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)

Jim Berry, Greg Fischer, Raymond Guiteras

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.

Michael Kremer, Jessica Leino, Edward Miguel, Sendhil Mullainathan, Clair Null

Can Higher Prices Stimulate Product Use? Evidence from a Randomized Experiment in Zambia

Policy Issue: 

More than 1 billion people living in low-income countries do not have access to clean drinking water,1 leaving them at risk for diarrheal diseases which are transmitted when a water supply is contaminated with fecal matter. Diarrhea remains a serious concern in low-income countries, where it caused 2.6 million deaths per year between 1990 and 2000.2 Even when diarrheal episodes do not prove fatal, they can have long-term consequences on a child’s cognitive and physical development. Multiple interventions from handwashing to water source protection have been considered, but questions remain. Particularly, it is not known whether people will be more likely to use a product if it is given for free, or if the consumer is charged a small positive price.

Context of the Evaluation: 

Contaminated water is a leading cause of diarrhea in Zambia, where only 64% of the population has access to safe drinking water sources. Among children under five, 21% have had diarrhea in the past two weeks, regardless of water source or location.3 Many homes in Lusaka, Zambia’s largest city, obtain water from un-sanitized sources. Clorin, an inexpensive chlorine bleach solution used to kill pathogens in drinking water, is a popular product in Zambia to reduce the incidence of water-borne illnesses, and approximately 80% of people have used it at some point. Charging for this effective health intervention could potentially discourage use, but by virtue of having paid for it, it is also possible that people might value the product more, increasing its use. Because it is hard to determine using observational data whether higher prices results in more product usage, or simply deliver the product to those who value it most, an experiment is needed help separate the effects.

Details of the Intervention: 

Researchers present evidence on the effect of prices on product use from a large-scale field experiment. The intervention consisted of a door-to-door sale of Clorin at a randomly chosen, below-market “offer price” to about 1,260 households with poor access to piped water or chlorine home-delivery. Clorin, retailing for about 25 cents, is inexpensive so as not to discourage use based on income. Those who chose to buy the product were then offered a randomly chosen discount, allowing for a varied “transaction price”. Researchers returned to those households and conducted a follow-up survey and chemical water test to determine how often Clorin was used.  

Screening and Sunk Cost Effect:Researchers sought to find whether higher prices can help target those who would most use the product (screening effect) by seeing if, as the offer price rose, those who chose to buy Clorin had higher usage, implying higher expected benefits. Researchers also sought to determine whether higher prices resulted in a higher propensity to use (sunk cost effect). Assuming households incur a higher psychological cost if they do not use a product they have paid more for, they will be likely to use Clorin if the price was increased. Therefore, for a given offer price, a higher transaction price could lead to a stronger desire to rationalize one’s purchase through use.

Results and Policy Lessons: 

Impact on Clorin Use:Researchers found that fewer people bought Clorin as the price rose; for every 1% increase in price there was a 0.67% decrease in quantity demanded. However higher prices did appear to screen out those who would not have used the product in any event, and a higher willingness to pay was associated with greater propensity to use. As the offer price increased by 10%, use increased by 4% on average among those who did buy the Clorin. No sunk cost effect was observed.

Overall, the use of chlorine does decrease with higher prices due to dampened demand, but this decline is partially offset by better targeting of the product to families who are likely to use it. Significantly, there was no evidence that higher offer prices screened out poorer or less educated households.

1Un/UNICEF, “Water for Life,” http://www.who.int/water_sanitation_health/waterforlife.pdf.
2 Disease Control- Priorities Project, “Public Health Significance of Diarrheal Illnesses,” http://www.dcp2.org/pubs/DCP/19/Section/2531.
3 PSI/Zamia, “Society for Family Health: PSI/Zambia,” http://www.psi.org/zambia

 

Nava Ashraf, Jim Berry

Balancing Health Benefits and Risks of ACT Subsidies for Africa

Policy Issues:

Malaria is one of the world’s foremost public health concerns, killing close to 1 million people every year.  In many malaria-endemic regions, resistance has developed to all but one class of antimalarial drugs, called artemisinin combination therapies (ACTs). ACTs sold in the retail sector are unaffordable for the poor, and although heavy subsidies can make them accessible, the benefits of treating more people and lowering transmission rates must be balanced against the risk of overtreatment, which can hasten the development of drug resistance. A new malaria testing technology, the rapid diagnostic test (RDT), has made it possible to perform malaria testing in the retail sector, but these tests are not demanded at prevailing prices. How can policymakers tailor the prices of subsidized drugs and diagnostic tests to target those truly sick with malaria and prevent those who do not need ACTs from taking them?

Context of the Evaluation:

In Kenya, ACTs are now the only effective class of antimalarial drugs. The incidence of malaria in Western Kenya is very high, with nearly 70 percent of households self-reporting an episode of malaria in the month before baseline. ACTs at government health centers in Kenya are nominally free, but health centers feature long waits and limited hours, are often stocked out of medication, and the remotely-located poor often cannot afford to travel the distance to get there. Consequently, many people opt to purchase cheaper, less effective anti-malarials over-the-counter at drug shops located closer to home.

The Affordable Medicines Facility for malaria (AMFm) is an initiative currently being considered by major international aid agencies in which ACTs would be heavily subsidized to first line buyers throughout Africa (the subsidy policy is currently being piloted in 8 countries). But such a high subsidy could lead to overtreatment.  If people who do not have malaria presumptively buy ACTs without a diagnosis, this can contribute to drug-resistance, waste subsidy money and delay appropriate treatment for the true cause of illness.  Improving diagnostic access could considerably reduce overtreatment, but there has been little research so far in this area.

Description of Intervention:

The intervention took place in the districts of Busia, Mumias and Samia in Western Kenya. Researchers distributed vouchers redeemable at local drug shops to all households within four kilometers of four rural market centers. The households were randomly assigned to one of three groups:

Comparison

Treatment

I. No subsidy

II. ACT Subsidy Only

III. ACT and RDT Subsidy

Households received a voucher to buy ACTs at the market price of 500 Ksh (about US$6.25)

Households received a voucher for ACTs giving them either an 80 percent, 88 percent, or 92 percent subsidy.

Households received an ACT voucher as in group II, and also received an RDT voucher with either an 85 percent or 100 percent subsidy.

In order to find out what fraction of people buying ACTs were truly malaria positive—a proxy for how well the ACT subsidy under the AMFm would be targeted—the   researchers also selected a random subset of the households in treatment II and III to receive the offer of a “surprise” free RDT after they completed their transaction at the drug shop.

Trained study officers were posted at each of the four participating drug shops during opening hours every day throughout the study period. When a household member came into a drug shop to redeem his or her voucher,  study officers recorded details such as medicines bought, symptoms, patient characteristics, and true malaria status in case an RDT was administered.  

Results and Policy Lessons:

An ACT subsidy increases access, especially for the poorest households (measured by the literacy status of the household head). Without subsidies, literate-headed households take ACTs for 37 percent of illness episodes as compared to 11 percent of episodes in illiterate-headed households. With subsidies, the coverage rates become 45 percent and 38 percent, respectively.

A lower subsidy level improved targeting to malaria-positive individuals without compromising access to ACTs among those who need them. At the two lower subsidy levels (80 and 88 percent), households were less likely to use an ACT voucher for adults, but no less likely to use a voucher for young children, who are much more likely to actually have malaria and for whom malaria is most dangerous. As a result, targeting improved.

At the two lower subsidy levels, about 75 percent of patients for whom care was sought at the drug shop tested positive for malaria, while at the 92 percent subsidy level only 56 percent tested positive. Households were very willing to take RDTs, even when asked to share some of the cost: when the test was available, over 80 percent of the households who sought treatment at the drug shop chose to take an RDT before deciding what medication to purchase. However, many chose to buy an ACT even if they tested negative.

This evaluation suggests that an information or marketing campaign about the reliability of rapid diagnostic tests might help convince people to use and comply with them – but even without such a campaign, moving from the target AMFm subsidized price (92 percent of the retail cost) to an 80 percent ACT subsidy with RDTs could increase the share of ACT takers who are malaria positive at the drug shop by 24 percentage points.

While these results suggest that a slightly lower ACT subsidy than the one proposed by the AMFm would improve targeting without compromising access, the results also make it clear that a large ACT subsidy is needed in order to increase access among the neediest. Taking some of the planned ACT subsidy money away from ACTs and putting it towards subsidizing and promoting RDTs could improve targeting and be particularly effective among adults, especially if adherence to test results can be improved.

Jessica Cohen, Pascaline Dupas, Simone Schaner

Communal Sanitation Solutions for Urban Slums in Orissa, India

Can improved toilet facilities, combined with innovative accountability systems for maintenance, increase the use of community toilets in urban India?

Can improved toilet facilities, combined with innovative accountability systems for maintenance, increase the use of community toilets in urban India?

Policy Questions:

In densely populated and rapidly growing countries, severe space constraints, poor utilities infrastructure, and temporary housing construction can render private household sanitation facilities infeasible. Improving communal toilets, which serve entire neighborhoods, may be a more feasible way to improve sanitation, health and well-being in such densely populated areas. However, these kinds of facilities face their own set of problems. Because the benefits of cleaner facilities extend beyond the individual, people may be unwilling to help with repair and maintenance. When the toilets then fall into disrepair, people often revert to open defecation, leading communal toilets to be abandoned. Can innovative systems of facility management help overcome these “collective action” problems and make communal toilets a sustainable option in urban slums?

Evaluation Context:

In the slums of Bhubaneswar and Cuttack in India, almost 45 percent of households use either public toilets, which are meant for a rotating population in commercial areas, or communal toilets, which serve a fixed residential population. However, the condition of these facilities is very poor. A preliminary survey showed that 53 percent of these toilets were either “dirty” or “very dirty”, and one in six facilities was completely non-functional. Households who were dissatisfied with the cleanliness of their community’s toilets were more likely to practice open defecation, and almost 30 percent of households reported doing so. Qualitative research suggests that these poor conditions may be caused by weak systems of accountability for toilet maintenance and repair.

Details of the Intervention:

This program sought to improve the physical infrastructure of community and public toilets, as well as to improve the associated management systems in order to ensure long-term maintenance. The physical infrastructure of a set of existing community toilets and a smaller set of existing public toilets will be updated to ensure that all have an adequate number of gender-separated toilets and washbasins; sufficient lighting and ventilation; and enough water for all services. A set of new toilets will also be constructed to these standards. A randomly chosen subset of both the community and public toilets will also be given enhanced, infrastructure, such as a space for bathing. Half of the improved community and public toilets, including both those with and without the enhanced infrastructure, will be randomly selected to be maintained by a private firm, while the remainder will be managed by the community according to a “constitution” that specifies responsibilities and rights.

In order to identify a solution that will produce the most attractive, sustainable and hygienic alternatives to open defecation for slum residents, researchers will test a variety of complementary household-level interventions, such as discount coupons for shared facilities and varying the pricing structure (monthly passes vs. pay-per-use). Researchers will also conduct a program of demand generation activities in a subset of communities around community and public facilities. These activities will be used to help communities notice the problems associated with open defecation and develop community cohesion to sanction it.

Researchers will collect data to measure take-up and maintenance of sanitation facilities over the life of the program. Household surveys will be used to examine satisfaction with the facilities, instances of diarrheal disease, and differential access within the household.

Results & Policy Lessons:

Project ongoing, results forthcoming.

Mushfiq Mobarak
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