Editor's Note: In this post, Agha Ali Akram of Evidence Action, explores why despite the availability of inexpensive and easy-to-use technologies and simple behaviors that can prevent diarrhea, social scientists have found it challenging to get high adoption rates and maintain participation amongst poor households, even when the technology is provided free. Ali Akram conducted this work independently and the following does not reflect the views/opinions of Evidence Action. This post originally appeared on DefeatDD's website, to view the original post click here.
Despite the availability of inexpensive and easy-to-use technologies and simple behaviors that can prevent diarrhea, it was an unpleasant surprise for me to learn that it kills more than half a million children a year, predominantly in the developing world. More troubling still, social scientists have found it challenging to get high adoption rates and maintain participation amongst poor households, even when the technology is provided free. This got me curious: why is this the case?
What I Did: The Experiment
In a randomized controlled trial in Karachi, Pakistan, I test the hypothesis that perhaps families need tools that clearly demonstrate the impact of health interventions – in this case, chlorine tablets for water purification.
Info-Tool required weekly recording of diarrheal incidence and monthly comparison to a reference level.
I provided households with a simple visual tool (called Info-Tool) to help them assess the efficacy of using tablets. Info-Tool allowed households to record incidences of diarrhea using simple bar charts. Additionally, at the end of each month, I provided them a bar chart of the normal rates of diarrhea they could expect for that month. Diarrhea varies with season, so the norm I provided was a moving monthly reference (related to the number of children under five in the household) and Info-Tool allowed households to visually compare their bar charts to the reference level.
Form of the experiment: control group in blue and treatment in green.
The experiment had a control group and treatment group, and rolled out in three phases. In Phase 1, which lasted three months, the treatment group used Info-Tool and built up a pre-tablet record of diarrhea prevalence. Info-Tool allowed them to understand where their levels tracked in comparison to the provided reference. In Phase 2, which also lasted three months, the treatment group continued to use Info-Tool but both groups were offered the option of accepting free chlorine tablets. In Phase 3, I discontinued the treatment group’s use of Info-Tool but both groups continued to receive freely provided chlorine tablets.
What I Found: Remarkable Results
Chlorine tablet use was significantly and persistently higher in the treatment group. At 74 weeks from the start of tablet delivery (beginning of Phase 2), the treatment group was almost twice as likely as the control group to accept the tablets, with the control group acceptance rate at 26% and the treatment group at almost 60% (see Figure 3).
Two results really struck me. First, my data show that as we enter the subsequent summer season (near the 46 week mark), both groups demonstrated higher tablet acceptance. Significantly, the treatment group’s summer increase in uptake was higher than the control group. To me, this suggests an impact of Info-Tool on households’ fundamental understanding of disease seasonality i.e. households seemingly better understood the “dynamics” of diarrhea.
A more striking result to me, however, was the fact that children in treatment households tended to measure significantly better than control households on health outcomes such as weight (22% gain), height (6% gain), and mid-upper arm circumference (3.5% gain). This suggests that the use of tablets had real measurable health impacts.
Predicted probability of accepting offered chlorine tablets by treatment arm. The x-axis has time (weeks) while the y-axis shows predicted probability of uptake in a given week. The control group is shown in blue while the treatment group is shown in red. Dotted vertical lines indicate specific dates and phases of the experiment.
The results suggest that allowing households to track and reference their disease prevalence increased their ability to detect the efficacy of chlorine tablets, thus making the intervention far more successful. More specifically, I believe that households were able to better learn about the effectiveness of tablets because Info-Tool provided a more precise signal about tablet effectiveness. It is also apparent that households possess a general sense of the seasonality of the problem but with the augmented learning from the Info-Tool, treatment households show a higher likelihood to accept offered tablets as the “danger” (summer) season started.
What this Means: Policy Recommendations
I believe this study points the way forward in two important ways. First, it demonstrates a powerful new way to address a major global health challenge i.e. under-five diarrhea with its associated health costs. I found that the intervention had strong and persistent effects a year after it began, inducing people to adopt chlorine tablets when they otherwise would not have.
Second, it confirmed to me that people can and do make beneficial health decisions – we’ve just got to help them “see” that those decisions have real benefits. Giving people clearer signals on how they benefit from their use of supposedly beneficial technology sparks greater participation. Moreover, I can imagine analogues to this technique being applied to other domains where health technology adoption is critical such as adoption of anti-malarial bed-nets and drug regimens for diseases like TB and HIV.
Editor’s Note: This post was authored by David Winder, chief executive of WaterAid USA. David talks about WaterAid’s work with local NGOs in Mozambique to make water and sanitation services affordable to poor, urban populations through innovative financing models. A version of this story originally appeared here.
Having just returned to New York from Maputo, the capital of Mozambique, I'm reminded how lucky we are in this city to have reliable water and sanitation services. Thanks to investment in water pipes and sewers in the 19th century, diarrheal diseases that ran rife through our city a few generations ago have all but been eliminated, and we take it for granted that safe drinking water is available at the turn of a tap.
As in many other large cities across the developing world, Maputo is facing rapid growth of low income settlements and major challenges in providing the population with access to safe water and sanitation. The latest data (UNICEF/WHO 2012) show that only 77 percent of Mozambique's urban population has access to improved water sources. The situation is even grimmer when it comes to sanitation, with only 38 percent of the urban population having access to safe sanitation.
The country has one of the highest infant mortality rates in the world with 86,000 children dying before their first birthdays every year. Diarrhea is one of the leading causes of child deaths and 44 percent of children under five are undernourished.
Increased investment in providing access to safe water and improved sanitation dramatically impacts child survival. In low-income areas of cities like Maputo, that is often a complex task. High population density, transient populations, and poor quality housing are part of the problem and present challenges to those striving to improve water and sanitation infrastructure.
Often in low-income urban neighborhoods the provision of piped water to homes is simply too expensive for ordinary families to afford. One way of tackling that problem is by helping local residents band together and negotiate affordable payment plans with water service providers with the help of local NGOs.
Last week I visited the community of Costa do Sol on the northern periphery of Maputo and found that a community water users' association, ACODECOS, established with the help of WaterAid and local partner organization ESTAMOS had achieved great success in expanding the number of household water connections over a five year period, with very positive results for the health of the community, particularly children. Data given to us by the Ministry of Health showed that the number of cholera cases had dropped from 371 in 2003/4 to only 21 in 2008/9.
One reason why this was achieved was ACODECOS' successful negotiation of a reduction in the household connection fee to $50 (from Aguas de Mozambique, a private company receiving 75 percent of its investment from government) that can be paid in installments.
Local resident Francesca Nhantos (shown in the photo at the top) told me that having piped water available in the home had transformed her life. "Before we had the standpipe, a water truck came to the village once a week and we had to pay 5-7 meticais (20 cents) for 20 liters of water and we weren't sure how clean it was so we had to boil it."
As Arminda told me, other changes, such as the installation of latrines, hygiene education, the provision of drinking water and toilets in schools and the disposal of solid waste, have also helped to dramatically improve the health of the community.
With the absence of piped sewerage in densely populated low-income urban communities, disposal of fecal sludge from latrines also poses a major challenge. Last week, I visited a pilot project managed by Water and Sanitation for the Urban Poor (WSUP), an organization working closely with WaterAid. This project shows how offering loans to small businesses can help with the development of affordable waste management services.
Paulo Biane Vaiene from the Maputo community of Maxaquene is one such entrepreneur benefiting from financial assistance. His small enterprise UGSM Vaiene started emptying small septic tanks using a small pump and tank called a "gulper" that was pulled by a donkey. With a loan from WSUP, he was able to buy a truck that has allowed him to cover more clients and expand his radius of operations. Business is thriving, more households can now take advantage of his services, which cost around $20 and are required twice a year, and public health is safeguarded by the safe disposal of the waste.
Just as Paulino has demonstrated that fecal sludge removal can be a profitable business, there are opportunities to develop small businesses selling a selection of toilet designs to families. A range of viable technologies has been developed, but business models need to be developed with finance plans to ensure that options are affordable to all families regardless of income. We found that all needed construction skills exist in the communities, so the focus needs to be on ensuring these skilled laborers are able to find employment that not only helps their families out of poverty but also helps communities stay healthy and meet their basic needs.
These experiences show how innovative financing models can impact on health in low-income urban communities. When water connection charges are not only reduced but split into installments, poor families can afford to get linked to the municipal piped water system, and the support of small private service providers ensures families have access to effective and affordable fecal sludge removal services until the sewage network can be expanded.
These examples also show the importance of linking larger systems — such as pipes for the water utility or waste management and sewage systems — with community and household-based needs and approaches. Reducing poverty and protecting people's health and well-being requires a combination of efforts, from local capacity building and small business development to larger-scale infrastructure development. I was inspired by the efforts being made by NGOs and community-based organizations to build healthy communities. The skills, the demand, and the creativity are there. We have so many opportunities now to make the most of them.
Editor’s Note: This guest post was authored by Alexandra Fielden, policy coordinator for Dispensers for Safe Water at Innovations for Poverty Action (IPA). In it, she discusses the benefits of IPA’s Chlorine Dispenser System, an innovative water treatment solution, and how the system has been implemented in villages in western Kenya. (Names have been changed to protect the identity of the individuals involved.)
Following the death of her daughter, Adimu was left to take care of her HIV-positive granddaughter, Tabia.
HIV has severely weakened Tabia’s immune system, making her especially vulnerable to waterborne diseases. “She would always need to go to the hospital,” says Adimu, “due to her weak immunity, she suffered from diarrhea regularly.” Visits to the local clinic to treat Tabia’s diarrhea were costly, uncomfortable, and time-consuming.
But since IPA’s Chlorine Dispenser System was set up in her community in Khasolo, western Kenya, Tabia has experienced far fewer cases of diarrhea and she is doing extremely well in school. “Chlorine has improved my granddaughter’s health since she no longer suffers from diarrhea,” says Adimu, with a smile.
In poor rural areas where constructing piped water systems are prohibitively expensive, the government and donor response has generally been to fund new water sources such as wells or boreholes.
However, this approach fails to ensure the safety of water during transportation and storage at the home. Because of unhygienic water collection behaviors and unsafe storage practices, re-contamination presents a major challenge in many settings. A study in western Kenya showed that spring protection led to a 66 percent reduction in fecal contamination at the water source, but the reductions were only 24 percent in water stored in people’s homes.
One inexpensive, safe, and effective option to improve water quality while protecting against re-contamination is to treat water with chlorine using IPA’s innovative Chlorine Dispenser System.
Installed at a communal water source, users simply turn a valve on the dispenser to release a metered dose of chlorine into their jerricans, which they then fill with water as usual. The chlorine mixes with the water and kills the germs that cause many diarrheal diseases. The chlorine provides protection from recontamination for up to 48 hours, and achieves an average diarrhea reduction of 41 percent.
Five-and-a-half miles northeast of Adimu and Tabia’s village lies Laban Springs, another community with access to the Chlorine Dispenser System. Here, Caroline explains that “the dispenser is easy to use, and being next to the water source reminds you to use it.” To encourage adoption, IPA partners with community volunteers, like Caroline, who serve as “dispenser promoters.” They work to educate the community about the dangers of contaminated water, to encourage use of the technology, and to ensure that a consistent supply of chlorine is available.
Results from a randomized trial in western Kenya documented that the CDS increases chlorine use six-fold compared to the existing approach of selling small bottles of chlorine through retail outlets. In target communities, preliminary studies showed that 50-61 percent of households had sustained detectable chlorine levels in household drinking water during unannounced visits over 3 years after CDS implementation, compared to 6-14 percent with access to the standard retail model.
A majority of the funding for CDS programs to date has been provided by the Bill & Melinda Gates Foundation. In addition, some early funding commitments were made by local governments in Kenya, the Kenyan Ministry of Education, and a Kenyan water services board for CDS pilot projects. The World Bank, the Japan International Cooperation Agency, the International Initiative for Impact Evaluation, as well as private foundations and individuals, have also contributed to start-up costs of the program.
Over the last several years, Dispensers for Safe Water (DSW) has been working in close collaboration with national ministries and local governments, as well as non-governmental organizations, to implement its programs in Kenya. Together, DSW and its partners have installed enough dispensers to provide access to safe water for more than 400,000 people across western Kenya.
DSW conducts regular spot checks to monitor the condition of the dispenser and its source, and to test that the dispenser is stocked with chlorine at the correct concentration and quality. In addition, the selection of responsible dispenser promoters and set-up of a local “hotline” for communities to report issues ensure that problems with the dispenser hardware are rapidly identified and remedied.
In 2012, DSW will continue to work with its partners to expand dispenser coverage; to pilot dispensers in other high-priority regions of Kenya; and to explore new areas where dispensers could lead to a significant reduction in diarrheal disease rates.
DSW also works in Haiti, Somalia, India, Bangladesh, Swaziland, and Uganda, and continues to explore the possibilities for piloting and scaling up dispensers in a number of target countries in sub-Saharan Africa. DSW aims to provide access to safe water for millions of people like Adimu, Tabia, and Caroline through the innovative Chlorine Dispenser System, a Proven Impact Initiative at IPA. To find out more, contact Dispensers for Safe Water: firstname.lastname@example.org.
Lack of access to clean water, inadequate sanitation, and poor hygiene are inextricably linked to the prevalence of gastrointestinal infections. Diarrhea, a common symptom of these infections, kills around 2.2 million people globally each year, mostly children in developing countries. Given this stark reality, diarrheal disease death rates are a critically important contextual indicator for those working in the WASH sector.
To help site users better account for this context in their work, WASHfunders has added the World Health Organization’s data on diarrheal disease death rates as a new overlay to its funding map. Simply go to the “indicators” tab and click on “diarrheal disease” to view incidence rates for any given country.
Are there other economic, health, or social indicators that inform your work on water, sanitation, and hygiene? Let us know at email@example.com so that we can continue to make site enhancements that meet your information needs.