Dispensers for Safe Water is a proven, sustainable, and highly cost-effective way for people in rural communities to have access to safe water. It is safe, easy to use, and free for customers, and as a result it is a water intervention with very high customer uptake.
Up to 80% of households within a community use our dispensers in the first three months of installation, and 40% on average for the months following. But we have seen that this customer uptake--what we call ‘adoption’--has gone down in some geographical areas. So we took a close look at what works in getting our customers to use Dispensers and chlorinate their water.
A review by Fewtrell et al. (2005) looking at water, sanitation and hygiene interventions found that hand washing, education, household storage, water quality and water source improvements are all effective in reducing diarrhea but are often costly and/or have impacts that are hard to sustain. If the adoption of behaviors or technologies falls off after an initial push, benefits can prove illusory. Researchers that developed the dispenser posit that it has relatively high rates of sustained adoption because it provides a combination of free, convenient, and salient access to water treatment directly at the water source. The Poverty Action Lab at MIT has calculated that this is a highly cost effective way of reducing diarrhea if adoption rates on the order of 50% and above can be sustained.
Dispensers for Safe Water--a free and convenient dispenser installed directly at the water source--is now serving more than three million people in Eastern and Southern Africa. In order to provide this rural water service, we install not only the hardware, the actual dispenser, but also closely work with a local health promoter who refills and maintains his or her dispensers. Our field agents on motorbikes run regular routes to all communities where dispensers are installed in Kenya. In Malawi, government staff do this last mile distribution. Other models are also possible, and we are actively pursuing opportunities to work with NGOS that have a strong local presence, for example.
Here is some of what we know works to boost customer adoption of dispensers, and some areas where we would like to know more:
Adoption Booster #1: Promoters
One of the primary components of Dispensers for Safe Water is the election of a local community ‘promoter’ who is responsible for marketing the dispenser in the village, reporting any problems, and refilling the dispenser with chlorine. In return, the promoter gets a small stipend for communication purposes and a team T-shirt. Promoters are critical lynchpins in a community actually using dispensers, it turns out. Whether or not the promoter uses the chlorine dispenser in his or her own household is one of the single biggest predictors of adoption in a community, resulting in as much as a 17% increase in adoption over communities whose promoter does not use chlorine.
What makes for a successful promoter?
We looked closely at a number of characteristics relevant to choosing a promoter, including - but not limited to - gender, age, distance to water points, education, and household characteristics. According to adoption rates, promoters aged 18-50 years are correlated with a 9% increase in community adoption relative to those aged 50 years and above. For every additional year in age, adoption decreases by 0.3%. In addition, our most successful promoters live near the dispenser,and have at least one child under age five at home. Where promoters lived more than 15 minutes round trip from the water source, communities were 10% less likely to test positive for chlorine.
Who communities choose as promoters is one thing, but having high-performing promoters another. We know that high quality initial training on the steps involved in using dispensers increases adoption (by up to 16%). We would love to know more about how to increase adoption at later stages. To that end, we have conducted a number of small randomized control trials looking at, for example, offering incentives and prizes to promoters and regularly calling to remind them of their role. These small “nudges” don’t seem to drive up adoption in qualitatively important ways.
We have noticed an increase in promoter fatigue. Currently we have only qualitative information on this - so this is to be taken with lots of caveats until we have more data. However, we may consider having new election of promoters, refreshing their supplies, or other strategies to rekindle enthusiasm as our program matures.
Adoption Booster #2: No Empty Tanks
Not surprisingly, chlorine tanks need to be full to be used. The longer a tank sits empty, the less likely it is that people will use the dispensers. Every time chlorine is delivered, our teams conduct spot checks to assess whether the dispenser has chlorine and is in good working order.
Our research shows that on average, households are 20% less likely to have chlorine in their drinking water where promoters report that the chlorine dispenser has ever been empty. In real time, this translates to a 1.4% decrease in adoption for every day a dispenser is empty in Kenya and a 5.5% decrease in Uganda.
So, we strive to keep our tanks full at all times. This includes chlorine deliveries made on time and reminders to promoters to fill dispensers every two months. Our evaluation teams randomly check dispensers to ensure our supply chain is working.
Adoption Booster #3: Community Education
To the uninitiated, our dispensers look like alien synthetic blue buckets sitting in an otherwise natural environment. Very few people would know what they were and how to use them, unless we provide that information.
To that end, every time we install a dispenser, our teams conduct community education meetings. Promoters are also encouraged to discuss dispensers at regular community meetings. We find that when promoters report conducting these meetings, adoption in those communities increases by 8.6%.
Says Martin Wanda, one of our field officers in Uganda: “A well-attended and a well packaged community meeting awakens the community members to know waterborne diseases and how human activities contribute to water contamination. They better understand the reasons why they should treat household water. It also provides a conducive forum for the program staff to clear any misconceptions about Dispensers for Safe Water.”
Kids as Teachers of Parents Works
Community Education Meetings are not the only way to convey information about Dispensers, however. Using lessons from Evidence Action’s Deworm the World Initiative, we know that many parents receive information from their children. So we conducted a school-based education campaign. A random group of schools were assigned to receive water sanitation education and we compared adoption in those regions to a control group.
The overall adoption rate was 13% points higher in districts that received the school-based education project. This is encouraging and something we will be building on.
Radio Jingles? We Don’t Know Yet
We have also conducted pilot programs using radio to spread the word. A review of this initiative found that only 6% of interviewed people reported hearing about dispensers on the radio.
We do not have information on whether this increased adoption, but it seems unlikely given the lack of reach of the messages. We are continuing to explore what constitutes effective mass communication campaigns that contribute to increased user adoption.
So, what are the take-aways?
We know that excellent promoters, a full chlorine tank, and community education are critical pieces in consumer adoption of chlorine for safe water. We also know that adoption is still decreasing month-to-month in some areas.
We are currently conducting qualitative research with individuals, promoters, and field officers in our communities across Uganda to delve more deeply in the reasons communities do or do not chlorinate their water. We are using human-centered design methods for this investigation and will have a report on the findings in the next few weeks.
Some of the reasons adoption is decreasing might be out of our control - people do not like the taste or smell of chlorine. Others might be easier fixes that we can control such as reducing turnover in program management positions and ensuring that the supply chain is highly reliable, for instance. In the areas where there was a decline in adoption, we are focusing on working more regularly with promoters, ensuring that the supply chain is rock-solid, and holding regular community education meetings. We also made some excellent new hires for key positions. Additionally, we will be analyzing the results of our qualitative study and look at testing specific marketing campaigns with end users of dispensers.
We have aggressive but doable growth goals for Dispensers for Safe Water including stable adoption numbers and are continuously scoring ourselves against those goals to hold us accountable.