROSAGUAS should continue environmental 
education activities, especially for schoolchildren, but its efforts should be more 
targeted and/or selective, with demonstration activities, ensuring that these activities 
reflect priority issues in the watershed. Deforestation may not be the most critical 
environmental threat to a community’s water supply or to operation of the system; 
contamination from agro-chemical applications or sedimentation from poor farming 
practices may be more serious threats. Specific threats need to be identified as part of 
the initial feasibility studies.
· The Environmental Objective. USAID should consider amending the contract to 
reduce or revise the results for this objective. Even if CARE were able to meet the 
targets (which seems unlikely), meeting the reforestation goal would not notably 
contribute to the overall purpose of the project of improving health nor would it 
48
specifically contribute to source water protection. Alternatively, USAID may want to 
refocus this objective to increase attention to household graywater drainage and, 
potentially, to wastewater management (see the recommendations in the water and 
wastewater systems section above). This change in direction in the project might 
include a closer working relationship with the environmental sanitarians (inspectores
de saneamiento) currently employed by the Ministry of Health in more urban areas. 
This shift would also translate into improving coordination between health and 
environment committees to address environmental health issues at the household and 
community levels.
· USAID Environmental Regulations. Enforce compliance with USAID 
environmental regulations. The PROSAGUAS program was issued a Positive 
Determination by the LAC Bureau Environmental Officer (BEO) (LAC-IEE-97-08), 
signifying that activities to be implemented under the program may have significant 
impact on the natural environment. An Environmental Assessment (EA) evaluating 
the potential impacts of program activities was required. However, the EA prepared 
for the Phase I program (Environmental Assessment of the Public Services 
Improvement Project Component III – Water Supply, Sanitation and Health, prepared 
by WASH, February 1990) was deemed sufficient for the PROSAGUAS program, 
subject to a review of the effectiveness and continued applicability of the 
recommendations and mitigation measures proposed therein. That review, which was 
also to include a discussion of how the mitigation measures would be implemented 
and monitored, was never conducted by LAC BEO. One of the requirements of the 
EA is that all project activities involving construction and disruption to the 
environment must undergo environmental review. CARE is not aware of the 
requirement to prepare project-specific environmental impact reviews, as part of EA 
requirements, and has not done so. Moreover, although CARE is aware of the 
potential environmental harm of project implementation, there is no systematic and 
consistent approach to mitigating potential environmental impacts. For instance, 
CARE does not have construction guidelines. The Mission should work with CARE 
to develop a specific checklist that should then be used on all construction sites ( see 
WASH Reprint: Environmental Guidelines for PVOs).
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5 SUMMARY OF CONCLUSIONS
The overall conclusion of the midterm evaluation is that PROSAGUAS is successfully 
achieving its expected results. The individual sections of this report present detailed 
findings and conclusions for each program component. This section summarizes the 
most noteworthy accomplishments of the program, as well as some areas of concern.
5.1 Major Accomplishments
Diarrhea prevention. In the three project sites (Conchagua, Moncagua, and Istagua) 
where pre- and post-project data have been collected, there have been substantial 
reductions in the prevalence of diarrhea in children under five years. The baseline and 
follow-up surveys were performed in the same season—dry or rainy season. In La 
Esperanza (Conchagua), diarrhea prevalence dropped from 33% in 1998 to 6.2% in 1999 
(an 81.2% reduction) ; and in Moncagua from 14% in 1998 to 4.4% in 1999 (a 68.5% 
reduction), both of these measured in the rainy season. In Istagua, there was a decrease 
in prevalence, measured in the dry season, from 14% in 1998 to 8.5% in 2000 (a 39% 
reduction). 
Water and sanitation coverage. PROSAGUAS is ahead of schedule in reaching the 
planned number of beneficiaries, 45,000, for both water supply and sanitation. 
Moreover, at the current rate of progress, the program will have significant savings in 
both funding and time. 
Improved household hygiene practices. PROSAGUAS has reached 45% of its target 
of 9,000 households to be trained in improved hygiene practices, according to program 
data. In general the Evaluation Team found that considerable progress has been made in 
the overall health component. The health and hygiene interventions are having a positive 
impact as evidenced in awareness of health issues, improved hygiene practices; and 
changes in behavior among the target population. The program methodology is generally 
appropriate and effective, and coordination with local and departmental MOH staff is 
good.
Strengthened local capacity. The program has been successful in working with and 
building on existing organizational structures in the communities, primarily through the 
Community Development Associations (ADESCOs) and the municipalities. The 
ADESCOs are usually the point of contact for PROSAGUAS in the community. In 
addition to selecting members of the various committees, these local community 
associations have collaborated in a variety of ways with the water users’ associations. 
For the most part, municipalities have also supported the program by providing land or 
otherwise collaborating in establishing the water systems. They have given legal 
standing to water management boards and audited financial records of the water systems. 
Striving for a consistent and constructive role for municipal authorities in oversight, 
monitoring, and support for the water users’ associations and water management boards 
50
is important in ensuring their sustainability. The community management structures 
created are viable and effective, and should be able to ensure sustainable operation of the 
water supply systems. Regarding the inclusion of women, substantial progress has been 
made in increasing the participation of women in organizational and management 
structures. However, while the number is impressive, women have not generally held 
positions with power or decision-making authority.
Development of small-scale utilities. The Evaluation Team was impressed by the fact 
that PROSAGUAS has in effect created small, not-for-profit water utility companies run 
by the community, with paid employees and other attributes of a commercial enterprise, 
at least in the larger water systems. This entrepreneurial character should contribute 
greatly to the sustainability and possibility for expansion of these systems to serve more 
people, within the limitations of their respective water sources.
Sustainability of water and sanitation systems and benefits. The systems created 
under the current phase of PROSAGUAS have a more business-like orientation than 
those initiated under Phase I. The newer projects also benefit from greater emphasis on 
community organization and education. These changes should enhance sustainability to 
an even greater degree than observed in the earlier projects, which have already 
demonstrated a high degree of sustainability in spite of the problems encountered. The 
health education component in PROSAGUAS project communities, together with 
provisions for follow-on after the project implementation period, is likely to result in 
sustained health benefits. 
Effectiveness and replicability of an integrated approach. The foregoing 
accomplishments demonstrate that the integrated approach used by PROSAGUAS is 
effective, particularly in its focus on improved health as the unifying purpose for water, 
sanitation, organizational, and educational interventions. The program also benefits from 
its increased emphasis on women’s participation and effective community administration 
and management. Overall the EHP team found that PROSAGUAS has achieved an 
appropriate balance between meeting physical outputs under the agreement and investing 
in the qualitative, or “software,” aspects of project implementation. It is premature to 
draw any firm conclusions with regard to the sustainability of Phase II projects, but the 
likelihood of success and sustainability is validated to a certain extent by the generally 
strong performance of Phase I community-managed systems. 
Sound program management and administration. The Evaluation Team concludes 
that in general the PROSAGUAS program is being well managed and administered, with 
a high-quality, dedicated professional staff at both central and field levels. As USAID’s 
partner in the PROSAGUAS activity, CARE has successfully put into place sound 
financial, accounting, and reporting systems which enable close monitoring of program 
activities and progress. Furthermore, CARE has successfully managed to scale up 
operations to include two new USAID cooperative agreements last year (MAS and 
AGUA), without having significant negative impact on the PROSAGUAS program. 
PROSAGUAS has also been noteworthy for the degree to which it has been able to 
leverage funding from other donors, ANDA, and the municipalities.
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5.2 Areas of Concern
Project selection trend toward more urban areas. In the first two years of 
PROSAGUAS, the final community selection process has favored selection of larger, 
semi-urban communities, which generally have greater access to various resources. 
While providing services to these types of communities is not without merit, this trend 
represents a distancing from the original target population of the program—those living 
in areas of rural poverty, in communities of generally less than 2,000 inhabitants. 
Use if monitoring and evaluation data. The monitoring and reporting system 
established by PROSAGUAS has been very effective in gathering information and data 
which are then fed into quarterly and annual progress reports for USAID. The monitoring 
of diarrheal prevalence and follow-up evaluations of progress against baseline studies, 
however, have not been used for program planning and management purposes, at least in 
part because of the time lag between data collection, analysis, and availability to program 
staff. Even more seriously, in terms of achieving program health goals, the information 
has not been made available to the communities where it was collected, greatly 
hampering awareness of problems and actions to resolve them.
Inadequate process documentation. Replicability of the PROSAGUAS model will 
depend to a great extent on process documentation which makes clear why and how the 
program has developed as it has. This is particularly important in the “software” areas of 
community organization, equitable and effective participation by gender and other social 
variables, and the health education/behavior change process. 
Adequacy of community involvement in initial design and construction decisions. 
Respondents, especially from Phase I projects, indicated that they had not been 
adequately involved in early decisions and were not well-informed on design, equipment, 
and cost considerations of their systems, making it difficult for them to act effectively in 
repairing or replacing elements later on or in expanding systems to increase coverage. 
While PROSAGUAS has addressed these issues to a greater extent than the earlier 
projects, for long-term sustainability, it is crucial to ensure that water committees and 
administrative/water boards are fully involved in and understand all key decisions during 
the design and construction process.
Targeting of health and sanitation education. The Evaluation Team felt that the 
program attempts to touch upon a very wide range of health issues; the range may be too 
much for the target population to fully absorb. To bring about behavior change, the 
health education messages need to focus on the most important high-risk behaviors with 
regard to diarrhea reduction. The messages must be tailored to specific audiences and 
frequently reinforced. The team found that the health education materials being used are 
not necessarily appropriate for all target groups. The materials and methodologies used 
must be as appropriate as possible to both urban and rural target populations in order to 
achieve the desired health objectives of the program.
52
Appropriateness of sanitation options for urban and semi-urban areas. Currently 
PROSAGUAS supports only VIP or compost latrines, which are appropriate for rural 
areas, but are likely to become increasingly less appropriate in rapidly urbanizing areas. 
This discrepancy will be especially evident with the increased number of household water 
connections. Inevitably, the demand will grow for pour-flush or flush toilet systems, 
which will require septic tanks or sewage systems. Communities will also need a means 
to address the graywater problem, which already exists but will increase in the future.
Documentation of real costs and subsidies for water and sanitation systems. It is 
important to document the full costs for both water and sanitation by project sites, in 
order to calculate the real cost per beneficiary under different conditions. It is also 
important to calculate, and where possible reduce or apply subsidies using a sliding scale, 
in order to enhance both sustainability and replicability of the PROSAGUAS model.
Unmet environmental objectives. Progress has been much slower than expected in 
achieving the targets in the environmental component of the project. It is obvious that 
PROSAGUAS will not meet the goal with relation to tree planting. The Evaluation Team 
is of the opinion that the program’s efforts in source-water protection are somewhat 
inappropriate, given that only two of the nine systems constructed rely on surface water 
or spring catchment, sources with a clearly defined micro-watershed. The focus of 
attention on tree-planting and soil erosion control activities in the program has tended to 
obscure the much more immediate environmental concerns with poor, or non-existent, 
drainage and the growing problem of graywater discharge in the more densely populated 
semi-urban communities. 
Furthermore, USAID environmental impact regulations are not currently being met.
Lack of long-term technical assistance. A trustworthy source of engineering, 
administrative, organizational, and legal assistance is needed to support the water boards 
once the 18-month project period is completed. This factor affects the long-term 
sustainability of the water systems. Its effect is most evident on Phase I systems, which 
are older and most of which had a less-thorough organizational and training process than 
the PROSAGUAS projects. Nonetheless, as time goes on, most systems will likely face 
problems they will find difficult to resolve on their own. Some type of support 
mechanism, or clearinghouse, through which communities can get access to reliable 
sources of information or referral to other organizations is clearly needed. There are 
several possibilities to explore for this support mechanism, including ANDA, the MOH, 
municipal governments, NGOs, and the private sector, or a combination of these 
organizations and institutions working together in association. What is certain is that this 
issue is an important one for sustaining the benefits of USAID’s investment of tens of 
millions of dollars. The need may be in the future for some project communities, but 
both USAID and CARE need to begin considering how to address the issue now. 
Limited success in achieving synergy with other USAID-supported programs and 
strategic objectives. While there has been some collaboration with related projects, such 
53
as AGUA and MAS, synergies could be greatly increased, to the benefit of all programs. 
There has been less collaboration with the local development project implemented by 
RTI under USAID’s democracy SO.
54
6 RECOMMENDATIONS
This section brings together and summarizes the recommendations relating to the 
individual components of the PROSAGUAS program. Some of the recommendations are 
directed to CARE for consideration during implementation of the second half of 
PROSAGUAS, and some are directed to USAID for consideration in the same 
program—either for possible modification of the current PROSAGUAS program or for 
design of similar programs and activities in the future, in El Salvador or regionally. More 
details regarding these recommendations can be found in the earlier chapters.
6.1 Recommendations for CARE
PROSAGUAS Program Management
· Program Monitoring. Program monitoring data should be analyzed and 
disseminated in a more timely manner. The results should be used to inform 
management decisions and adjust program direction and focus as necessary. The 
analysis of data should concentrate on qualitative aspects of program performance as 
well as numerical progress. 
· Financial Tracking. The new FIS-SCALA financial information management 
system should be used for greater flexibility in tracking and analysis of financial data. 
The Evaluation Team specifically recommends that PROSAGUAS configure the new 
system to allow the calculation of costs per system and costs per beneficiary by 
system or latrine type. This calculation should be able to differentiate between direct 
and indirect program costs, other cash contributions, and in-kind contributions 
(materials and labor). Reaching that level of detail is critical for CARE if the 
organization is to engage in the policy reform process regarding the water sector with 
ANDA or other international agencies. Transparent and credible financial data will 
be an important part of informing this debate at the national level. 
· Internal Communications. PROSAGUAS management should look for ways to 
improve the lines of communication between field-level staff across the three regional 
offices. Field-level staff (and thereby the program) would benefit by having regular 
meetings to share experiences with each other and to discuss innovation and 
approaches to use within the program.
· Policy Dialogue. PROSAGUAS should maintain the positive engagement it has 
achieved with ANDA and become active in the policy debate with regard to water 
sector reform. PROSAGUAS experience could be used as a model in the debate, as 
far as is possible within the existing program terms of reference set out by USAID. 
55
Community-Level Project Management
· Documentation and Dissemination of Methodology. PROSAGUAS’s current 
strategy document does not yet address all issues in a systematic way. CARE should 
be encouraged to complete that important document which would be useful both for 
internal consistency of approach (“institutional memory”) and as a contribution to the 
wider dissemination of PROSAGUAS’s experience to a broad national or even 
regional audience. 
· Community-Level Monitoring. Monitoring data currently collected by 
PROSAGUAS should be made available to both the field staff at the regional level 
and the communities and individual households, so that they can be active 
participants in resolving their own problems and replicating successful interventions. 
Efforts should be made to reduce to a minimum the time it takes to give feedback.
· Community Selection Criteria. In the second half of the program, the selection 
process for new communities sites should be based on an integration of relevant 
health and poverty indicators and the existing levels of water and sanitation coverage 
(especially for rural areas). PROSAGUAS management staff should work together 
with ANDA and MOH in identifying high priority regions and municipalities. 
Community Organization
· Community Involvement in Design and Implementation. Involvement by water 
committees in project design and implementation should be strengthened, so that 
these committees and administrative/water boards are fully involved in decisions and 
are familiar with the equipment used, the reasons for project design and technology 
choices, and cost and source of equipment and materials, to facilitate maintenance, 
repair and system expansion.
· Process Documentation. Improved documentation of the community 
organization/participation process, including participation by gender, would 
contribute greatly to replicability of the project. Documentation should describe and 
analyze the process of organization, including identifying constraints to participation 
by gender and other factors (especially poverty); participation by young people 
should also be reviewed. The documentation should give examples of how 
constraints have been addressed; how communities (by gender) participate in 
decision-making throughout the project, and if or how the level of participation 
changes during the implementation period. It would also be helpful to track levels of 
participation after the implementation period has been completed, effectiveness of 
provisions for follow-up on health and environmental conditions, and the local 
management of the water system.
56
Health Education
Health Monitoring and Evaluation. The health monitoring and evaluation system 
should be refocused to include greater analysis of health results and investigate 
reasons for unexpected results. Health information should be synthesized and given 
to the community promoter, if there is one, and to the MOH promoter, 
administrative/water board, and CARE staff for possible follow-up, especially if 
problematic situations emerge which require further intervention. It would also be 
useful if the monitoring/ evaluation system could be adapted to track changes in key 
behaviors identified in the KAP surveys. A limited number of longitudinal studies 
may be useful in determining program impact on health-related behavior.
KAP Studies. Program staff should revise the KAP surveys to identify the most 
important, highest-risk behaviors related to diarrhea incidence, prevalence, and 
mortality. The findings should be used to prioritize a few key behaviors, and focus 
educational interventions on changing those behaviors, with frequent reinforcement.
· Educational Methodologies and Materials. The PROSAGUAS staff should 
carefully assess the effectiveness of the currently rural-focused educational 
methodologies and materials in urban and semi-urban settings; adapt and revise the 
methodologies and materials as necessary.. Such revision would be a wise use for 
any “surplus” funds, as these “software” components are as important to program 
success as “hardware” investments. The program should document any 
methodological or materials revisions it makes; these revised materials should be 
made available for replication for future urban projects.
Water Supply and Sanitation Infrastructure
· Sanitation Options. The choice of sanitation options available under the program 
should be broadened to include technologies more appropriate for urbanized areas 
and for households with water connections. PROSAGUAS staff should assess the 
hardware and software costs of the current latrine choices and compare them with 
other options such as flush toilets, small-bore sewer systems and primary wastewater 
treatment plants. PROSAGUAS should also investigate the collection and handling of 
the sludge produced by VIP latrines or the compost produced by the compost latrines. 
PROSAGUAS should review information on alternative wastewater collection and 
treatment, much of which is freely available from EHP in Washington. 
PROSAGUAS should also explore the potential use of the WAWTTAR software 
(Water and Wastewater Treatment Technologies Appropriate for Reuse) developed 
by EHP, which DASAGUAS has.
· Wastewater. PROSAGUAS should begin to assess the financial and management 
aspects of the inevitable and upcoming need for providing wastewater services. At 
present, the latrine sanitation systems are managed at the household level (with 
varying degrees of success). A wastewater or graywater collection and treatment 
system will need to be managed by either the administrative/water boards created by 
57
PROSAGUAS, by municipalities, or by ANDA. These management options will 
need to be compatible with management of water systems. Operational and 
management costs and additional tariffs will also need to be considered by 
PROSAGUAS as it moves forward. 
· Benchmarks for Small-scale Utilities. PROSAGUAS should develop and promote 
the use of benchmarks that reflect the health of small-scale community-run utilities 
(as opposed to the more traditional rural water management boards). The 
benchmarks could be used by the water management board to assess how well they 
are doing, as well as by PROSAGUAS staff or ANDA to monitor progress and 
provide technical assistance. Use of such benchmarks should be initiated in all 
PROSAGUAS projects.
· Costs. PROSAGUAS should calculate and document the full costs for both the water 
and sanitation systems by specific project sites. That information will be useful for 
understanding the costs per beneficiary under different conditions (i.e., dispersed 
rural or dense urban populations, deep aquifers or capped springs, etc.). 
· Subsidies. The subsidy for construction of latrines should be reduced. There should 
also be a reduction of subsidies per household for water supply, based on community 
income levels, e.g., in general terms, the subsidy should be less in urban areas and 
greater in rural areas. PROSAGUAS should try to implement such a sliding scale for 
subsidies during the remaining program period.
Environment and Source Water Protection
· Environmental Education. The program should continue environmental education 
activities, especially for schoolchildren. Environmental messages, along with 
demonstration activities, should be more targeted and selective, however, ensuring 
that they reflect priority issues in the particular watershed. Deforestation may not be 
the most critical environmental threat to a specific community’s water supply or 
operation of the system. The most serious factor might be contamination from agro￾chemicals or sedimentation from poor farming practices, for example.
6.2 Specific Recommendations for USAID in the Second Half of 
PROSAGUAS
· The Environmental Objective. USAID should consider amending the contract to 
reduce or revise the results for this objective. Even if PROSAGUAS were able to 
meet the targets, that would not notably contribute to the overall purpose of the 
project—improving health—nor would it specifically contribute to source water 
protection. Alternatively, USAID may want to reduce and/or refocus this objective to 
increase attention and action towards household graywater drainage and, potentially, 
wastewater management (see the recommendations in the water and wastewater 
systems section above). 
58
· USAID Environmental Regulations. The Evaluation Team recommends that 
USAID enforce compliance with its own environmental regulations and work with 
PROSAGUAS to develop a specific environmental checklist that can be used on all 
construction sites and in all beneficiary communities. 
6.3 Broader Issues for USAID to Consider with regard to PROSAGUAS
· Urban vs. Rural. The majority of projects implemented during the first two years of 
the PROSAGUAS program serve populations living in what can be described as 
small towns or peri-urban areas (referred to as “semi-urban” in El Salvador), rather 
than truly rural. The reasons for working in these communities are clearly understood 
and appreciated by the Evaluation Team. The trend, however, toward working with 
larger projects and providing service for more urban populations is not consistent 
with the Mission’s rural poverty criteria. Therefore the team suggests that USAID 
consider the consequences of this issue as it relates more generally to addressing rural 
poverty. 
· Rural Water Sector Reform. At present there is no coherent engagement by 
USAID with the GOES and other stakeholders regarding reform of the rural WS&S 
sector. USAID is one of the most important donors in the rural sector, and CARE is 
probably the biggest single implementing agency and certainly has some of the best 
experience (in terms of both engineering and software) in the country. As a result of 
the current sector reform process, there is now the real potential for fundamental and 
positive change, and it would be very beneficial if USAID and CARE’s rural 
experience and knowledge are used to inform this debate nationally. By contributing 
to the development of a sound rural WS&S sector, USAID will also benefit by being 
able to replicate and scale up the PROSAGUAS experience.
6.4 Opportunities for Use of “Surplus” Funds
In the first two years of the program, PROSAGUAS has made rapid progress toward 
meeting its stated numerical targets for provision of WS&S services. (This has occurred 
partly from working in more densely populated “semi-urban” communities than was 
originally planned.) Given this pace, there is the real possibility that a considerable 
amount of funds will remain in the budget even after all targets have been met. The 
Evaluation Team has identified the following possible options for reprogramming 
“surplus”funds; the list is not exhaustive and these suggestions are not presented in a 
particular order of priority: 
· Add Projects and Beneficiaries. Perhaps the most straightforward option is to 
continue working with the successful PROSAGUAS approach and simply add to the 
number of WS&S projects and beneficiaries reached under this current cooperative 
59
agreement. PROSAGUAS staff suggest that they could reach as many as 55,000 
beneficiaries (10,000 more than the current 45,000 target).
· Complement the AGUA Project. Another possibility is to use resources from the 
PROSAGUAS program (human, logistical, and material) to provide a sanitation and 
hygiene component to the AGUA project under the SO4, which would go a long way 
to maximizing the environmental health benefits of that program. 
· Support Development of Rural WS&S Norms. Resources could also be diverted to 
work together with ANDA and the Water Supply and Sanitation Network (“Red 
Nacional”) to develop coherent and viable guidelines and norms for rural WS&S that 
could then be used by other donors, NGOs, municipalities, and ANDA itself.
· Help Develop Permanent Technical Assistance Capacity. Provide technical 
assistance to local municipalities, ANDA, the Ministry of Health, and possibly others 
to begin to develop a national technical support program for community-managed or 
small municipal water systems (e.g., develop an entity which could supply 
engineering, administrative, legal, and health technical assistance, or, alternatively, 
create a clearinghouse of sources of technical assistance in the public and private 
sector which these small systems could call upon). 
6.5 Recommendations for Future USAID/El Salvador Strategy
USAID/El Salvador has a relatively long history of working in and financing water 
supply and sanitation programs to improve health and has distinguished itself by the 
success of its programs. Water supply is today and will continue for the foreseeable 
future to be a very high priority for the Government and people of El Salvador. 
Especially in light of the success of the PROSAGUAS program, the EHP Evaluation 
Team unequivocally recommends that the Mission continue to support water supply and 
sanitation programs in its future five-year strategy. If the Mission does decide to 
continue to support water supply and sanitation programs, the EHP team makes these 
additional recommendations:
· Maintain an Integrated Focus. USAID programs should maintain an integrated 
approach which joins water, sanitation and hygiene/health elements. Trying to 
implement programs with just one or two of those elements would greatly reduce the 
benefits of USAID’s efforts to date. Continuing to use an integrated approach will be 
particularly important if the Mission chooses to implement water programs in the 
future through a Strategic Objective team other than the Health SO team. 
· Improve Integration with Health. If future Mission water programs are 
implemented through other SO teams or even if such programming remains within 
the Health SO, the Mission should seek to improve integration of WS&S efforts with 
other Mission health programs and to look for opportunities for synergy in achieving 
health impacts and preventing disease.
60
· Broaden Poverty Focus. Given the clear demographic trends within El Salvador, it 
will soon be a largely urban country. The Mission should consider explicitly 
broadening its poverty focus to include the urban poor.
APPENDICES 
A. Scope of Work 
B. Persons Interviewed 
C. Question Guide for Previous Phase WS&S Projects 
D. Question Guide for Current PROSAGUAS Projects 
E. Documents Reviewed 
F. Project Sites Visited 
G. PROSAGUAS Indicators by Objectives 
H. EHP Diarrheal Disease Prevention Indicators 
I. World Bank Utility Benchmark Indicators 
Appendices p. 1 
Appendix A: Scope of Work 
Revised: 6June 2000 
(note revisions from 29 March version are only in the General Timeframe section) 
EVALUATION TEAM TERMS OF REFERENCE 
Task: 
Program: 
Mid Term Evaluation of PROSAGUAS project and 
assessment of water and sanitation systems 
constructed under previous phase of Project No. 519- 
0320. 
CARE Water Supply and Sanitation Cooperative 
Agreement 
USAID Cooperative Agreement No.: 519-A-00-98-00041-00 
Grantee: CAREJEl Salvador 
General Timeframe: June 7 - August 30,2000 
Team Planning Meeting: June 22,2000 
Field Work: July 5 -July 22,2000 
Report Submittal: draft on July 21,2000 
Final: 2 weeks after receipt of Mission comments 
Level-of-Effort/El Salvador: 
Team Leader (U.S. Expatriate) 25 days 
Health EdKommunity Organization Spec 20 days 
Rural WS/S Specialist 20 days 
Eval. Team Assistant (USAID Fellow or NEP.) 20 days 
Level-of-Effort/U;S : 
Team Leader (for Final Report preparation) 5 days 
In-Country Itinerary: 
4 days in San Salvador (for briefinglevaluation team meetings 
12 days in field 
4 days in San Salvador (for debriefindreport finalization) 
Total 20 days 
Appendices p. 3 
Scope of Work: Two main aspects will be carried out under this task: 
1 - AssessmentEvahation of previous WS/S proiects. During the planning 
meeting, the team will review the following questions and possible add others to determine 
the lessons learned and sustainability of the water and sanitation systems constructed under 
previous phase of Project No. 519-0320: 
Why Health Committees organized and created during the implementation stage 
had not continued working after the NGO left the community? 
How important is it for the community that the Health Committees continue 
working or not? What long-term impact have these committees had on the community; 
what were the consequences where the committees have been discontinued? 
Why some water boards have been able to save more money than others? How 
can this practice be promoted in all locations? 
Has the approach used by USAID in the design and implementation of the water 
and sanitation systems adequate? 
Are the technologies employed for the construction of water systems appropriate? 
2) Concerning the current CARE Cooperative Agreement. Under the direction of 
the team leader, the evaluation team will examine the following key areas and answer the 
related questions: 
General: 
Has the grantee made adequate progress towards meeting overall grant 
objectives as set forth in the cooperative agreement? Do such objectives 
remain appropriate, or do they require some modfication? 
Has liaison and coordination with other agencies (donor, governmental, local 
NGO, international NGO) and other SOs been effective? How can it be 
improved? 
Have proper agreements been signed by the communities concerning 
formation of committees, establishing a fee collection mechanism, providing 
for community labor and establishing women’s involvement. 
Has the project focused adequately on the community selection criteria 
determined by USAID? 
Appendices p. 4 
Has the program been able to achieve an appropriate balance between 
meeting physical outputs under the agreement (i.e. number of wells) and 
qualitative aspects of program implementation (i.e. the extent of community 
participation, skills transfer to local staff, etc.)? 
As above, has the program been able to bridge the gap, which often exists 
between “technical” considerations (i.e. system construction), and “social” 
considerations (i.e. water use education, community organization, etc.)? 
Are appropriate monitoring systems in place to ensure adequate supervision 
of program evolution at the community level? 
Are plans and strategies for long-term sustainability appropriate? 
Is there an adequate participation by women in Community Water, 
Environmental, and Health Committees? Is gender-desegregated data being 
appropriately provided, and are gender considerations being properly 
addressed? 
Have the changes in the implementation approach of the project made 
during the current phase impact on the communities? Is it a better 
approach? 
Is this water and sanitation project implementation methodology worth to 
continue and or to be replicated by other USAID Missions or donors? 
Community Organization: 
Is the overall community organization process, as well as specific programs 
and methodologies appropriate? These include the Water Boards, 
Community Water Committees, Community Health Committees, 
Community Environmental Committees Municipalities, etc. 
Do communities and Water Boards recognize their responsibilities with 
regard to fee collection, long-term maintenance and repair of installations? 
Is program staff training in community organization effective? What, if any, 
needs are being unmet, and what areas can be improved? 
Health Education: 
Are health education methodologies appropriate, and are they being used 
effectively? Do they appear to be having the desired impact on health 
related behavior, and are adequate systems in place for measuring this? Is 
there an effective collaboration among Health Committees and the Health 
Appendices p. 5 
Promoters from the Ministry of Health, or NGO Health Promoter? What are 
suggested areas to be improved andor supplemented? 
Are the materials developed by the program thus far appropriate (training 
documents, posters, videos, audio programs), and are they being used 
effectively? What are suggested areas to be improved and/or supplemented? 
Is program staff training in health education effective? What, if any, needs 
are being unmet, and what areas can be improved? 
Water Supply and Sanitation Systems Development: 
Are the technologies employed for the construction of water systems 
appropriate? 
Are community boards appropriately trained and prepared to independently 
undertake activities? 
Has technical staff been able to contribute effectively to social mobilization 
and education? 
Are adequate systems in place for ensuring proper use of USAID-provided 
commodities? 
Are latrine models and related programmatic interventions appropriate? 
Environmental Component: 
Is CARE adequately addressing the environmental issues and the community 
members are more conscious of the environmental problems, its 
consequences and possible solutions? 
As a result of CARE interventions, are the communities taking proper 
actions to adequately carry out the micro-watershed management? 
Program Management: 
Are sound systems in place for assuring appropriate use of USALD funds in 
the following areas: financial management, personnel management, general 
administration, and communications. 
Are reporting systems adequate for assuring dissemination of program 
information and developments. 
Appendices p. 6 
Does CARE maintain appropriate systems regarding matching fund 
contributions? 
Are adequate planning systems in place? 
How can overall program management improved? 
Core Team Member Qualifications: 
Team Leader: 15 years of experience in the management and implementation of 
water supply and sanitation programs, which emphasize community participation 
and training. Knowledge of and experience in well drilling and village-based 
construction programs. Also requires significant experience in program evaluation 
and the coordination of multi-disciplinary/multi-cultural evaluation teams. Good 
knowledge of Spanish (i.e. 3+ or better) is desirable. 
Health Education Community Organization Specialist: 7 years of experience in 
the design and implementation of international health education and community 
organization programs, with at least five years of experience with water supply and 
sanitation programs. Good knowledge of Spanish (i.e. 3+ or better) is required. 
Rural Water Supply and Sanitation Specialist: 10 years experience in 
institutional assessments, tarriff studies, cost recovery, operations and maintenance, 
customer relations and sustainability of systems. Good knowledge of Spanish (i.e. 
3+ or better). 
Logistical Support: 
The contractor is to include all necessary costs to carry out this evaluation. 
Report 
Ten days after the conclusion of the field work, the contractor shall deliver to USAID a draft 
report in English. Ten days after USAID’S review and acceptance of the draft report, ten 
bound copies of the final report in English shall be delivered to USAID/EI Salvador. 
The report shall contain an analysis of the main areas of the assessmentkvaluation and must 
respond the questions above mentioned. Also, it shall contain a conclusions and 
recommendations section 
Appendices p. 7 
The report shaI1 include the following actions: 
1) Executive summary 
2) 
3) 
4) Assessment/evaluation findings 
5) Conclusions and recommendations 
6) Lessons Learned 
7) Paginated table of contents 
Scope of work and methodology 
Composition of the Evaluation Team 
Purpose of the current CARE’S C.A. 
The purpose of this cooperative agreement is to provide additional water supply and 
sanitation for health activities to be carried out under the Amendment No. 11 to the 
Public Services Improvement Project No. 5 19-0320, and to reduce incidence of diarrheal 
diseases in children under five years by providing access to potable water supply and 
sanitation systems to the communities where the activities will be carried out. 
For the selection of the beneficial communities under this Cooperative Agreement, CARE 
should consider the following selection criteria: 
a) Selected Watersheds Areas which include eighteen municipalities as follows: San 
Francisco Menendez, Jiquilisco, Puerto El Triunfo, Tecapan, California, Usulutan, Santiago 
de Maria, San Agustin, San Francisco Javier, Ozatlan, San Dionisio, Berlin, Alegria, 
Mercedes Umana, Jujutla, Guaymango, San Pedro Puxtla and Corinto. 
Note: No more than 50 % of the available funds allocated under water and 
sanitation activities should have been invested in these watershed areas. 
b) Emphasis in rural poverty areas 
c) Leveraging funds through sharing costs with other donors 
d) Synergy with other USAlD activities 
e) Strong commitment from communitiesAoca1 governments 
f) Technical feasibility 
Besides the water and sanitation facilities that will be provided, promotion, organization, 
health, and environmental education activities will be developed by the implementing 
entity in the beneficiary communities. A participatory methodology approach will be 
utilized to make community individuals and local government authorities active 
participants in the construction, operation, utilization, maintenance, and administration of 
the potable water and sanitation facilities installed under this amendment. 
Other US AIDE1 Salvador Activities designed to increase municipal government capacity 
often include construction of water systems, but do not include community organization 
and health education activities. Where feasible, these additional activities under Project 
Appendices p. 8 
No. 519-0320 will add that component to enhance the sustainability of the systems and 
the health impact for that community. 
Objectives: 
1. 
2. 
3. 
4. 
5. 
6. 
7. 
8. 
Work in each community to organize the beneficiaries in a Water Board to 
construct, operate, utilize, maintain, and administer potable water supply and 
distribution systems. 
Work in each community to organize the beneficiaries in a Health Committee to 
promote hygiene practices including the proper use and maintenance of latrines, 
properly disposition of children’s feces, adequate storage and use of water, etc. In 
communities with a Ministry of Health (MOH) or NGO health promoter, this 
Committee will act as a permanent liaison with him or her while working in 
activities that strengthens and support the community’s appropriate health 
behaviors. 
Ensure women’s participation in this intense community organization as members 
and leaders in decision-making roles, to the maximum extent possible, on each of 
the Community Water Committees and Community Health Committees. 
Sign an agreement with each community documenting the formation of these 
Committees and the inclusion of women, identified a fee collection mechanism, 
and specified the amount and type of community labor before construction begins. 
Where appropriate and feasible, include in this organization process the 
participation of the nearby local municipality in the administration of the water 
system, or agreeing to provide technical support for future major repairs. 
Propose the most appropriate water supply and sanitation system (WS&S) 
solution in accordance with social and economic analyses of the community and a 
technical analysis. The water systems solutions may include water systems, either 
gravity or pumped; yard taps, standpipes or household hookups; drilled or hand 
dug wells; hand pumps or taps; depending on the terrain, water source and 
community. The sanitation systems solutions may include latrines, either the 
ventilated, improved pit (VIP) or composting type, depending on ground 
conditions and water-levels. 
Provide extensive water, sanitation and health education to the communities, with 
a special focus on mothers and others who care for small children, in order to 
promote appropriate hygiene behaviors that would lead to less diarrheal diseases 
and other water related infections. 
In communities with Health Promoters from the Ministry of Health or local health 
NGOs, coordinate and provide assistance to these promoters in community and 
Appendices p. 9 
individual health and hygiene education, by the sharing of information and data 
and collaboration in training activities. 
9. For the selection of the communities benefited under this Cooperative Agreement, 
CARE should consider the above mentioned selection criteria. 
10. More intensive coordination with other Mission, or USAIDWashington projects 
or other donor-assisted efforts will be instituted. The intention is to create a 
synergistic health or development effect in the community and to add health 
components to non-health Activities where beneficial. For example, Activities 
designed to increase municipal government capacity often include construction of 
water systems, but do not include community organization, health education 
activities and latrine construction. Where feasible, Project No. 5 19-0320 will add 
that component to enhance the sustainability of the systems and the health impact 
for that community. Also, intense coordination between SO4 "Increased access 
by rural house hold to clean water" and this Project will be developed. 
11. Health education and assistance in community organization will be expanded to 
involve additional local groups, such as municipal government staff, local NGOs, 
and others, that perhaps should be involved in the construction, monitoring, 
administration, and maintenance of the water supply systems and sanitation 
facilities. The intention is to determine alternative and perhaps better mechanisms 
than those developed to date. 
12. An initial survey of the number of diarrhea cases will be carried out at the 
beginning of the activities in every beneficiary community. Every six months the 
implementing entity will return and check the new data. The implementing entity 
will work with the local Health Committees and the Ministry of Health or local 
NGO's promoters to coordinate with them for collecting and using the data for 
their use and for use by the implementing entity. 
13. Follow up activities will be carried out in communities where water and sanitation 
systems were previously provided under Projects Nos. 5 19-0320 and 5 19-0394. 
The purpose of these actions is to find out if a) The communities are properly 
operating, maintaining and administering the water supply and sanitation systems 
provided, b) Proper behavior concerning hygiene habits are still observed, etc. A 
quick and adequate technical assistance will be provided in those communities 
facing these kinds of weaknesses. The recipient shall visit all the communities 
where household connections and tap stands were provided and will randomly 
choose to visit some communities where drilled or hand dug well were provided. 
14. When adequate and possible, hydrological studies and/or designs of water 
systems will be carried to facilitate communities to get funds from other financial 
sources to constructs water and sanitation systems that won't be constructed under 
this Project. 
Appendices p. 10 
Target PopuIation: 
The target population will mainly be the rural residents, especially the women and 
children who live in the communities which qualify under the established criteria. In 
addition the persons who operate, maintain and manage these facilities will benefit, as 
will the organizations assuming responsibility for providing the ongoing services that will 
result from the implementation of these activities. 
Selection of communities for the water supply system depends on the results of the social 
feasibility analysis, the available water source, geologic and topographic conditions, and 
the estimated cost per beneficiary. For those beneficiaries of new water supply systems 
without adequate Iatrines, new ones will be provided, either VIP or composting, 
depending on ground conditions and water levels. 
Communities with population above 2,000 persons could be benefited under this 
extension if providing assistance to them is in accordance with and contributes to the 
achievement of the Project and Mission objectives. 
This effort is expected to benefit approximately 45,000 rural residents by the year 2002, 
of whom approximately 6,525 are infants and children under age five years. 
Appendices p. 11 
Appendix B: Persons Interviewed 
Jose Antonio Ramos Chorro 
Ken Ellis 
Brad Carr 
Betty Gonzalez 
Todd Sorenson 
Julio Herrera Davila 
Rigoberto Cruj Monje 
Raul Rodriguez Choto 
Ana Josefa Blanco de Garcia 
Vilma de Ceron 
Ricardo Mancia 
Jonathan Claros 
Roberto Hernandez 
Marvin Meiia 
Rafael Guerra 
Francisco Gueverra 
Martin Segovia 
USAIDE1 Salvador, Strategic Objective No. 3 
(Health)PROSAGUAS Project manager 
USAIDE1 Salvador Mission Director 
USAIDE1 Salvador, Strategic Objective No. 4 
(Envir0nment)AGUAS Project manager 
USAIDE1 Salvador, Strategic Objective No. 4 
(Environment )AGUAS Project 
USAIDE1 Salvador, Strategic Objective No. 2 
(Democracy)Municipal Strengthening Project manager 
UNICEFE1 Salvador Program Development Officer . 
Responsible for UNICEF's water and environmental 
sanitation program. 
UNICEF funded environmental engineer assigned as 
advisor to COMURES. 
Head of ANDA's Rural Systems division 
Executive Director of CALMA 
Calma 
PROSAGUAS Proaam director. CARE 
PROSAGUAS Program deputy director, CARE 
PROSAGUAS Regional Director for the Eastern Region 
PROSAGUAS Renional Director for the Western Rerion 
PROSAGUAS Regional Director for the Central Region 
PROSAGUAS director for earlier phase program follow up 
PROSAGUAS Evaluation and Monitoring suecialist 
Appendices p. 12 
Appendix C: Question Guide for Previous 
Phase WSgS Projects 
Approach: Determine the lessons learned and sustainability of the water and sanitation 
systems constructed under previous phase of Project No. 519-0320 and assess whether 
measures are being taken to address these problems in the new projects: 
EHP definition of sustainability: Sustainability is the ability of a WS&S development 
project to maintain or expand a flow of benefits at a specified level for a long period after 
project inputs have ceased. In the narrowest meaning, the project is the physical 
infrastructure established and maintaineaoperated by the participating institutions. More 
broadly, the project also includes the household level hygiene behavior changes and 
community level organization established to achieve health impacts and community 
empowerment. 
Benefits exceed end-of-project levels? 
Benefits non-existent (systems failed) 
Benefits continue at end-of project level? 
Benefits drop down to below end-of-project level? 
Community level questions guide: 
Technical: 
Are most of the people covered by the project using the WS&S facilities? (>50%) 
Are the community WS facilities in operational order? 
Are trained repair persons and supplies of spare parts easily available? 
Do you think that the correct WS technology was chosen? 
Do you think that the correct sanitatiodlatrine technology was chosen? 
Organizational: 
Who owns this WS system? Who is responsible for O&M? 
Are community WS&S committees confident of managing the WS&S facilities and 
related activities? 
Are more women participating in WS&S committees? 
What role did the community play in the original project design and construction? 
Why Health Committees organized and created during the implementation stage had 
not continued working after the NGO left the community? 
Appendices p. 13 
7 
Administrative: 
Are the management committees functioning? How often do they meet? What do 
they do? 
Do you have adequate funds if something major breaks down? How much to you 
have in savings? 
What is your monthly income and operating expenses? 
Payment history - level of morosidad 
What was the community agreement for O&M? Is there a written document? 
Can you show us any written records of O&M? Past repairs, etc? 
Health and other impacts: 
0 Are the household level latrines being used? (>75%) 
What are the benefits of this project (then and now) 
Do you think that the health of children has improved? Why ? 
Are the household doing anything different now than before (i.e washing hands, 
storing water properly, etc.) 
How important is it for the community that the Health Committees continue working 
or not? 
What long-term impact have these committees had on the community; what were the 
consequences where the committees have been discontinued? 
External Factors: 
What support do they get from outside agencies: CARE, ANDA, Alcaldias, MOH? 
What has happened in this community since the project was built? War, hurricane, 
migration, inflation, refugees? Money from USA? 
Other: 
What would you recommend for future projects? 
Appendices p. 14 
Appendix D: Question Guide for Current 
PROSAGUAS Projects 
Program Administration: (USAID, CARE HQ) 
1) Are sound systems in place for assuring appropriate use of USAID 
funds/commodities in the following areas: financial management, personnel 
management, general administration, and communications? 
2) Are adequate planning and reporting systems in place? Are appropriate 
monitoring systems in place to ensure adequate supervision of program evolution 
and information exchange? 
3) Does CARE maintain appropriate systems regarding matching fund 
contributions? 
4) What is CAFE’S absorptive capacity and ability to manage multiple USAID 
programs? 
5) How can overall program administration be improved? 
Program Management: (USAID, CARE HQRegional) 
6) Has CARE made adequate progress towards meeting overall objectives as set 
forth in the cooperative agreement? Do such objectives remain appropriate, or do 
they require some modification? Is the meaninghnderstanding of technical and 
social objectives/indicators clear to all parties? 
7) Has liaison and coordination with other agencies (donor, governmental, local 
NGO, international NGO) and other SOs been effective? How can it be improved? 
8) What has been the involvement of local NGOs? (with an eye towards 
replicability) 
9) Has the program been able to achieve an appropriate balance between meeting 
physical outputs under the agreement (i.e. number of wells) and qualitative aspects 
of program implementation (i.e. the extent of community participation, skills transfer 
to local staff, etc.)? Are both social and technical objectives and indicators clearly 
understood by all parties? 
Appendices p. 15 
10) Is the project implementation methodology worth continuing andor 
replicating by other USAID Missions, donors, and government entities? Has 
CARE documented project implementation? 
11) How were the changes in the approach from Phase I of the project 
incorporated into design and implementation of Phase II? Have the changes had a 
positive impact at the community level? What are mechanisms for incorporating 
future changes, lessons learned, etc.? (Adaptive management) 
12) Technical criteria for community selection, within those satisfying USAD 
criteria (low hanging fruit) 
Activity Management (individual projects): (CARE HQLRegional) 
13) Has CARE developed a Project Cycle/Implementation methodology, guidelines 
for use by project staff? Implementation Team? 
14) Have proper agreements been signed by the communities concerning formation 
of committees, establishing a fee collection mechanism, providing for community 
labor and establishing women’s involvement. (also ask communities) 
15) Has the project focused adequately on the community selection criteria 
determined by USAD? 
16) Are appropriate monitoring systems in place to ensure adequate supervision of 
program evolution at the community level? 
Community Organization and Participation: 
17) How is community participation defined by all relevant actors? e.g. in-kind 
labor; collaboration in projects; participation in decision-making with respect to 
level of service, technology, etc.; assumption of responsibility for management. 
(CARE HQRegional, community) 
18) How are the communities organized, e.g. how does the process begin, who 
initiates the process, what are the steps, what are the criteria for considering a 
community adequately organized? (CARE HQEegional) 
19) Is the overall community organization process, as well as specific programs and 
methodologies, appropriate? What is the rationale for the different types of 
committees (water boards, community water committees, community health 
committees, community environmental committees)? Are the roles of the different 
committees, and the municipalities, understood clearly and in the same way by all 
relevant actors? (CARE HQRegional, community) 
Appendices p. 16 
20) Do the various community committees communicate and collaborate with 
each other? What are the influencing factors and results of such collaboration or 
lack of it? (CARE HQBegional, community) 
21) Do communities and water boards recognize their responsibilities with regard to 
fee collection, long-term maintenance and repair of installations? (CARE, 
community) 
22) How inclusive is the community organization process with regard to 
attempting to integrate, and actually integrating, different groups by gender, age, 
educational level, occupation, income? What are the factors which most clearly 
influence participation (positively or negatively) by such social groups? (CAFE 
HQRegion al , community ) 
23) Is there adequate participation by women in community water, environmental, 
and health committees? Is gender-disaggregated data being appropriately provided, 
and are gender considerations being properly addressed? (CARE HQRegional, 
community) 
24) How is “adequate participation by women” defined and understood by all 
relevant actors? e.g., number of women on committees? Role of women on 
committees (active participation in leadership and decision-making)? Breadth of 
participation by women (e.g. participation on water committees and boards as 
well as health committees)? Upward trend in participation in both numbers and 
leadershipldecision-making? (CARE HQRegional, community) 
25) How do requirements for labor inputs affect women’s (especially women￾headed households) participation in and benefit from the projects? (CARE 
HQRegional, community) 
Health Education: 
26) What are the high-risk behaviors, especially relating to children, by which 
groups? Do they vary by community, social group, region, etc.? What analyses 
has CARE made of behaviors? Are health education interventions and materials 
specifically and appropriately targeted to such behaviors/groups? What effects 
have they had? (CARE HQRegional, observation) 
27) What are the major impediments to changing health-related behaviors? Can 
these be addressed through improved health education? If not, are there other 
types of interventions the project could take to address these impediments? 
(CARE HQmegional, community) 
28) Are health education methodologies appropriate, and are they being used 
effectively? Are adequate systems in place for measuring the results of health 
Appendices p. 17 
G 
education? (CARE HQRegional, health prornoters/staff, observation) 
29) Is there an effective collaboration among health committees and the health 
promoters from the Ministry of Health, or from NGOs? What are suggested areas 
to be improved and/or supplemented? (CARE HQ/Regional, community, health 
promoters) 
30) Are the materials developed by the program thus far appropriate (training 
documents, posters, videos, audio programs), and are they being used effectively? 
What are suggested areas to be improved and/or supplemented? (CARE 
HQ/Regional, health promoters/staff, observation) 
3 1) Is CARE program staff training in health education effective? What, if any, 
needs are being unmet, and what areas can be improved? (CARE staff) 
32) What has been CALMA’s role? Has it been effective? (CARE, CALMA) 
Water Supply and Sanitation Systems Development: 
33) Are the technologies employed for the construction of water systems 
appropriate? How were they selected? (CARE HQ/Regional, ANDA, 
observation) 
34) Are community boards and committees appropriately trained and prepared to 
independently undertake activities? (CARE, community, municipalities) 
35) What is the process for ensuring adequate operation and maintenance of 
facilities (availability and access to spare parts, technical/administrative skills, role 
of private sector)? (CARE HQRegional, community) 
36) What are the guidelines for establishing tariff and fee structures? 
HQRegional, ANDA) 
(CARE 
37) Are there GOES technical guidelines for project design and implementation 
(ANDA)? 
38) Are communal facilities contemplated or part of project design (washstands, 
showers)? (CARE HQ) 
39) What is being done to treat water supplies either at the system or household 
levels? (CARE HQRegional, community) 
40) Are latrine models and related programmatic interventions appropriate (cultural 
factors, water table, cost, materials)? (CARE HQRegional, community) 
Appendices p. 18 
Environmental Component: 
41) Is CARE adequately addressing the environmental issues (drainage, solid waste 
management, vector control, source water protection, etc.)? (CARE HQRegional, 
observation) 
42) Are community members more conscious of environmental problems, their 
consequences and possible solutions? What does the environmental education 
component consist of? (community, CARE) 
43) As a result of CARE interventions, are the communities taking proper actions to 
adequately carry out micro-watershed management? Are there explicit linkages to 
the AGUA activity? (community, CARE) 
44) Environmental activities vs. environmental compliance (Reg 216, GOES) 
Appendices p. 19 
Appendix E: D ocu me nts Reviewed 
Reform Program for the Water Sector and the Potable Water and Sanitation Subsector 
in El Salvador, May 1998. 
Evaluacion Global de Los Servicios de Agua Y Saneamiento: Informe Analitico, por 
Roberto Arturo Arguello, July 2000, WHO/PAHO/UNICEF 
WASH Reprint: Technical Report No. 93, Helping Communities Manage Their 
Water finances, by Sarah Fry, September 1993, EHP. 
Instrumento para la participacion de la Comunidad, by Lyra Srinivasan, PNUD 
Modulo de Educacion Sanitaria, by Prosaguas, CARE. 
Modulo Integrado para la Atencion de Enfermedades Prevalentes en Niiios menores 
de Cinco Aiios, by Prosaguas, CARE. 
La Letrina Abonera seca, by UNICEF, UNICEF-El Salvador 
Higiene Basica, by UNICEF, UNICEF-El Salvador. 
El Agua Para Tomar, by UNICEF, UNICEF-El Salvador. 
Conocimientos y Practicas de Salud, by Prosaguas, Diciembre 1999, CARE. 
Conocimientos, Actitudes, Practicas y Barreras Sobre saneamiento Basico y Salud 
Infantil, by Prosaguas, Diciembre 1999, CARE. 
USAID RFA, by Prosaguas. 
Water and Sanitation or Health Program, by Care International in El Salvador, 
November 10,1997, CARE. 
Potable Water and Sanitation - An Experience to Share, by USAID, CARE.1999. 
Plan de Intervencion para la Proteccion de la Microcuenca Abastecedora del Recurso 
Agua del Canton la Ceiba, San Francisco Menendez, Ahuachapan, Junio 2000, Care, 
Salva Natura, USAID, MAG CENTA. 
Evaluacion del us0 y mantenimiento de letrinas construidas por el Proyecto de CREA 
Intemacional de EL Salvador, by Creative Associates International, Inc., US AD. 
Sub Proyecto de Letrinas Cantones la Loma, la Cruz, y Buenos Aires del Municipio 
de San Pedro Perulupan y Canton la Flor del Municipio de San Martin Depto. de 
Custlan, by Prosagua, CARE. 
Decentralilized Municipal Water and Sewage Company of San Julian, El Salvador, 
by Carlos Linares, July 2000, EHP. 
WASH Reprint: Technical Report No. 35, Assessment of the Operations and 
Maintenance Component of Water Supply Projects, by James K. Jordan, M.S.I.E., 
C.P.E., Peter Buijs, Alan S. Wyatt., June 1986, EHP. 
WASH Reprint: Technical Report No. 94, The Sustainability of Donor-Assisted Rural 
Water Supply Projects, by Jonathan Hodgkin and WASH Project Staff, April 1994, 
EHP. 
A Review of Sanitation Program Evaluations in Developing Countries, by Anne 
Lafond, UNICEF, EHP. 
Administracion de Recursos Humanos, Manual Para el Alumno. 
Appendices p. 20 
Organizacibn Empresarial, Principios Basicos de Administracion, Manual para el 
Participante. 
Manual general, Administracion Financiera. 
Organizaci6n Financiera Contable, Manual para el alumno. 
Factibilidad y Socioeconomico, CARE-El Salvador 
Resumen de Evaluaciones de 10s Proyectos Ejecutados por Prosaguas, CARE-El 
Salvador. 
La Letrina Abonera Seca, by UNICEF; UNICEF-El Salvador. 
La Letrina de Fosa, by UNICEF, UNICEF-El Salvador. 
Higiene Basica, Manual de Educacion Sanitaria para la Persona Facilitadora, by 
UNICEF, UNICEF- El Salvador. 
Estrategias Operativas para la Implementacion de Prosaguas, CARE- El Salvador, 
Prosaguas, USAID.Capacitacion Financiera y Asistencia Tecnicas, CARE-El 
Salvador. 
PROSAGUAS Quarterly Reports: 
Abril-Junio, 1998 
Julio-Septiembre, 1998 
Octubre-Diciembre, 1998 
Enero-Marzo, 1999/ Anual 
Abril-Junio, 1999 
Julio-Septiembre, 1999 
Octubre-Diciembre, 1999 
Enero-Marzo, 2000/Anual 
PROSAGUAS Annual Reports 
Plan anual 1999-2002 
Plan de Trabajo 1998-2002/ plan anual 1998-1999 
Documento de diagnostic0 de 55 sistemas (reporte correspondiente a1 trabajo del 
Objetivo N0.8) 
Documentos de monitoreo por comunidad: 
Resumen de evaluaciones de 10s proyectos ejecutados. 
Proyecto de la Nueva Esperanza, Conchagua: 
1. LineaBase 
2. Primera evaluacion 
3. Segunda evaluacion 
Appendices p. 21 
0 Proyecto de 3-H, Moncagua: 
1. LineaBase 
2. Primera evolucion 
0 Proyecto de Istagua: 
1. LineaBase 
2. Primera evaluacion 
Lineas Bases de 10s Proyectos: 
1. Los Conacastes 
2. CaraSucia 
3. Multiple La Lorna 
4. Analco 
5. Corinto 
3 modelos de convenio: 
Region Occidente: Convenio de proyecto Cara Sucia. 
Region Central: Convenio de proyecto Istagua. 
Region Oriental: Convenio de proyecto 3-H Moncagua. 
Appendices p. 22 
Appendix F: Project Sites Visited 
From previous phase: 
El Jacatal 
El Pal& 
El Seiior 
El Sincuyo 
La Conquista 
La Puebla 
Montepeque 
Pandeadura 
Rosario Tabl6n 
San Matias 
Teponahuaste 
From current phase (PROSAGUAS project): 
Cara Sucia 
Conchagua 
Istagua 
Los Analcos 
Los Conacastes 
Moncagua 
Multiple La Lorna 
Appendices p. 23 
Appendix G: PROSAGUAS Indicators by 
0 b je ctive 
(Lista de Indicadores para PROSAGUAS por 
0 bjectivos) 
Ob-ietivo 5: Asegurar la adopci6n de practicas adecuadas de higiene, de us0 apropiado 
de las letrinas y su mantenimiento. 
Indicador Verificable (I). 
0 Del 100% de las comunidades del programa a1 menos el 70% de 10s habitantes 
mostrarin mejoria en 10s parhetros CAP relativos a la higiene personal, domkstico y 
ambiental, que incluyan lavado de las manos, conservaci6n de la comida y 
mantenimiento y us0 de las letrinas 
Obietivo 7: Asegurar la adopcidn de otras prkticas mejoradas de salud que logren un 
impacto direct0 e indirect0 en la incidencia, reduccidn, prevalencia y mortalidad 
de la diarrea en niiios menores de 5 aiios. 
Indicador Verificable (1): 
Todos 10s habitantes mostrarin mejoria en 10s parhetros CAP en relacidn con la 
prevenci6n de enfermedades diarrGicas, preparaci6n y administracibn de suer0 de 
rehidrataci6n oral, prgcticas de lactancia materna, vacunacibn, prevenci6n y 
tratamiento de las infecciones respiratorias agudas (IRA’S), y apropiada destetacidn 
Obietivo 1: Incrementar el acceso a1 suministro de agua potable. 
Indicador Verijicable (I): 
A1 menos un 97% del total de 10s habitantes de cada comunidad del programa tendriin 
acceso a1 agua potable. 
Ob-ietivo 9: Proporcionar asistencia tkcnica a comunidades adicionales que estin 
construyendo infraestructura para agua y saneamiento por proyectos de 
USAID. 
Appendices p. 24 
Indicador Verificable (3): 
0 Acuerdos para asistencia tCcnica de CARE a las municipalidades serh firmados con 
a1 menos 5 de ellas o con otras instituciones que estkn ejecutando programas de agua 
y saneamiento con fondos de USAID. 
0 La organizaci6n comunitaria se ajustara para asegurar adecuados sistemas de 
administracih y O&M. 
0 Los parhetros de salud e higiene CAP, ser5n 10s adecuados entre un 70% de 10s 
habitantes de cada comunidad del programa. 
Ob-ietivo 11: 
ej ecuci6n. 
Diseiiar y formular 10s sistemas de agua y saneamiento para su futura 
Indicador Verificable (1): 
0 DiseAo de sistemas que incluyan estudios hidrol6gicos, que han sido aprobados por 
ANDA y revisados por USAID. 
Objetivo 4: Aumento en el acceso a letrinas. 
Indicador Verificable (2): 
A1 menos un 95% de 10s habitantes de cada comunidad que se beneficiaran con 10s 
nuevos sistemas de agua potable tendr5n ademiis facilidad para un adecuado 
saneamiento. 
Tecnologia, construcci6n y ubicacidn adecuada de las letrinas, de acuerdo a 10s 
estiindares tkcnicos y de salud establecidos. 
Obietivo 8: Suministrar asistencia tCcnica a las comunidades que fueron proveidas con 
sistemas de agua y saneamiento por proyectos realizados por USAID 
anteriormente. 
Indicadores Verificables (10): 
0 Indicadores para un adecuado Sistema de Agua, Mantenimiento y Operacih. 
A1 menos un 95% de 10s hogares de cada comunidad tienen acceso al agua potable. 
0 A1 menos un 95% de 10s hogares de cada comunidad estiin satisfechos con el servicio 
de agua proporcionado. 
Appendices p. 25 
Cada comunidad tiene un operador(es) para el sistema de agua quien es capaz de 
operar y dar mantenimiento a1 sistema de una manera adecuada. 
El cloro residual en la distribuci6n de la red sera mantenido entre 0.1 - 0.5 mg/litro de 
acuerdo a 10s esthdares de ANDA. 
El n6mero de hogares con significativas fugas de agua no sea mayor del 10% del total 
de hogares servidos en cada Comunidad del programa. 
El n6mero de hogares que no pagan cuotas de agua es menor a1 10% del total de 
habitantes que tienen el servicio. 
En el 85% de las comunidades, el numero de mujeres capacitadas en organizaciones 
locales y/o municipales es por lo menos el 33% del numero total de personas que 
conforman estas entidades. 
El promedio del ingreso mensual obtenido por medio de las cuotas de agua y otras 
fuentes es mayor que el promedio mensual gastado en el mantenimiento del sistema, 
permitiendo la creacidn de un fondo para el mantenimiento del sistema de agua. 
Indicadores para un Adecuado Saneamiento 
En el 85% de las comunidades del programa, a1 menos el 70% de 10s habitantes 
demostraran una mejorfa en 10s parhetros KAP relacionados a higiene personal, 
domestica y ambiental, asi como al us0 y mantenimiento de letrinas. 
La tecnologia de las letrinas, su construcci6n y ubicaci6n sera conforme a 10s 
esthdares de salud y tCcnicos establecidos. 
Obietivo 10: Medir el impact0 del programa en la reducci6n de la incidencia, 
prevalencia y mortalidad de la diarrea en niiios menores de 5 aiios. 
Indicador Verificable (1): 
El 26% de la reducci6n en la incidencia, prevalencia y mortalidad por enfermedades 
diarriicas con relacidn a la linea base. 
Ob-ietivo 2: Asegurar el suministro de agua potable a travis del adecuado manejo, 
mantenimiento y administracih. 
Indicadores Verificables (9): 
0 El sistema proveer6 una cantidad adecuada de agua a1 menos a un 95% de 10s hogares 
en cada comunidad. 
Appendices p. 26 
A1 menos el 90% de 10s hogares del programa en cada comunidad pagartin sus cuotas 
de agua en tarifas regulares bBsicas y aceptables. 
En las comunidades beneficiarias, el n6mero de mujeres trabajando en las 
organizaciones responsables de 10s sistemas de agua y saneamiento serh a1 menos el 
33% del ndmero total de la poblacibn que comprenda estos comites. 
A1 menos el 95% de 10s hogares en cada comunidad estarin satisfechos con el 
servicio de agua provisto. 
Las comunidades del programa tendrh un operador del sistema de agua que seri 
capaz de operar y dar mantenimiento de manera apropiada a1 sistema. 
El cloro residual en cada red de distribucibn se mantendra entre 0.1 - 0.5 mg/litro de 
acuerdo a 10s estgndares de ANDA. 
El ndmero de hogares con significativas fugas de agua no sea mayor del 10% del total 
de hogares servidos en cada Comunidad. 
El promedio mensual de ingresos obtenido por el pago de las cuotas de agua 
consumida y otros recursos sera m5s alto que el promedio mensual gastado en el 
sistema de mantenimiento permitiendo la creacibn de un fondo para el mantenimiento 
del sistema de agua. 
El sistema general proveera un servicio continuo de a1 menos el 95% de 10s usuarios, 
except0 en periodos miis bajos de lo normal y periodos de mantenimiento y 
reparacibn. 
Objetivo 3: Asegurar la sostenibilidad del recurso agua por medio del manejo de 
micro-cuencas. 
Indicadores Verificables (5): 
El 100% de las juntas administrativas de 10s sistemas de agua y 10s comitCs 
ambientales creados como parte del programa recibir6n capacitaciones de como 
proteger sus fuentes de agua. 
Capacitaciones en las heas de proteccibn a las micro-cuencas, como construir 
barreras vivas, y canales de infiltracidn del agua serh proporcionados a 10s 
agricultores que arriendan o poseen terrenos en las micro-cuencas y a la vez son 
beneficiarios del sistema de agua. 
A1 menos 835,000 &-boles serh plantados. 
Appendices p. 27 
Por lo menos tres personas del Brea deI proyecto de agua serBn capacitadas en el 
manejo de las micro-cuencas. 
En el 100% de 10s reglamentos que legislen la administracidn de 10s sistemas de agua 
y saneamiento contendrgn reglas especificas que legislen lo relativo a la prevencidn, 
deforestacih y erosi6n en cada comunidad beneficiaria. 
Ob-ietivo 6: Proveer asistencia a 10s promotores de salud. 
Indicadores Verificables (1): 
Por lo menos el 85% de 10s promotores del MSPAS y ONG locales que trabajan en 
las comunidades del programa tendran capacitaciones en temas con enfoques 
actualizados. 
Ohietivo 12: Implementar un efectivo monitoreo, evaluaci6n y sistema de reportes del 
programa. 
Indicadores Verificables (1): 
0 Todos 10s indicadores de progreso del programa, sus resultados y el impact0 
propuesto en este plan serBn monitoreados y evaluados por el programa de manera 
confiable y en el tiempo oportuno. 
Appendices p. 28 
ndicadores de Cambio de ComD( 
INDIGADOR OPERAGIONAL 
lncidencia de diarrea en menores 
de 5 atios 
Prevalencia de diarrea en <5 aAos 
Porcentaje de personas que 
manifiestan lavarse las manos 
despues de usar letrina 
Porcentaje de hogares libres de 
excretas visibles en el patio 
Porcentaje de personas que lavan 
con agua y jabon las verduras y 
frutas que consumen crudas 
Porcentaje de hogares que usan 
letrina 
Porcentaje de hogares con letrina 
libre de moscas 
Porcentaje de menores de 6 meses 
alimentados ljnicamente con 
lactancia materna 
Porcentaje de personas que 
conocen al menos 2 signos de 
diarrea grave 
Porcentaje de personas que 
administran Sales de rehidratacion 
oral a sus niAos(as) que 
presentaron diarrea las Liltimas 2 
semanas 
Cobertura de letrinas 
tamiento 
FORMULA DE CALCULO 
Casos de diarrea hov x 100 
Total nitios <5 afios en muestra 
Casos de diarrea las ultimas 2 
semanas xlOO 
Total nitios <5 atios en rnuestra 
Personas que mencionan lavarse las 
manos despuCs de usar letrina x 100 
Total de entrevistados 
Hogares libres de excretas visibles 
Hogares visitados 
Entrevistados que manifiestan lavar 
con iabon las verduras y frutas x100 
a 
Total de entrevistados 
Hogares que usan letrina * x 100 
Hogares visitados 
Hogares con letrina libre de moscas 
XI 00 
Letrinas observadas* 
Menores de 6 meses alimentados con 
leche materna xl00 
Total menores 6 meses en la muestra 
Personas que mencionan dos signos 
de gravedad xlOO 
Total de entrevistados 
Personas que manifiestan haber 
administrado suer0 oral xlOO 
Total de personas con casos de 
diarrea las ultimas dos semanas 
Casas con letrina xlOO 
Total de casas visitadas 
Appendices p. 29 
Appendix H: 
Indicators 
EHP Diarrheal Disease Prevention 
Appendices p. 30 
Cleansing of Hands Sanitary Disposal of Feces 
Proportion of households. . . rn Where the mother (or 
caretaker) reports washing 
her hands at least once 
within the previous 24 hours 
on each of the four critical 
occasions. 
n Where the mother (or 
caretaker) demonstrates all 
elements of adequate 
handwashing technique. 
Drinking Water Free of 
Fecal Contamination 
Proportion of households. . , 
Where all family members 
three years or older usually 
use a sanitary facility for 
defecation (report). 
Where the feces of children 
under three are disposed of 
in a sanitary fashion (report). 
Where the house area and 
yard are free of human fecal 
contamination (observation). 
n 
rn 
Proportion of households. . . rn That use water from an 
acceptable source for 
cooking and drinking. 
H That either have in-house 
piped water or have a 
system of water collection, 
transport, storage, and 
access that maintains water 
free of contamination. 
Proportion of sanitary 
facilities. . . That appear to be in use 
(observation). 
That are free of soiling with 
human feces (observation). 
rn 
rn 
Food Free of 
Fecal Contamination 
Percent of infants 6 months and under 
That are exclusively breastfed. 
Proportion of households. . . rn Where the mother reports 
washing her hands before 
preparing or serving food or 
feeding children. 
Where food is eaten within 3 
hours of cooking. 
Where cups and spoons rather 
than bottles are used to feed 
infants and small children 
(report, observation). 
w 
Appendices p. 31 
Access Quality 
Continuous access to safe 
water at household level. 
rn Access to devices for water 
collection, transport, storage. 
rn Access to sanitary excreta 
disposal. 
Access to soap or ash for 
handwashing. 
rn Access to sufficient water 
quantity (20 liters per capita 
per day). 
Demand 
Water supply: collection 
time, continuous availability, 
level of potability. 
rn Sanitary excreta disposal: 
odors/aesthetics, durability 
of solution, ease of 
maintaining cleanliness, 
cultural appropriateness of 
design. 
Behavior change: locally 
appropriate design, use of 
participatory processes. 
An understanding that 
diarrhea is preventable. 
Knowledge of the causes of 
diarrhea and the means to 
prevent it. 
Willingness to pay for 
adequate water supply, 
sanitation, soap or ash and 
to participate (money or in￾kind contribution). 
Functioning community 
environmental health 
committee. 
Community norms 
supportive of appropriate 
behavior. 
Sustainability 
Effective policies and 
institutions that support 
access and quality. 
rn Percent of costs recovered 
from users. 
rn Evidence that operation and 
maintenance are taking 
place. 
financing 
personnel. 
environmental health 
committees. 
Availability of capital 
rn Adequately trained 
rn Functioning community 
&@=- Appendices p. 32 
Appendix I: Benchmarking para Empresas 
de Acueducto y Alcantarillado 
DEFINICIONES DE DATOS 
La lista de datos del Kit de iniciacibn, y sus correspondientes definiciones, se encuentran 
en la tabla adjunta. Casi todos 10s datos se requieren o como numerador o como 
denominador para uno o m8s indicadores de costo y desempeiio contenidos en el Kit. Los 
pocos datos que no se usan para este propdsito se han incluido para proporcionar 
informaci6n adicional que sera de gran ayuda para hacer comparaciones entre empresas. 
Dichos datos adicionales se identifican con las letras PIS (Para Informacidn Solamente). 
Introduzca tantos datos como pueda en el sistema de captura de datos. Tambikn 
introduzca tantos aiios como le sea posible - considerando como primer aiio 1994, no uno 
anterior. Por favor tenga cuidado que todos 10s datos anuales se refieran a1 a50 fiscal. 
Cuando un valor sea cero introduzca “0” 
Cuando el dato no est$ disponible deje la celda en blanco 
Los datos nacionales de GDP, tasa de cambio e inflaci6n se encuentran en el archivo 
Paises.doc en el disco del Kit de iniciacih. Dichos datos se han tomado de las 
estadisticas del Banco Mundial. 
Appendices p. 33 
Ref. 
1A 
la 
Ib 
2a 
2b 
2c 
11 Informaci6n General: Area de servicio de la em 
Datos Comentario Unidad 
Informacih General: Empresa 
Nombre de la empresa Nombre completo. Por favor indique: Texto 
Nombre largo - hasta 50 caracteres 
Nombre corto - hasta 20 caracteres 
Nombre de la persona a contactar, Detalles completos del contact0 dentro de la empresa, que permita la comunicacidn con el Texto 
direccibn, telCfono, fax, e-mail Banco y otras ernpresas 
Pais (PIS) Pais en el cual la ernpresa esta localizada Texto 
Regidn (PIS) Regi6n dentro del pais Texto 
Ciudad (PIS) Ciudad en la cual 10s servicios de la empresa estin centralizados Texto 
30 
1B Informacih General: Pab 
5 GDP per capita 
6 Tasa de cambio 
7 Inflacidn promedio anual (PIS) 
8 Salario rninimo anual (PIS) 
32a 
32b 
34 
35 
GDP per capita annual del pais (Fuente: archivo Paises.doc que se encuentra en el disco 
del Kit de iniciaci6n) 
Tasa de cambio annual con respecto a1 ddlar (Fuente: archivo paises.doc en el disco del 
Kit de iniciaci6n) 
iniciaci6n) 
Salario rninimo annual del paislregi6dciudad 
US$ 
Rata 
% 
Moneda 
Tasa promedio de inflaci6n anual (Fuente: archivo paises.doc en el disco del Kit de 
36 
3 
Poblaci6n total 
Tipo de servicio que presta 
Naturaleza del irea de servicio 
Ndmero de unidades poblacionales servidas con 
acueducto (PIS) 
Nhmero de unidades poblacionales servidas con 
alcantarillado (PIS) 
Nhmero total de personal 
Grado de participaci6n privada en la operacidn 
-esa 
Total de poblacidn bajo la responsabilidad de la empresa, sin considerar si reciben 
servicin n no 
Especifique: (A) Acueducto solamente, (B) Alcantarillado solamente, (C) Acueducto y 
alcantarillado, (D) Acueducto, alcantarillado y otros 
Especifique: (1) Urbana, (2) Rural, o (3) Urbana y rural 
Ndmero total de unidades poblacionales bajo la responsabilidad de la empresa, sin 
considerar su cobertura 
Nlimero total de unidades poblacionales bajo la responsabilidad de la empresa, sin 
considerar su cobertura 
Nhmero total de personal trabajando en la empresa. En tCrminos equivalentes a empleados 
de tiempo completo 
Mirar el us0 del sector privado en la operaci6n rutinaria de la empresa ej: O&M, 
'000 habitantes 
# Equivalente 
a tiempo 
comdeto 
A,B, etc. 
Ref. 
Poblacidn servida 
Conexiones de agua a fin de aiio 
Datos 
Poblacidn bajo la responsabilidad de la empresa con acceso a1 servicio a travb de 
conexidn intradomiciliaria y puntos de agua comunitarios. 
Ndmero de conexiones de agua a fin de aiio 
. I. 
,. 
70 
-. 
rutinaria de la empresa 
(Excluyendo capital para creacidn y puesta en 
marcha) 
Poblacidn servida Poblaci6n bajo la responsabilidad de la empresa con servicio de 
alcantarillado a travks de conexi6n domiciliaria 
'000 habitantes 
,-. 1 1 . .*. 1 P. * - .TI C. . - _^^^ 
I11 
40 
I4 
78 
41 
LUIlgllUU Ut: la lt3U 
Ndmero de quejas 
~urigituu cotai ue la reu ae aicaritariiiauu 
Ndmero total de quejas de usuarios relacionadas con el servicio de alcantarillado durante 
el aiio 
nm. 
# 
42 
43 
53 
53a 
54 
55 
58 
59 
59a 
59b 
GO 
61 
62 
Cornentario Unidad 
paisajismo, seguridad, facturacidn A)Ninguna, B)Contratos de mdltiples servicios, C) 
Contratos de Gestidn, D) Contratos de Leasing, E) Contratos de concesidn, F) 
BOOTBOT (s), G) Venta total a1 sector privado 
Suscriptores conectados a fin de aHo Ndmero de suscriptores a fin de aiio (el ndmero de suscriptores puede que no corresponda 
a las conexiones, ej: ciudades con edificios, condominios, etc. que tienen una sola 
N6mero de quejas Ndmero total de quejas de usuarios relacionadas con el servicio de acueducto durante el 
'000 habitantes 
'000 
'000 
# 
'000 
'000 
Km 
Millones m3/afi0 
Millones m'/afio 
Millones m3/afio 
Millones m3/afio 
Millones m3/aiio 
# 
Horaddia 
# 
I I 1 conexiones ae aicantariiiaao a Tin ae ano I iuumero ae conexiones a rin de ano I uuu 
72 I Suscriptores conectados a fin de aAo I Ndmero de suscriptores a fin de afio (suscriptores puede que no corresponda a las I '000 I conexiones, ej: ciudades con edificios, condominios, etc. que tienen una sola conexidn). I 7A IT ---:A..?l l- I- --J IT---lr..lr_r.l 2-1- J J. -1 .... *-..:>l.l- TJ 
Ref. Datos .’ I 
80 Tratamiento de aguas residuales 
79 Nlimero de daiios 
Comentario Unidad 
Nlimero total de dafios en la red de alcantarillado durante el aiio 
(cribado y pre-sedimentacidn) 
# 
Porcentaje de agua residual que recibe tratamiento, por lo menos de nivel primario % 
Costo de todos 10s servicio dentro del dato numerado con (94) que se han contratado con 
firmas privadas 
Valor net0 de 10s activos fiios a fin de afio 
90 Total de ganancias de operacidn 
90a 
90b 
94 Gastos de operacidn 
96 Costos de personal 
Facturacidn total a usuarios residenciales 
Facturacidn total a usuarios industriales 
Costos totales del servicio de la deuda anual (incluyendo intereses y abonos a capital) 
Cantidad de capital invertido durante el aRo 
Total de las cuentas por cobrar a fin de aiio, incluyendo facturaci6n de agua y todas las 
demis cuentas. 
Facturacidn total de acueducto y alcantarillado, cargos por conexidn, cargos por 
extracci6n de pozos, cargos por reconexidn y otros ingresos, incluyendo subsidios peso 
excluyendo todos 10s impuestos. 
Cantidad total facturada a usuarios residenciales durante el aRo - incluir 10s cargos fijos 
y por volumen linicamente. 
Cantidad total facturada a usuarios industriales durante el aiio - incluir 10s cargos fijos y 
por volumen linicamente. 
Gastos totales de operacidn de acueducto y alcantarillado excluyendo depreciacidn y 
cargos financieros (intereses y abonos a capital) 
Incluye todos 10s costos relacionados con el personal (salarios, sueldos, pensiones, otros 
beneficios, etc.) 
Moneda local 
Moneda local 
Moneda local 
Moneda local 
Moneda local 
99 Moneda local 
11 1 
114 
119 
120 
Moneda local 
Costo de servicios contratados 
Total de activos fijos netos 
Total del servicio de la deuda 
Inversi6n annual 
Cuentas por cobrar a fin de aiio 
Moneda local 
Moneda local 
Moneda local 
146 Cargos fijos por mes para usuarios 
residenciales 
Cargos por conexidn - agua 
Cargos por conexidn - alcantarillado 
147 
148 
El componente fijo de la factura (si lo hay) para el abastecimiento agua y del servicio de 
alcantarillado. Escriba “0” si no existe el cargo fijo 
Costo de conexidn para usuarios residenciales de acueducto 
Costo de conexidn para usuarios residenciales de alcantarillado 
Moneda local 
Moneda local 
Moneda local