Clean Water in Northern Ghana

This study assesses the willingness of households in Northern Ghana to purchase a ceramic water filter. The Kosim filter is sold by Pure Home Water (PHW), a Ghana-based NGO, and has been demonstrated to be highly effective at improving water quality without needing electricity. We will also measure the health effects of household-level water treatment in areas with high waterborne disease loads.  

Policy Issue: 

Diarrheal diseases, which result poor water quality, are a leading cause of death in the developing world, killing approximately 1.8 million people per year. Achieving the Millennium Development Goals of reducing the proportion of people without sustainable access to safe drinking water is especially difficult for the rural poor. Delivering treated water through pipes has resulted in sustained health gains in developed countries and urban areas in developing countries, but is not considered feasible in rural areas with dispersed populations and weak institutions for maintenance. Community interventions, such as spring improvement or communal wells, have not produced strong results, and policy makers are increasingly interested in household and point of use treatments. However, the effectiveness of such treatments in rural environments, the role of education and marketing to encourage use, and how to expand access with limited resources remain largely unknown.

Context of the Evaluation: 

Diarrheal diseases account for 12% of childhood deaths in Ghana, and are the third largest cause of death for children under the age of 5. These diseases are caused by the ingestion of water contaminated by fecal matter, and 20% of Ghana’s population does not use an improved water source. The sparsely populated northern region of Ghana is one of the least developed parts of the country, and has even less access to clean water than the national statistics would suggest. The majority of its residents make their living in agriculture, living far away from one another. This low population density makes any state- or community-wide water treatment intervention costly and impractical.

Details of the Intervention: 

This study will evaluate the demand, use, and impacts of one household level water treatment technology. The Kosim filter is a ceramic filter marketed and sold by Pure Home Water, a Ghana-based NGO. This simple product has been proven to be highly effective at improving water quality and is appropriate for the region, since it removes particles and pathogens from water without the use of chemicals or electricity which require some form of delivery.

Researchers are measuring the willingness to pay of households for the Kosim filter by offering a random selection of households the opportunity to purchase the filter through door-to-door sales. Households will also be offered a randomized price for the filter, to determine price effects and willingness to pay for preventive health technologies.

Researchers will collect data from 1,500 households on water quality, education, income, consumption, health, diarrhea disease knowledge and water treatment and storage practices to see how these variables affect the willingness to pay for a filter. The randomized offer price provides a means to estimate the filter’s health impact and health spillovers among neighbors, without letting a set price screen out households who have a lower value for clean water. Thus, researchers can evaluate different techniques for creating behavioral change, such as the adoption of new water treatment technologies and storage techniques, and the propensity of individuals to drink treated water and provide treated water to their children.

Results and Policy Lessons: 

Forthcoming

[1] As of 2004. WHO, “The Top Ten Leading Causes of Death” (accessed Nov. 6, 2009)

[2] WHO, “Mortality Country Fact Sheet 2006, Ghana.” (accessed Nov. 6 2009)

[3] United Nations, Human Development Report 2009 "Ghana" (accessed Nov. 6, 2009)

Chlorine Dispensers for Safe Water in Kenya

Policy Issue:
Two million children die of diarrheal disease each year and contaminated water is often to blame. Treating water with chlorine could substantially reduce this toll. The most common approach to chlorination in areas without piped water infrastructure is to offer small bottles of chlorine for sale to consumers.However, chlorine use has been slow to catch on in this system. In this Kenyan study area, for example, less than 10% of households regularly use chlorine at a monthly cost of approximately US$0.30, despite several years of vigorous social marketing that has raised awareness about the product
 
Details of the Intervention:
Researchers examined free provision of dilute chlorine via a point-of-collection system, which includes a container to dispense the product placed at the water source, a local promoter to encourage the product’s use, and free provision of a supply of chlorine solution packed in bulk. This bulk supply dramatically reduces delivery costs relative to the retail approach, which requires packaging chlorine in small bottles, and relative to door-to- door distribution, which in addition significantly raises marketing costs. Hence, bulk distribution to water sources makes free provision more realistic. Additionally, this delivery method makes chlorine use very convenient. Users can treat drinking water when they collect it. The required agitation and wait time for chlorine-treated water are at least partially accomplished automatically during the walk home from the source. The source-based dilute chlorine disinfection approach to water treatment makes this act salient and public, in addition to making it cheaper and more convenient. The dispenser provides a daily visual reminder to households to treat their water at the moment when it is most salient—as water is collected—and maximizes the potential for learning, norm formation, and social network effects by making the dispenser public. Potential users can see others who use the dispenser, and they have the opportunity to ask questions; they will also know that others will see whether they use the dispenser
 
Results and Policy Implications:
Take-up of chlorine provided through dispensers dramatically exceeded take-up of chlorine for treating water for in-home use. When communities were randomly assigned to receive a promoter and a community dispenser, take-up was approximately 40% in the short run (three weeks) but climbed to more than 60% by the medium term (three to six months), representing 37- and 53-percentage point gains, respectively, compared to the communities that did not receive them.
 
In contrast to the take-up levels achieved with the dispensers, clinic-based coupon redemption started higher and dropped over time. More than 40% of households that were given coupons redeemed them 8 months into the program, but this figure fell to 20% by 12 months. This finding suggests that the success of the dispenser may be due not only to the zero price but also to the reduction in the psychic cost of remembering to treat water that is achieved by source-based treatment as well as other attributes, like the visual reminders. Although take-up rates are slightly lower than those achieved in some trials, the dispenser system relies far less on outside personal contact (e.g., from repeated household visits from enumerators) than do those approaches; hence, costs are significantly lower. The chlorine dispenser is extremely cost-effective, with a comparative study finding dispensers the most effective from a range of low cost approaches to reducing diarrhea. 
 
The success of the chlorine dispensers at the proof-of-concept stage described here led to a concerted effort to scale the intervention up as a sustainable program. As of April 2014 over 1.8 million people were being served by chlorine dispensers, with plans to reach four million by the end of 2014.
 
The program has transitioned to Evidence Action, a new organization started with the support of IPA to scale evidence-based initiatives. More information can be found on their website here.
 

Creating a Toilet Habit, Kenya

Despite expanding access to sanitary options such as community toilets, many individuals, especially in urban slums, continue to practice open defecation. One potential explanation is that open defecation has become an ingrained habit. Applying lessons from psychology and neuroscience, researchers are evaluating whether a combination of economic incentives and a marketing campaign can foster a new habit—using hygienic latrines instead defecating in the open—among slum dwellers in Kenya.
 
Policy Issue:
Sanitation coverage for urban dwellers in low-income countries remains low. In Sub-Saharan Africa, for example, only 42 percent of the urban population has access to sanitation. Even when individuals have access to sanitation options, such as community toilets, usage of these facilities remains low and many households continue to practice open defecation. One potential explanation for the persistence of this practice is that it has become an ingrained habit that individuals continue to engage in despite having a better alternative.
 
Can interventions designed using lessons on habit formation from psychology and neuroscience encourage individuals to switch to a better habit? Private sector firms have successfully used this type of interventions to foster new habits. For example, advertising campaigns that associated triggers (a feeling of uncleanness when people run their tongue across bacteria plaque on their teeth) and rewards (a tingling sensation after brushing) with brushing regularly with mint-scented toothpaste encouraged millions to adopt it as a daily routine. However, there is little evidence on whether similar interventions would work when it comes to individuals’ hygiene choices in developing countries. 
 
Context of the Evaluation:
The study takes place in Mukuru, a slum in the Kenyan capital of Nairobi. About 80 percent of the 500,000 people living in the slum do not have adequate access to sanitation. Sanergy is a social enterprise working to address this unmet sanitation need. Sanergy builds and franchises community toilets (called Fresh Life Toilets, or FLTs) to local entrepreneurs. These entrepreneurs charge pay-per-use fees for the toilets they operate and generate additional income by converting human waste to fertilizer at a central processing facility. Each FLT serves up to 100 users per day and provides personal hygiene products such as soap and water. While Sanergy has grown its network of toilets rapidly since its launch in 2010, low demand continues to be a challenge. 
 
Details of the Intervention:
Applying lessons from psychology and neuroscience, researchers are partnering with Sanergy to evaluate whether a combination of economic incentives and a marketing campaign can foster a new habitusing hygienic latrines instead defecating in the openamong slum dwellers in Kenya.  
 
Sanergy will issue discount vouchers intended to instill toilet usage as a habit, and pair these with a marketing campaign that will associate a certain characteristic of the FLT (for example, water and soap) with a feeling of cleanliness. In addition to this marketing campaign, Sanergy will also advertise to a random subset of voucher recipients a financial reward that increases with the number of vouchers redeemed.
 
While all 3,000 individuals participating in the evaluation will receive vouchers, the specific features of the vouchers will vary across recipients. Sanergy will randomly assign individuals to one of four treatments groups or to a control group:
 
 
 
Intensity of Voucher Discount
Control group
 
Number of Vouchers
 
60 percent
100 percent
(free usage)
20 percent
60
High number, low discount
High number, high discount
Nominal discount to incentivize participants to present their vouchers upon usage
30
Low number, high discount
Low number, high discount
 
Within each group, Sanergy will offer a randomly selected subset of individuals time-delimited vouchers, which will be redeemable only during a specific two-hour window during the day. The remaining individuals will be offered vouchers that can be used anytime during the day. 
 
Researchers will recruit households living within a two-minute walk from a FLT and collect data on how often they use their nearby FLT during the subsidy period and in the year after the subsidies end. Researchers will also track the exact times at which individuals use the toilet.
 
Results and Policy Lessons:
Study ongoing, results forthcoming.

 

Mushfiq Mobarak

Demand for Rainwater Harvesting Devices in Uganda

Accessing safe drinking water is a major challenge in many developing countries. In order to improve access to safe drinking water, Relief International (RI) has developed a rainwater storage device (RSD), which consists of a rubber bag approximately 1.5m across and 1.5m tall when full. Researchers are evaluating this new technology in Kamwenge district in Uganda. 

Policy Issue: 

In many developing countries, poor access to safe drinking is an acute problem, with both health and social repercussions. Lack of safe water for drinking, bathing, and other household tasks is the primary cause of diarrheal diseases, which account for 15 percent of deaths among children under five years of age.[1] Poor access to water also entails large time costs associated with gathering water. In some parts of Africa, women spend up to eight hours per day collecting water. New technologies, such as rainwater storage devices, could improve access to safe drinking water and decrease the time needed for water collection. However, such new technologies are only useful to the extent that they are affordable and acceptable to the intended beneficiaries. Before any large investments are made in the development and distribution of a technology, it is necessary to determine the potential size of the market, the most effective marketing strategies to promote adoption, and the potential impacts it could have on the lives of the poor.

Context of the Evaluation: 

In order to improve access to safe drinking water, Relief International (RI) has developed a rainwater storage device (RSD), which consists of a rubber bag approximately 1.5m across and 1.5m tall when full. The bag is held up by a simple earthen foundation and is fed by a series of gutters. It can hold up to 1000 liters of water, which is estimated to meet the basic needs of a family of five for ten days. 

Researchers are evaluating this new technology in Kamwenge district in Uganda. Residents of Kamwenge are particularly likely to benefit from a rainwater storage device, as the district receives substantial rainfall during the two rainy seasons – the first and smaller of the two lasts from the end of February to the end of April, while the second and longer season lasts from mid-September to the beginning of December. 

Details of the Intervention: 

This study will assess the demand for rainwater storage devices and determine potential marketing strategies. Specifically, researchers will randomly vary the incentives and marketing conditions associated with the sale of rainwater storage devices to different households. Researchers will experimentally vary the price for the device by offering discount vouchers to random subsets of households.

Researchers will also randomly apply two different marketing schemes across villages. In the first scheme, a product ambassador will be chosen from each village and given training and materials to promote the device within the village. In the second marketing scheme, the first household within each village that purchases the device at full price will receive free installation. Both marketing schemes are intended to increase locally available information about the device and promote take-up by others in the village. 

The intervention will be implemented in two distinct waves spread 6 months apart, in order to study the importance of information transmission in generating demand for the new technology. For instance, it may be the case that second-wave households would have had some indirect experience with the new technology through their friends who adopted in the first wave, affecting their likelihood of adoption. The two-wave strategy also creates the opportunity to examine whether the overall level of demand changes once society becomes more familiar with the product and its price is anchored. 

A follow-up survey will measure women’s participation in the workforce, child school attendance, and changes in household economic activity among adopters and non-adopters.

Results and Policy Lessons

Results forthcoming.

1. World Health Organization (WHO). World Health Statistics 2011.http://www.who.int/whosis/whostat/EN_WHS2011_Full.pdf

Mushfiq Mobarak

Experiments to Improve Participation in a Recycling Program in Northern Peru

Policy Issue:
Economic growth in Latin America has come at the cost of increasingly acute environmental pressures. Expanding trade and consumption has led to increased waste generation and pollution requiring more developed solid waste disposal systems. Markets lack a price mechanism to internalize the environmental cost of this growth.  Policy makers often apply taxes, subsides or other mechanisms to attempt to align private incentives with public environmental preservation. Aside from altering financial incentives, growing evidence from psychology and behavioral economics research shows that behavior can successfully be influenced by leveraging social norms and emotions.  
 
Context:
Over 20,000 tons of solid waste are produced every day in Peru, most of which is dumped in waterways or informal trash heaps, making solid waste management an area of increasing concern for the country. PRISMA, a local NGO, operates a recycling program in Northern Peru whereby it trains and supports workers in forming associations that collect recyclables door to door from participating households. In addition to providing the informal workers with some initial tools and training, PRISMA further assists workers by canvassing the areas of operation to introduce the recyclers to the community and encourage the residents to segregate recyclable and take part in the recycling program. PRISMA was interested in identifying viable strategies to increase program uptake (34% at baseline), and reduce attrition of participating households from the program.
 
Description of Intervention:
Researchers worked with PRISMA to test a series of information messages aiming to improve take-up and participation its recycling program.
To improve take-up of households in communities where PRISMA planned to expand the program, researchers conducted a randomized evaluation to test the impact of different messages in eliciting program participation.  One week before the first PRISMA canvasser’s visit, a paper flyer was delivered with the a generic message about PRISMA’s program and one of nine specific messages eliciting pressures such as, social norm, peer comparison, conformity, authority, environmental or social benefits to increase participation.
 
Households that owned a cell phone and were willing to share their number (about 35% of the sample) received text messages once a week with the specific message in addition to the flyers. 
 
With a sample of 1,785 existing participants, researchers tested strategies to reduce program dropout and increase the amount and quality of the recyclables collected. Plastic bins were randomly distributed to households participating in the study. Some bins had a sticker specifying which items could be recycled.  Household that provided cell phone numbers were randomly assigned to receive either a generic or personalized SMS reminders to recycle or to serve as a comparison group without SMS reminders. SMS messages were sent the day before the weekly visit by the recycler, for a period of six weeks. Data collection for this component of the study lasted for eight weeks and included a careful accounting of the quantity and quality of recyclables received.
 
Results and Policy Lessons:
Results of Treatments on Program Enrollment: The results reveal no statistically significant effects from the different treatment messages. No significant impact on program take-up for the information campaign conducted through flyers alone or through flyers with text messages were found. Messages conveying social norms and applying social pressure were not successful in leveraging behavioral change. Two interpretations for this outcome are proposed by the researchers: a) these messages and norms were not relevant in this context, b) the large presence of informal recyclers operating outside of the program rendered separation of recyclables at the household level a non-issue.
 
Results of Treatments on Compliance: Households who received plastic bins turned in recyclables 3-8 percent more of the times and produced on average more (about 0.2 kg) and more valuable recyclables (about 0.1 pesos).  This finding suggests that convenience of storing recyclables is a barrier to greater program participation. 
The SMS reminders had no significant impact on the level and quality of participation of households in the program, suggesting that forgetfulness is not a serious constraints among households enrolled in the program. There was no clear difference in recycling compliance between households who received plain bins and those who received bins with explanatory stickers.

Market Structuring of Sludge Management for the Benefit of Vulnerable Households in Dakar

Poor sanitation in the developing world leads to childhood diarrhea, a leading cause of mortality in children under five.1 This project seeks to identify ways to increase demand and reduce prices for an improved sanitation technology, mechanical desludging. Researchers are measuring the effects of social and behavioral factors (social pressure, learning, and payment formats) on household demand, and the effect of different auction mechanisms on collusion and prices paid by consumers.

Policy Issue:
In urban areas of developing countries where houses are not connected to publicly-provided sewer systems, a household’s waste goes into its own septic tank or unimproved pit, which then has to be emptied, or “desludged.” A household can either pay to have the pits shoveled out manually, which often means dumping it near adjacent homes, posing health hazards to both workers and residents, or hire a mechanized desludger which pumps the sludge into a truck that then delivers the sludge to a treatment plant. Mechanized desludgers are more expensive, but also more sanitary. Because they are often underutilized, research is needed to better understand how to increase demand and decrease prices for these services.
 
Context of the Intervention:
In Dakar, Senegal, waste pits fill on average every six months, but only an estimated 30 percent of households use mechanized desludging because of the expense. Estimates suggest that a mechanized desludging costs approximately five days’ wages while a “baay pelle” (a worker who shovels the pit manually) costs approximately two days’ wages. The Office National de l’Assainissement du Senegal (ONAS), part of the Senegalese Ministry of Sanitation, is seeking to identify ways to boost usage of the more expensive, but more sanitary, mechanized desludging.
 
Details of the Intervention:
This project seeks to understand how to increase use of mechanized desludging, from both the demand (customer) side and supply (provider) side. 
 
Demand Side Interventions:
Four thousand households will be randomly assigned to receive a discount of either 10 or 50 percent on mechanized desludging services. To understand the extent to which social pressure influences use of mechanized desludging, this discount will be made by public lottery for half of the households, and for the other half it will be offered privately. A further 800 households will be surveyed to evaluate the effects on those nearby who were not offered subsidized mechanized desludgings.
 
The impacts of learning from others and coordination will be measured when 100 randomly chosen households are told either how many or specifically which of their neighbors have signed up, and are then given the opportunity to sign up. To measure learning from doing, researchers will see whether those who received subsidized services continue after the discount ends. 
 
A number of payment structures will also be tested. Eighty percent of households will be asked to leave a deposit at the time of the survey if they would like to sign up for the subsidized mechanized desludging. One third of households will be asked to pay the remainder at the time of service, one third will be given a savings account earmarked for desludging and billed monthly, and one third will be given the same earmarked savings account, but allowed to contribute whenever they wish. Half of households will also be offered a general, non-earmarked savings account. Varying the frequency of payments and savings options will test the relative importance of commitments and mental accounting to encourage payment and usage.
 
Supply Side Interventions:
Anecdotal evidence suggests that desludging firms discuss prices among themselves and coordinate pricing for the different neighborhoods of the region. A new call center, developed by the researchers together with ONAS and the NGO Water and Sanitation for Africa (WSA), will handle contracting of desludging jobs for households in the study. When households are ready for desludging, they can call the center and desludging truckers will bid on their job using text messages. The new call center will allow researchers to test whether changing the auction mechanism can lower pricing for customers. Jobs will be assigned randomly to either an open auction, with the current lowest bid and firm name sent out by text message every 15 minutes, or a sealed bid format, where bidders compete anonymously. This randomization will test if either bidding strategy leads to lower prices than the current system, which involves customers negotiating individually with truckers.
 
This call-in center will not only be available to those households participating in the demand-side interventions; it will also be available to households across Dakar, with a geographic roll-out over time. Together with WSA, researchers are surveying an additional 4,000 households in baseline, midline, and endline surveys to estimate the impact of the roll out of the call-in center on the general unsubsidized population. These households will be far enough away from the demand-side households that they should not be affected by the subsidies offered to those households. Researchers are also surveying all 150 sanitation truckers in the Dakar area.
 
Results and Policy Lessons:
Results forthcoming
 
 

World Health Organization. 2009. “Fact sheet N°330: Diarrhoeal disease.” http://www.who.int/mediacentre/factsheets/fs330/en/index.html.

 

Harvesting Rainfall: Cistern Deployment in Northeast Brazil

What is the impact and cost-effectiveness of rain-fed water cisterns as a main source of water access in rural areas lacking other water sources? This project studies a 16,000 liter cistern for residential use which is filled during the rainy season, and – in theory – should provide families enough water for cooking and drinking during the dry season.

The technology is well developed, and the Brazilian government has been providing thousands of these cisterns to a target population of millions in northeast Brazil for the last 8 years. However, a rigorous randomized control trial of the adequacy of this technology and its impacts at the household level has not been performed up to now.

We have partnered with the local NGO building the cisterns (ASA) and the Brazilian Government (MDS), and obtained their support for a randomized control trial of their program. Funding for cistern-building has been obtained from the Spanish Development Agency in Brazil and the Brazilian Government.

Source Dispensers and Home Delivery of Chlorine in Kenya

 

Policy Issue: 

Diarrheal diseases are a leading cause of morbidity and mortality in the developing world, killing an estimated 2.6 million people per year between 1990 and 2000. Children under 5 experience an average of 3.2 diarrheal episodes per year1 and diarrheal diseases account for 20 percent of deaths in this age group.2  Even when diarrheal episodes are not fatal, they can have long-term impacts on children’s cognitive and physical development. Diarrheal diseases are often transmitted when a water supply is contaminated with fecal matter, and may be endemic in places where the water supply is irregular. Practices from handwashing to water source protection are proven to reduce diarrhea episodes, yet the adoption of such practices has been slow in regions across the developing world.

 
Context of the Evaluation: 

Despite widespread awareness of the dangers of drinking unsafe water, there is extremely low adoption of sanitation or clean water practices in rural Western Kenya. While three quarters of households have heard of point-of-use water chlorination and 70 percent admit that drinking dirty water causes diarrhea, only 5 percent of households report that their main drinking water supply is chlorinated. The most common method of water chlorination is through the individual purchase of chlorination products, which must be added to water at home. Community level chlorination has been considered as another strategy to increase chlorine take up. Much cheaper than individually packaged bottles, point-of-collection chlorine dispensers can be used at the sources where people collect their water. Here, social pressure may be maximized by making each individual’s sanitation choice publicly known.

 
Details of the Intervention: 

Researchers sought to examine the impact of factors including price, persuasion, promotion and the chlorination products themselves with a two-phase study. Prior to the study baseline surveys were administered to a random selection of households.

In the first phase, households were given seven WaterGuard bottles, an individual water treatment product, each sufficient for one month’s supply of clean water. They were also provided with improved drinking water storage pots with a tap to prevent contamination and detailed instructions on use. One third of this group received twelve coupons for a 50 percent discount on WaterGuard bottles, each valid for one month during the next year, and calendars with reminders. Another third received additional verbal persuasion messages beyond the basic WaterGuard instructions, and another third received no additional coupons or messages. To estimate social networking effects, the free WaterGuard bottles were distributed in different percentages in each community, allowing researchers to see if higher community levels of use increased individual adoption. A follow-up survey was administered between 2 and 7 months after the free WaterGuard was distributed.

In the second phase researchers compared six different treatments designed to increase WaterGuard adoption. For the first three treatments, scripted promotional messages were delivered at either the (1) household level, (2) community level, or (3) both. The second two treatments included repeated promotion of chlorination through a home visit by a community elected promoter. Despite volunteering to work for free, the promoter was paid either a (4) flat rate, or was (5) paid based on how many households had chlorinated water at follow-up visits. The last treatment (6) combined the incentivized promoter model with an unlimited supply of free WaterGuard delivered through a point-of-collection chlorine dispenser at the local water source. Follow-up surveys were conducted 3 weeks and 3-6 months after the start of the study.

 
Results and Policy Lessons: 

Impact of Free Home Distribution: Most households have a low willingness to pay for chlorine, despite its well known benefits. After receiving a free 7-month supply, chlorine was detected in 58 percent of households, much more than the 2 percent starting level. Still, only 10 percent of the distributed coupons were redeemed. Where WaterGuard bottles were distributed freely, additional persuasive messages had no effect on take up, and in retail markets they only had short-term effects. There appeared to be no “social networking” effects of living in a community with a higher level of chlorination, and no evidence was found that price was an effective screening mechanism to target households who are more likely to benefit from cleaner water.

Impact of Persuasion: Hiring local community members at a low wage to promote chlorine use among their neighbors is highly effective at increasing use. Chlorine was detected in 40 percent of households visited by a promoter, compared to only 4 percent in those who weren’t visited. Incentivizing these promoters had only modest effects. Communities with point-of-collection chlorine dispensers in combination with promoters saw 61percent of households chlorinate their water, up from only 2 percent prior to the study, suggesting that this is a highly cost-effective way to promote take up.

Scale-Up: Investments in marketing campaigns and coupon schemes proved to be ineffective strategies to encourage point-of-use chlorination. Free chlorination dispensed at water sources along with community promoters provided the most effective strategy to improve water cleanliness, potentially preventing diarrheal incidence in areas such as rural Kenya.

 

1 Disease Control- Priorities Project, “Public Health Significance of Diarrheal Illnesses,” http://www.dcp2.org/pubs/DCP/19/Section/2531.

2 Parashar, Umesh, et al. “Global Illness and Deaths Caused by Rotavirus Disease in Children,” Emerging Infectious Diseases. Vol. 9. May, 2003.

Cleaning Natural Springs in Kenya

 

Policy Issue: 

Diarrheal diseases are a leading cause of morbidity and mortality in the developing world, killing an estimated 2.6 million people per year between 1990 and 2000. Children under 5 experience an average of 3.2 diarrheal episodes per year,1 which accounts for 20 percent of deaths in this age group.2 Even when diarrheal episodes are not fatal, they can lead to severe dehydration and have long-term impacts on children’s cognitive and physical development. Diarrheal diseases are often transmitted when a water supply is contaminated with fecal matter, and may be endemic in places where the water supply is irregular.

 

Context of the Evaluation: 

Diarrhea is widespread in rural Kenya, where 43 percent of the population gets their drinking water from nearby springs, usually transported in 10 to 20 liter jerry-cans. Landowners have no incentive to improve the sanitation of water sources on their property because custom requires them to allow everyone free access to springs. As such, water is often contaminated by surface rainwater runoff as it seeps from the ground, and this contamination is spread to the population who collect drinking water at the spring. However, people are often reluctant to change their habits to include behaviors that may reduce diarrhea incidence such as hand washing or daily chlorination of water, resulting in low uptake for these “point of use” interventions.

 
Details of the Intervention: 

Researchers sought to find an inexpensive way to improve water quality at the source, and thereby reduce the burden of diarrhea by making improvements to springs. Working with a local NGO, they identified 200 springs in the Busia district of Kenya, and persuaded each local community to contribute 10 percent of the costs of the improvement project, usually in labor. At a cost of about US$1,000 per site, half of these springs had their sources encased in concrete, forcing water to flow through a pipe rather than seeping from the ground, thus preventing contamination from groundwater. NGOs conducted community meetings at which user committees comprised of local residents were selected and placed in charge of maintaining the protected springs. These committees were responsible for performing basic maintenance, including patching concrete and clearing drainage ditches, at an average cost of US$35 per year via community contributions.

Household characteristics such as income, education and health were approximately equal among the two groups at the start of the program, suggesting that there were no systematic differences between communities that had their springs protected and those that didn’t. Throughout the program, statistics were collected on the level of water contamination and diarrheal disease in all communities and by examining changes in these measures, impacts of the intervention could be assessed.

 
Results and Policy Lessons: 

Impact on Diarrhea: The simple infrastructure investment of “spring cleaning” significantly reduced both water contamination and the incidence of diarrhea. There was 66 percent less E-coli contamination in treated springs than in untreated ones, and an average of 24 percent less contamination in users’ home water supplies among households who collected water from multiple springs and those who only used protected springs. This incomplete transfer of benefits may be due to the fact that households may transport and store water in contaminated vessels.

Despite these mitigating factors, diarrheal incidence in children under 3 years old fell by 4.7 percentage points, or 25 percent, though there was no significant effect on children ages 5 to 12. Interestingly, diarrhea reduction was disproportionately concentrated among girls, suggesting that spring cleaning could be an effective tool for the improvement of female child survival.

Behavior Modification: Possibly due to the apparent benefits of using protected springs, families began increasing their use of protected springs for drinking water, relative to other sources. However there were no significant changes in water transportation, home water chlorination, boiling or hygiene practices, implying the experience with significantly cleaned water did not increase people’s taste for water improvement.

Willingness to Pay: Researchers used the information gathered about changes in use of protected springs to estimate how much time households were willing to expend to get cleaner water, and by extension how much they were willing to pay for it. These empirical estimates were approximately one third of what households report they are willing to pay for clean water and less than one-tenth of the value that policymakers often use when assessing social programs. The travel habits of residents of Busia, Kenya suggest that they are willing to spend at most 10.1 work days, or about US$0.89 to avert a diarrhea case. Using a high estimate for the value of time, this suggests a valuation of US$2,715 per averted child diarrhea death, far below the estimated value of a statistical life, and the cost-effectiveness cutoffs usually used in analyses of health projects in less developed countries. This implies that people either do not understand the causal link between clean water and diarrhea, which anecdotal evidence suggests they do, or that they place a lower value on improving infant and child health than typically assumed.

 

1 Disease Control- Priorities Project, “Public Health Significance of Diarrheal Illnesses,” http://www.dcp2.org/pubs/DCP/19/Section/2531. 

2 Parashar, Umesh, et al. “Global Illness and Deaths Caused by Rotavirus Disease in Children,” Emerging Infectious Diseases. Vol. 9. May, 2003.

 

Household Water Connections in Morocco

Many people in the developing world lack access to clean water.  Can providing clean water make kids healthier? Will children attend school more often? Will adults be able to work more regularly? We worked with the Government of Morocco to evaluate the impact of offering piped water connections at a subsidized price, and on credit. It turned out that there were no major health or educational benefits as most households already had access to free public taps, but people were willing to pay for a private tap at home, and the time saved walking to the tap made for more free time and higher self-reported happiness.

Policy Issue: 

Households in developing countries spend considerable amount of time fetching water. The time-burden of water collection does not typically spare anyone in the household, but in many countries it is borne primarily by women and girls. Most interventions to connect poor households to the drinking water network are primarily concerned with improving physical health. Yet, over and beyond its direct effect on physical health, improved water access could have important effects on the household well-being. By reducing the time burden of water collection, improved water access not only frees up time that could be spent on additional leisure or production (paid labor or schooling), but also removes an important source of stress and tension. But it might also be welfare-reducing as women face restricted mobility outside of excursions to collect water. An in-home water connection could cut off an important opportunity to socialize.

Context of the Evaluation: 

In urban Morocco, the setting of this study, households that rely on public taps spend more than seven hours a week collecting water, despite a relatively high density of water taps. In our sample, 65% of households without a water connection report that water is a major source of concern: 15% have had a water-related conflict within the family and 12% with their neighbors. Thus, both within the family and between families, water seems to be the primary source of stress and tension.

Details of the Intervention: 

J-PAL worked in collaboration with Amendis, the local affiliate of an international private utility company, which operates the electrical and wastewater collection networks as well as the drinking water distribution in Tangiers, Morocco. In 2007, Amendis launched a social program to increase access to piped water and sanitation. As of the end of 2007, approximately 845 low-income households living in “on-the-grid neighborhoods” of Tangiers (i.e. in principle easily connectable) did not have a household water connection because they could not afford the connection fee. These households had free access to public taps in their neighborhood, however, and they also all had sanitation facilities at home.

The program provided a subsidized interest-free loan to install a water connection. The loan was to be repaid in regular installments with the water bill over three to seven years. The subsidy did not cover the cost of installing the connection or the cost of water consumed. To pilot-test the program, a door-to-door awareness campaign was conducted in early 2008 among 434 households, randomly chosen from the 845 that needed a connection. Those households received information about the credit offer as well as help with the administrative procedures needed to apply for the credit. The remaining households (the comparison group) were eligible to apply for a connection on credit if they wanted to, but they received neither individualized information nor procedural assistance until 2009.

Results and Policy Lessons: 

Since the participating households already had access to the water grid through free public taps, no improvements in the quality of water consumed by households have been found. Despite significant improvement in water quantity, no change in the incidence of waterborne illnesses was found. Nevertheless, households are willing to pay a substantial amount of money to have a private tap at home. Getting connected generates important time gains, but does not lead to increases in labor market participation, income, or schooling attainment. The spared time seems to be used for leisure and social activities.  Because water is often a source of tension between households, home connections appear to improve social integration. Overall, despite the financial cost, households’ self-reported happiness improves substantially when they are connected to the water system at home.

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