Where there is water, there is life

Adoption of Household Chlorination in Emergency and Development Contexts

in Rural HaitiMichael Ritter

Our ApproachDeep Springs International is a non-profit organization that incubates social enterprises in Haiti under the brand Gadyen Dlo (“Water Guardian”)

Gadyen Dlo system is a Safe Water System which consists of a 5-gallon bucket with spigot and lid along with a bottle of locally produced 0.7% sodium hypochlorite solution

Users add 1 capful to 5 gallons of water and keep refillable bottle in the home; community health workers or technicians sell refills and conduct chlorine residual tests

Deep Springs supports the Gadyen Dlo social enterprise by strategic planning, technical expertise, networking with partners, and subsidies to fill the gap between sales revenue

Emergencies in Haiti

Gadyen Dlo pilot project started in 2002; Deep Springs began managing in 2008

Jan. 12, 2010: 7.0 earthquake>222,000 fatalities; 3 million affectedLeogane: >80% buildings destroyed

October 2010: first cholera case confirmedSince the first case (first 24 months):

600,885 cases and 7,568 deaths“One of the largest epidemics of the disease in modern history to affect a single country”–Pan-American Health Organization

Leogane Quake ResponsePre-quake program

40 health workers selling Gadyen Dlo1,500 households with systems

Quake response165 community health workers (CHWs) trained (125 new CHWs) in Jan. 2010Free distributions (Jan. – July 2010):

15,200 containers distributed1.7 million chlorine tablets distributed

Current program reaches 19,740 households (over half of population of Leogane)

Cholera ResponseAfter earthquake, increased chlorine production capacity in response to quake and in preparation for future disasters

Cholera outbreak resulted in dramatic increase in demand for chlorine among households, government, NGOs

Continued to sell refills directly to households through existing channels (local health agents and distributors)

Developed new distribution channels: bulk sales to NGOs and government

Partners include:

Bulk distributions Household programs

Responsibility for chlorine production Deep Springs Deep Springs

Responsibility for delivering chlorine to users, training

users, ongoing M&E

Partner(Deep Springs provides

train-the-trainer sessions)

Deep Springs (through local distributors

and supervisors)

Number of people reached since start of cholera

2,273,859 individuals525 million liters treated Estimated 2,800 deaths

averted – (P&G assumptions)

307,390 individuals (66,824 HHs)have systems, receive ongoing M&E

Cost recovery Full cost recovery Deep Springs subsidizes promotion and M&E

Financial contribution from users Free to households Households pay $1.25 for bottle

refill; distributors make margin

Post-Cholera Distribution Channels

Observations of Bulk DistributionsBulk distributions reached large scale: DINEPA / UNICEF project aimed to distribute 500,000 bottles of Gadyen Dlo chlorine for free in high-risk zones as part of Phase 3 of national cholera response strategy

Initial adoption was much weaker than in household programs: CDC analysis (364 households) who were targeted in northwest dept. (distributions conducted by local political leaders)

50.3% received a bottleOf those who received:

82.7% reported treating; 51.8% had positive chlorine residual

Sustained adoption even weaker than initial adoption: Deep Springs has production capacity to continue to serve these HHs, but currently provides promotion, M&E and distribution point to <5% of HHs in bulk distributions

Bottles of chlorine sold in Jolivert

Aug-05

Jan-06

Jun-06

Nov-06

Apr-07

Sep-07

Feb-08

Jul-08

Dec-08

May-09

Oct-09

Mar-1

0

Aug-10

Jan-11

Jun-11

Nov-11

Apr-12

Sep-12 -

1,000 2,000 3,000 4,000 5,000 6,000 7,000 8,000 9,000

10,000

BulkHousehold

Household sales (avg. bottles per

month)

Bulk sales (avg. bottles per month)

Total sales (avg. bottles per month)

Pre-cholera 62 months

Aug ‘05 to Sept. ’10735 0 735

Post-cholera24 months

Oct ‘10 to Sept. ‘12790 927 1,717

Tests conducted

(n)

% tests with positive chlorine

residual

% reported Gadyen Dlo use +

positive chlorine residual

Pre-quake: Gadyen Dlo salesAug. 2009 (internal data) 38 47% 47%

Quake response: free tabletsFeb. 2010 (Lantagne) 252 86.7% N/AMar. – Sept. 2010 (internal data) 1,892 83.5% N/A

Post-cholera: Gadyen Dlo salesOct. 27-28, 2010 (Lantagne) 143 90.0% 22.4%Nov. 2010 – Mar. 2011 (internal data) 1,239 89.7% 48.0%Nov. 2011 – Mar. 2012 (internal data) 200 80.0% 46.2%

Leogane Household Program

Observations from Leogane ProgramTapping existing local networks allows quick scale-up AND high adoption

Free distribution in response to quake achieved 10-fold expansion and increased correct use from 47% to >80%

Increased adoption of HWT products in general has been sustained, but brand-specific use (% using Gadyen Dlo) similar to pre-quake levels

Despite larger total sales relative to pre-quake due to expansion to new households, income generation for health agents and program cost recovery remain challenges

Will / when will free chlorine no longer be available?Will those currently using free products convert to buying Gadyen Dlo or stop treating water?

Qualitative FindingsQualitative data collected in July – August 2012

12 focus group discussions (users); 30 in-depth interviews (distributors)

Gadyen Dlo distributors have difficulty selling in presence of free chlorine

Free products more of an issue in densely populated areas

Areas like Leogane more wary of outside aid than other areas

Distributors who are compensated based on HH visits still conduct visits and education with those who use other products; motivated by improving health of community and do less brand promotion

Conclusions for Other ContextsLocal chlorine production and distribution can be rapidly scaled up if technical knowledge exists prior to emergency

Working with existing, trusted local networks leads to greater correct use in short-term as well as greater sustained use

Rapid scale-ups in emergencies may require more top-down management, but local management early in response leads to more sustainable results

Establishing and strengthening these networks could serve multiple goals of disaster preparedness as well as long-term sustainable programs

Key IssuesMatching distributors (and their motivations) with goals for each phase

May not be one network which is most effective for all phases; may require changing individuals in these roles

Health agents were more effective than political leaders in delivering and promoting adoption in emergencyEntrepreneurs more effective than health agents in Gadyen Dlo sales

Trainings on selling product vs. health education Importance of incentives (positive and negative) for sales

Impact of free distributions on long-term use and program financingImportance of having a national policy on free distributions and executing / enforcing the strategy

DeepSpringsInternational.org