SAFE WATER SYSTEMS FOR THE DEVELOPING WORLD
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Safe Water Systems for the
Developing World:
A Handbook for Implementing
Household-Based Water Treatment
and Safe Storage Projects
Department of Health & Human Services
Centers for Disease Control and Prevention
Safe Water Systems for the Developing World: A Handbook for
Implementing Household-Based Water Treatment
and Safe Storage Projects
was produced by the CARE/CDC Health Initiative,
the Estes Park Rotary Club and the
Gangarosa International Health Foundation
through a contract with Patricia Whitesell Shirey,
ACT International, Atlanta, Ga. USA.
Technical advisor: Robert Quick, MD, MPH
Centers for Disease Control and Prevention
Original graphics: Robert Hobbs
Centers for Disease Control and Prevention
Layout and cover design: Jody Blumberg, Sara Cote
Centers for Disease Control and Prevention
Use of trade names and commercial sources is for identification only and does not imply
endorsement by the Centers for Disease Control and Prevention or the United States
Department of Health and Human Services.
ii
Acknowledgments
The following individuals provided valuable assistance in the form of
original material or critical review:
Centers for Disease Control and Prevention
Eric Mintz, MD, MPH
Steve Luby, MD, MPH
Robert Tauxe, MD, MPH
Jeremy Sobel, MD, MPH
Patricia Riley, CNM, MPH
CARE USA
Peter Lochery
Luke Nkinsi, MD, MPH
Gangarosa International Health Foundation
Eugene Gangarosa, MD
Pan American Health Organization
Dra. Caroline Chang de Rodriguez, (Ecuador)
Ing. Ricardo Rojas (Centro Panamericana de Ingenieria Sanitaria,
Peru)
Population Services International
Janet Livingstone
Besecker Gray Consulting
Samantha Gray
Medical University of South Carolina
Angelica Thevos, MSW, PhD
The Swiss Federal Institute for Environmental Science and
Technology/Department of Water and Sanitation in Developing
Countries
Martin Wegelin
Bruno Gremion
iii
Contents
Foreword ....................................................................................... . xi
Introduction.................................................................................. xiii
Steps for a Safe Water System Project...................................... .. 1
1.0
2.0
Gather background data on the need, target
population, and feasibility of a water intervention.........
1
Decide to do a project and set project objectives..........
5
Consider the major steps and resources required to
begin and sustain a project........................................
6
2.2
Specify overall goals of a Safe Water System...........
7
2.3
Select target population, appropriate pilot project site
and area for later expansion.......................................
8
Specify measurable, specific objectives of the
project.........................................................................
9
2.1
2.4
3.0
Write a proposal to donors for a Safe Water
System Project.................................................................... 13
4.0
Assemble team to do the project...................................... 19
5.0
Decide on products............................................................ 25
6.0
7.0
5.1
Choose a production method for disinfectant............ 26
5.2
Choose bottles for disinfectant solution..................... 31
5.3
Choose a vessel for water storage in the home........ 33
5.4
Choose process or product to use if water is
turbid........................................................................... 41
Decide on methods of distribution................................... 43
6.1
Consider possible methods of distribution
including existing systems or infrastructures............. 44
6.2
Assess alternate distribution methods for
the project................................................................... 50
6.3
Select methods of distribution and plan them in
more detail.................................................................. 52
Plan strategy for changing behavior................................ 55
7.1
Conduct formative research....................................... 64
7.2
Identify specific target audiences............................... 67
v
7.3
7.4
7.5
7.6
Plan positioning (e.g., brand name product with
logo to appeal to mothers)
Plan key messages
67
68
Select methods for behavior change and specify
communication channels
70
Specify communication materials needed
(e.g., label with dosing instructions)
71
77
78
8.0 Plan for cost recovery
8.1 Decide on an approach to cost recovery
8.2 Set the prices of water storage vessels and
disinfectant.................................. J
8.3
8.4
Plan any subsidies or special payment methods ....
Plan how funds will be managed
79
82
85
9.0 Prepare for production, procurement and
distribution of products
9.1
9.2
Set up production of vessels or procure vessels ....
87
87
Set up production of disinfectant bottles, caps and
labeling or procure a source
88
9.3
Set up production of disinfectant or procure
a source of supply
9.4
9.5
Set up distribution system for products
89
94
List the activities and the desired outputs
(quantities)
10.0 Prepare to implement the behavior change strategy .
10.1 Develop brand name and logo
10.2 Develop key messages
10.3 Make detailed plans for implementing the
..........
methods for behavior change
95
97
98
99
102
10.4 Plan training of staff to implement behavior
change methods
103
10.5 Develop communication materials and training
materials
10.6 Arrange use of channels selected
10.7 Pretest messages and materials
10.8 Produce and distribute materials
vi
.........................
104
106
108
109
10.9 Train persons who will implement the behavior
change methods...................................................... 110
10.10 Plan additional behavior change interventions,
if possible.................................................................
111
10.11 List the activities related to behavior change and
desired outputs (quantities)..................................... 112
11.0 Plan monitoring and evaluation of the project............ 113
11.1
Identify the activities/indicators/outcome measures
to be monitored........................................................ 115
11.2 Decide how the findings will be acted on................ 116
11.3 Identify sources for monitoring data and data
collection methods................................................... 116
11.4 Schedule monitoring................................................ 120
11.5 Design and pre-test simple forms and
questionnaires for recording information................ 120
11.6 Review the project objectives and relevant project
activities in terms of expected effects..................... 120
11.7 Identify indicators/outcome measures to evaluate ... 121
11.8 Determine sources of data for evaluation and data
collection methods.................................................
121
11.9 Plan for data gathering including schedule
and staff.................................................................
125
12.0 Implement the project...................................................
127
12.1 Produce and distribute vessels, disinfectant, and
educational/promotional materials.........................
128
12.2 Launch the pilot project (special event).................
129
12.3 Supervise and support activities to implement the
behavior change strategy and sell vessels and
disinfectant through distribution systems as
planned; monitor the activities...............................
12.4 Continue supplying bottles of disinfectant.............
130
133
12.5 Evaluate the pilot project.......................................
133
12.6 Implement the project on a larger scale................
133
Alternative Water Treatment Technologies..........................
137
References...............................................................................
144
vii
Annexes
A. Collecting background data: Sample questionnaire on
knowledge and practices..................................................
B. Developing a proposal for a Safe Water System project..
C. How to test concentration of freshly-produced sodium
hypochlorite for quality assurance....................................
Hypochlorite Production Record....................................
D. Planning worksheets:
Worksheet for assessing possible household water
storage vessels..............................................................
Worksheet for assessing possible distribution methods
E. Examples of educational and promotional materials........
F. Training in motivational interviewing................................
G. Formative research............................................................
Sample focus group discussion questions about water
treatment and storage....................................................
Sample focus group discussion guide for brand name,
logo, and slogan ....................................
H. Potential channels of communication.......
I. Example training curriculum from Zambia: Clorin home
water chlorination......................................
viii
147
148
154
157
159
160
161
162
167
170
172
174
176
179
List of Figures
1. Background data for a Safe Water System project..............
. 3
11
2. Example objectives for a Safe Water System project
14
3. Example outline for a proposal
4. Comparison of methods for production of disinfectant
solution
30
36
5. Comparison of possible vessels for water storage
6. Example worksheet for assessing possible household
39-40
water storage vessels
7. Example worksheet to assess possible distribution methods
51
8. Formative research needs for planning for behavior change
66
73
9. Package labels.......................................................................
10. Steps of a water vessel for work project...............................
84
11. Requirements for installation and operation of hypochlorite
90
generators..................................
12. Procedure for production of hypochlorite solution
92
13. Production and distribution activities to lead to achievement
95
of the objectives..........................................................
14. Key messages or topics for education and promotion
100-101
15. Characteristics of good educational and promotional
105
materials
16. Sales and behavior change activities to lead to
107-108
achievement of the objectives
118-119
17. Example: Plan for monitoring
123-124
18. Example: Plan for evaluation
19. Household treatment systems - Advantages and
140-142
constraints
143
20. Household treatment systems - Costs......................
ix
Foreword
In 2000, just 10 years after the end of the Water and Sanitation
Decade, the lack of access to safe water remains a problem for more
than a billion people in the developing world. Annually, 2 to 3 million
children less than 5 years old die of diarrheal diseases, a large propor
tion of which are acquired through exposure to contaminated water. In
addition, after 39 years, the 7th pandemic of cholera continues un
abated, claiming the lives of a high percentage of children and adults
who acquire the disease. There are a number of reasons for the
persistence of these problems, in spite of the investment of billions of
dollars in safe water by donor agencies and governments. Population
shifts from rural to urban areas have stressed existing water and
sanitary infrastructure and exceeded the capacity of most countries to
keep up with demand. Large population dislocations caused by armed
conflict and natural disasters have created enormous logistical prob
lems in providing water and sanitation services, as have dispersed
populations and poor transportation infrastructure in many rural areas.
While larger scale projects, such as the construction of deep wells or
piped water systems, remain an important objective of many develop
ment agencies, a shortage of time and resources will leave hundreds
of millions of people without access to safe water into the foreseeable
future.
The Centers for Disease Control and Prevention (CDC) and the Pan
American Health Organization developed the household-level water
quality intervention described in Safe Water Systems for the Develop
ing World: A Handbook for Implementing Household-Based Water
Treatment and Safe Storage Projects to help bridge the enormous gap
in developing countries between populations served by existing water
projects and those most in need. This handbook, produced by the
CARE/CDC Health Initiative, is a valuable tool for providing inexpen
sive and feasible appropriate-technology alternatives in situations
where resources are not available for improvements in infrastructure.
While we fully support efforts to build the infrastructure necessary to
create a healthier living environment for people in developing coun
tries, we also recognize that such efforts will not meet the enormous
global need in the near term. Because of that, CARE and CDC have
joined together under the CARE/CDC Health Initiative to conduct
implementation projects in Kenya and Madagascar that build on the
successes of projects in other countries. We have designed this
manual for program managers and technical personnel in other parts
xi
of the world who may find this approach helpful in implementing their
own projects.
We hope that you find Safe Water Systems helpful and invite your
comments and suggestions (www.cdc.gov/safewater) on making it
more useful.
Peter D. Bell
President and CEO
CARE USA
xii
Jedr^ P. Ijoplan, M.D., M.P.H.
Director^
Centers for Disease Control and Prevention
Introduction
There is no question that, for many populations in developing coun
tries, the need for safe water is great. The ultimate solution for the
problem is to provide systems of piped, disinfected water, but this
approach is expensive, time-consuming, and will take decades to
realize. To address immediate needs, other approaches are required
while progress is made in improving infrastructure.
In our experience, alternate locally available approaches are few in
number and often impractical. Boiling water is expensive, time-con
suming, and, in areas where wood is needed for fuel, harmful to the
environment. The use of commercial bleach to disinfect water is not
always practical or acceptable because the price can be high, the
concentration variable, and the product is often marketed for unap
pealing activities not related to consumption, such as washing clothes
or cleaning toilets. A variety of alternative technologies have been
developed, but most are unavailable in developing countries, and
many are expensive or have not been adequately field-tested.
In 1992, in response to the Latin American cholera epidemic, the
Centers for Disease Control and Prevention (CDC) and the Pan
American Health Organization (PAHO) developed a household-based
intervention to meet the immediate need for improved water quality,
which is called the Safe Water System1. The Safe Water System is
inexpensive, easily disseminated, and has the potential for recovering
some of the costs of implementation. The Safe Water System has
been extensively field-tested and several non-governmental organiza
tions are implementing large-scale projects. We feel that the Safe
Water System adds a useful, practical, flexible approach to interven
tions for water quality and hygiene.
The Safe Water System: What is it?
The Safe Water System is a water quality intervention that employs
simple, inexpensive and robust technologies appropriate for the
developing world. The strategy is to make water safe through disinfec
tion and safe storage at the point of use. The basis of the intervention
is:
• point-of-use treatment of contaminated water using sodium
hypochlorite solution purchased locally and produced in the
community from water and salt using an electrolytic cell;
xiii
• safe water storage in plastic containers with a narrow mouth,
lid, and a spigot to prevent recontamination;
• behavior change techniques, including social marketing,
community mobilization, motivational interviewing, communica
tion, and education, to increase awareness of the link between
contaminated water and disease and the benefits of safe water,
and to influence hygiene behaviors including the purchase and
proper use of the water storage vessel and disinfectant.
Potential target populations for the Safe Water System
The Safe Water System was designed for populations that must obtain
their water from the following sources:
• surface water sources such as rivers or lakes;
• shallow groundwater that is potentially contaminated, particu
larly open shallow wells;
• piped systems in which the water is inadequately treated or
flow is intermittent, allowing contamination through leaks where
pipes are connected;
• piped water systems in which intermittent flow requires house
holds to store water;
• water tankers;
• water vendors whose source of water is not safe or whose
tanker or storage tank is not likely to be clean.
Other potential target populations are those that exhibit poor hygienic
behaviors in the collection and storage of water. Such behaviors would
include not cleaning containers before filling them with water and using
wide-mouthed containers to collect and store water. Disinfection is not
always necessary in these cases (e.g., if the source water is safe) but
the practice of disinfection ensures safe water and supports the
essential improvements in behavior including the use of a safe storage
container.
Field trials
Field trials of the point-of-use water disinfection and safe water storage
system conducted by CDC in South America, Africa, and Asia have
demonstrated that it is practical, acceptable, effective, inexpensive,
and a potentially sustainable means to improve water quality and
prevent waterborne diseases:
xiv
Acceptability and microbiological effectiveness
• Families in rural and in peri-urban communities in Bolivia,
Ecuador, Nicaragua, Peru, Pakistan, and Zambia used the
Safe Water System to dramatically improve household drinking
water.2-31415’6,7
• Street vendors in Bolivia and Guatemala used the Safe Water
System to dramatically improve the quality of the beverages
they sell and of the water they use to prepare beverages, and
wash hands and utensils.8 (Quick’ unPublished data>
• Health care workers in Guinea-Bissau used the intervention to
dramatically improve the quality of oral rehydration solution
prepared, stored, and dispensed to patients on a cholera
ward.9
Prevention of waterborne diseases
• Families in Bolivia and Zambia who used the Safe Water
System had between 44% to 54% fewer episodes of diarrheal
diseases when compared with control families who did not use
the intervention. The largest protective effect was among
infants and young children.3,10 (Quick, unpublished data)
Potential sustainability
• Large scale social marketing projects in partnership with
Population Services International (PSI) in Bolivia, Zambia, and
Madagascar have demonstrated the potential for sustainable
Safe Water System projects through partial cost recovery.
• In Madagascar, a partnership between CARE, PSI, and CDC
has enabled the Safe Water System to be implemented as part
of a community mobilization project and serve as a tool to
facilitate the mobilization process.11
• Safe Water System projects in Bolivia, Zambia, and Madagas
car have mobilized their programs rapidly to respond to
cholera epidemics and natural disasters.12
• Field trials in Zambia conducted by the Medical University of
South Carolina (MUSC) have demonstrated increased rates of
utilization of water disinfection and safe storage practices of up
to 70% in target populations through the use of motivational
interviewing, a novel behavior change method.13
The Safe Water System vs. other technologies
Results of the above field trials and implementation projects show how
the Safe Water System has been successfully applied in rural and peri
urban settings in Latin America and Africa for populations of up to
200,000 people. The results have been carefully documented, and this
manual reflects the extensive experience gained. We believe that the
Safe Water System is appropriate in many situations. Before you
decide to design a project around the system, however, two important
questions must be answered:
• Is household treatment an appropriate priority for the target
population?
• What type of household treatment should be selected?
/s household water treatment an appropriate priority?
The effectiveness of different interventions in preventing the transmis
sion of diarrhea is well documented. Safe excreta disposal, improved
hygienic behavior, and use of an adequate quantity of water all typically
result in greater reductions in diarrhea than improved water quality.14
This hierarchy of effect is counterbalanced, however, by a number of
factors relating to household-level water quality interventions in gen
eral, and the Safe Water System in particular:
• In many communities, the demand for an improved water
system both in terms of quantity and quality is greater than
that for improved excreta disposal.
• In many communities, there is a lack of awareness of the
effect of improved sanitation and hygiene.
• A household-based intervention, like the Safe Water System,
can be a low-cost method of improving water quality.
• The Safe Water System offers the possibility of at least partial
cost recovery.
• A household-level water quality intervention can be imple
mented as a stand-alone activity or as a low-cost component
of an environmental health program.
• When social marketing and participatory processes are used
effectively for promotion and education on water quality, there
is potential additional benefit of increasing the general aware
ness of hygienic behavior.
xvi
Each of the above factors should be taken into account when deciding
on an intervention for a community. This manual will help you decide if
the Safe Water System is appropriate for your community. Other
interventions for household water treatment are briefly discussed in the
section of this handbook, entitled Alternative Water Treatment Tech
nologies, beginning on page 137. Information about sanitation, water
supply, and hygienic interventions will need to be obtained locally from
NGOs, Ministries, and other agencies.
What type of household treatment should be selected?
A number of methods for water disinfection at the household level
have been developed. In deciding which methods would be most
appropriate for a given population, a program manager must consider
a variety of factors:
• Is water quality improvement a priority for the target popula
tion?
• Do representatives of the population believe that a particular
method is appropriate for them?
• Is that method affordable to the target population?
• Is the target population willing to pay for it?
• What is the potential for cost recovery?
• How complex is the process of implementation?
• What is the complexity of behavior change required?
• How difficult will it be to monitor key processes and evaluate
impact?
• Do potential donors feel that this approach is justified?
This manual focuses on the Safe Water System because, in a variety
of field trials and implementation projects, we have found it to be
relatively inexpensive, easy to implement, easy for target populations
to accept, adaptable to a variety of conditions, and effective in improv
ing water quality and preventing diarrhea. We recognize that other
appropriate technologies are available and that some of them might be
more appropriate in some settings than the Safe Water System. In a
final section, we provide information about a variety of other appropri
ate technologies for household water treatment, including a brief
description, advantages and disadvantages, and cost. We do not
pretend that the list of technologies is complete, or that the information
is comprehensive. We hope that it is enough to provide interested
xvii
people the basis for beginning to investigate technologies that might
be appropriate for the populations they serve.
Purpose of this manual
This manual was developed for program managers, technical staff, and
other organization personnel who would be involved in implementing a
project to improve water quality. The manual is designed to take
people through the necessary steps to initiate the planning process,
assemble a team, decide between various water treatment and stor
age options, and devise strategies for distribution, cost recovery,
promotion, behavior change, and monitoring and evaluation. We hope
that the manual is thorough enough to provide local program people
with information and tools to plan and implement their own projects,
but we have included contact information for people with experience in
similar projects who may provide technical assistance.
We also hope that the manual in future revisions can become a
clearinghouse for new approaches and technologies for the improve
ment of water quality as knowledge and experience are gained in the
laboratory and the field. This manual is available in hard copy and also
on the Safe Water web page, which can be accessed through the CDC
Home Page (www.cdc.gov). We invite anyone with questions, com
ments, criticisms, suggestions for improvement, or information on
different technologies to contact us through the website. We plan to
update the website on a regular basis so that it can become an evolv
ing resource to the community of people who are working to create a
safer environment for people around the globe.
How to use this manual
This manual is organized into 14 sections plus annexes. Following the
introduction, 12 sections take program personnel through 12 steps to
plan and implement a project using the Safe Water System. Because
many of the steps take place concurrently, the responsibility for tasks
described in different sections can be assigned to different people.
Nine annexes provide additional detail for some steps, model forms,
worksheets, example brochures, and monitoring instruments. The final
section describes other water treatment technologies that some
projects may want to consider.
We hope that this manual will be a useful resource. We welcome your
comments and questions and look forward to working together toward
the goal of providing safe water for all.
xviii
STEPS FOR A
SAFE WATER SYSTEM PROJECT
1.0
GATHER BACKGROUND DATA ON THE
NEED, TARGET POPULATION, AND
FEASIBILITY OF A WATER INTERVENTION
Tasks:
->
Specify the data needed as background for the
project
Plan how to collect the data
Collect the data
Organize and analyze the data
Interpret the data
1
Good background information is essential when deciding whether
to implement a Safe Water System project. It is also necessary
when writing a proposal for funding.
To assess the need for intervention, you need to:
• identify the populations at risk (that is, lacking potable water)
• define the nature and extent of disease problems that may be
attributable to unsafe water
• assess the feasibility of a water intervention in terms of the
infrastructure and other support available
• determine the community’s interest and likelihood of accep
tance of the intervention
Gather data from available sources, and undertake informal
observational surveys or interviews. Possible sources of data
include groups and individuals who work with water supply or
water projects, and reports of studies of water supply, demand, or
quality. These individuals and reports may be found in:
• the Ministry of Health (MOH)
• other government ministries responsible for water
• NGOs such as CARE
• UNICEF
• universities
• local governments
• water companies
• water testing labs at universities or municipal governments
Consider working with local committees or organizations, such as
mothers’ clubs or water committees, to participate in data collec
tion, analysis, and planning. If you involve community representa
tives in the assessment, their participation can pay dividends
later in terms of greater community adherence to, and ownership
of, the project.
This step is not a baseline survey for evaluation purposes.
However, these data will supplement information that will be
obtained from formative research for project implementation.
Useful information to gather and analyze is listed in Figure 1. See
Annex A for a sample questionnaire with questions about relevant
knowledge and practices.
2
Figure 1: Background Data for a Safe Water System Project
Epidemiological data (Sources of data: MOH, special studies )
• How common are diarrheal diseases? What proportion of clinic visits?
• Which populations are most affected?
• Have cholera outbreaks occurred? When and where do cholera outbreaks
typically occur?
Water infrastructure (Source of data: Ministry responsible for water)
• What proportions of urban and rural populations are not served with potable
water systems?
• Where are underserved populations located?
• What is the microbiologic quality of source water in target populations?
Water handling practices (Source of data: Survey)
• Who collects and handles household water supplies?
• How common is it to store water in the home?
• Is household water storage particularly common in certain populations?
• What types of water storage containers are used?
• Do target populations use unsafe water handling practices, such as dipping?
• What water treatment practices are commonly used, if any?
Socio-cultural aspects (Source of data: Survey research)
• What do target populations understand about disease transmission through
water?
• What do target populations understand about causes and prevention of
diarrhea?
• Is clean water a high priority for target populations?
• Are there cultural barriers to water interventions (e.g., religious or ancestral
associations with water supply)?
• Who makes decisions about household expenditures?
Economic aspects (Source of data: Donor agencies, NGOs, water ministry)
•
•
•
•
What are potential sources of external funds?
What donors have previously funded water projects?
Can target communities pay for products?
Is ability to pay seasonal (e.g., in agricultural communities)?
Possible support and infrastructure (Source of data: government, NGOs)
• Which government departments and officials can be approached for support?
• What NGOs are present in country?
• Which areas have a government or NGO infrastructure to build on?
• Which organizations are potentially available for the various aspects of
implementation (e.g., hospitals, health centers, NGOs, women’s groups, local
companies)?
3
2.0
DECIDE TO DO A PROJECT AND SET
PROJECT OBJECTIVES
Tasks:
-> Consider the major steps and resources required
to begin and sustain a project
Specify overall goals of a Safe Water System
-> Select target population, appropriate pilot project
site and area for later expansion
-> Specify measurable, specific objectives of the
project
u
■h
■
5
Every country’s resources for health and development are
limited. It is crucial that each country use its own and donated
resources in ways that will have the greatest benefit. It is unwise
to invest in projects that are unsustainable or that provide little
real benefit. Therefore, before deciding to undertake a Safe
Water System project, decision makers must realistically assess
the work and resources required and the likely benefits of the
project.
2.1
Consider the major steps and resources required to begin
and sustain a project
A Safe Water System project requires careful planning and
coordination of a broad range of activities. The Safe Water
System is a potentially useful tool to improve water quality and
reduce diarrhea. It is flexible and adaptable to a variety of
conditions. It consists of:
• hardware - the products: locally produced disinfectant
solution and the safe water storage vessels
• software - the project components: promotion, education,
motivational interviewing, and/or community mobilization
designed to create behavior change, that is, the purchase
and use of the products
Safe Water System projects will differ considerably from country
to country and from region to region within a country. There are
significant possible variations in each of the components of the
intervention, such as:
• type of water storage container
• method of manufacture of the disinfectant
• infrastructure to distribute the containers and disinfectant
• approaches to behavior change.
Planners should study the background information (collected in
step 1.0) and the rest of the guidelines presented in this manual
to plan a project. The project design should:
• address the need for improved water in households
• suit the socio-cultural characteristics of the population
• build on available infrastructure
• be appropriate for the level of funding and other resources
6
• be creative so as to best engage persons who need the
intervention
• enable the target populations to obtain the necessary
products
• effectively change key behaviors of the target populations.
If plans or resources are inadequate or short-sighted, the inter
vention will be short-lived (for example, if it is based on donation
of water storage vessels and disinfectant to a population in
need). In that situation, decision makers should wisely decide to
postpone a Safe Water System project until adequate resources
are available and a plan is in place for full or partial cost recovery.
It is recommended to begin with a pilot project, in order to test
the best products and procedures while working in a small area.
The intention should be to expand later to include more families
and other areas needing safe water.
Base a decision to undertake a project on a realistic consider
ation of the major steps and resources required to start and
sustain the project and the results possible. Plan an approach to
the major components of the project, so that you have an idea of
the work and resources that would be involved. Then make a
final decision whether to proceed.
Resources required will vary according to the approach to the
project. For example, a social marketing project budget for 22
months (total population of 200,000 in Madagascar) was about
$175,000 (in 2000).
2.2
Specify overall goals of a Safe Water System
The goals that you set for the project will help guide decisions.
The overall goals of the project are:
• to improve water quality in homes by means of a sustainable
technology
• to decrease death and diarrhea from contaminated drinking
water
• to improve hygienic behaviors related to water use
7
2.3
Select target population, appropriate pilot project site and
area for later expansion
Broadly, the target population will be a group of households that
do not have safe water. The specific project site and target
population should be a particular group of households that need
improved water storage and disinfection in the home. This might
include one or more of the following groups:
• a population with
surface water
sources (river, lake),
or unsafe ground
water sources,
especially shallow
wells
• an urban population
with piped water
where flow is
intermittent and
storage is required, or piped water source is of questionable
quality (contaminated)
• a population that must store water because the source is
outside the home
• a population that stores water in wide-mouthed containers
Select an appropriate pilot site. Possible criteria for a selecting
an appropriate pilot site and target population include:
• There is a need for safe water in homes, as evidenced by
waterborne diseases and/or observed unsafe water handling
and storage practices.
• Community leaders recognize that drinking water safety is a
major problem.
• There are government or NGO infrastructures to build on.
(Whenever possible, it is better to use and strengthen
existing systems than to establish separate structures which
are project-dependent and which may not be sustainable in
the long term.)
• Local population has interest in participating in the pilot
project and is motivated to help with preparatory work.
8
• There is a functioning neighborhood organization, such as
Neighborhood Health Committee, with active and effective
health promoters.
• A pilot project is feasible (i.e., includes a number of house
holds that can be supplied with vessels and disinfectant and
can be reached with education, promotion, and behavior
change activities consistent with levels of funding, staff and
other resources).
• Local authorities give permission to implement the pilot
project.
The project may also choose an area for later expansion. This
may be an enlargement of the pilot area, or a different area with
similar characteristics as the pilot area.
2.4
Specify measurable, specific objectives of the project
The objectives will depend on the overall goals and information
available regarding the transmission of waterborne diseases,
local infrastructure, socio-cultural factors, and economic factors.
Objectives should be specific, measurable, achievable, realistic,
and related to a timeframe. These criteria for good objectives
are easy to remember if you think of the acronym SMART
The objectives should contribute
to achievement of the overall
goals but will be more specific
and limited, so that they are
feasible to achieve during the
pilot project. You must have a
rough plan for the major compo
nents of the project, so that you
can estimate key areas of
progress and feasible levels of
Project Objectives
Specific
Measurable
Achievable
Realistic
and related to a
Timeframe.
achievement.
The objectives should be measurable with specified time frames.
They should be measures of progress, not merely process
(actions that do not necessarily produce results). For example, a
radio campaign is a process, favorable recognition rates in the
target populations are progress. Examples of objectives for a
pilot project’s first year of operation include:
9
• 60 retail shops in the target area will have a consistent
supply of vessels and disinfectant
• Sell 1,200 vessels to households in the target area
• 7,500 bottles of disinfectant will be produced
• 25% of homes in the target area will use an approved water
storage vessel
• 70% of target population will recognize the brand name of
the Safe Water System products
Objectives must be feasible to monitor or evaluate. For example,
possible objectives state desired levels of sales of vessels, sales
of disinfectant, acceptability of products, water quality, reduction
of diarrheal diseases. Of these, sales and acceptability are
easier to measure. Water quality is somewhat more difficult.
Change in the level of diarrheal diseases in a population is
difficult to measure. Consider monitoring and evaluation of the
project before specifying the objectives (see section 11.0).
Below are some example objectives for a Safe Water System
project. Objectives are specified for 4 areas: access to the
intervention, water treatment and storage behaviors, improve
ment in health, and satisfaction with the intervention.
10
Figure 2: Example Objectives For a Safe Water Project
1. Increasing access to the intervention (products)
1.1 Sell 20,000 bottles of disinfectant in first 3 months
1.2 Sell 1,000 water storage vessels in first 3 months
2. Changing water treatment and storage behaviors
2.1 70% of target population will recognize the brand name of the
Safe Water System products (vessel and disinfectant) after 6
months
2.2 30% of households will report use of approved water storage
vessel and disinfectant after 6 months
2.3 25% of households will have knowledge of correct dose of
disinfectant after 6 months
2.4 25% of households will have observed safe water storage
practices after 6 months
2.5 10% of households will have measurable residual free
chlorine levels >0.2 mg/liter after 6 months
2.6 10% of households will have zero E. coli colonies in stored
water after 6 months
3. Improving health
3.1 Reduce diarrhea rates in target population by 20% after 1 year
4. Achieving satisfaction
4.1 80% of users in target population will report satisfaction with
products after 6 months
In later steps, you will plan activities to be done so that the
project will achieve these objectives. (See sections 7.0, 9.0 and
10.0.) If you then find that some objectives are too ambitious,
modify them to be consistent with activities planned.
11
3.0
WRITE A PROPOSAL TO DONORS FOR A
SAFE WATER SYSTEM PROJECT
Tasks:
-» Study this manual to become familiar with the
components of a Safe Water System project and
the activities involved.
Study the background information gathered in
step 1.0.
-> Become informed about potential donors and the
type of proposal they will need.
Draft the proposal using all available information
and current plans. Refer to Annex B for guidance,
and other references and contacts.
-> If a detailed proposal will be required, continue
with planning and decisions as described in this
manual until sufficiently detailed plans are devel
oped to put into the proposal.
13
Figure 3: Example Outline for a Proposal
Application Form for Health Grant Program
Project Description
Core Elements
A. Title of project
B. Summary: Include project location(s), project staff, contact
persons, target population, duration, budget
C. Introduction: Describe background on the country/region
water situation and overview of the project
D. Problem statement: Specify the problem and its causes,
needs assessments, rational for project
E. Project description: List goals and objectives, process and
impact indicators, main activities
F.
Operational plan: Propose specific intervention strategies,
how the Ministry of Health, communities and other agencies
will actively participate
G. Project management: Indicate staffing required, manage
ment structure and lines of communication, physical require
ments and purpose
H. Monitoring and evaluation: Specify information systems,
baseline studies if any, timing of evaluation, reporting and
feedback system, role of partners in monitoring and
reporting
I.
Budget
Supplementary Elements
J.
Innovative aspects of the proposal
K. Capacity building to be achieved
L.
Sustainability
M. Leveraging/multiplier potential for additional funding beyond
this donor.
14
Usually a proposal will describe details of the major components
of the project, such as the water vessels and disinfectant, how
they will be produced or obtained, and plans for distribution,
education of households, promotion, monitoring and evaluation,
and a budget. Therefore, you would need to complete the
decisions and plans described in steps 4.0 - 8.0 (that is, plans
for assembling a team for the project, the products, method of
distribution, strategy for behavior change, and cost recovery) in
order to write the complete proposal. It is also important to know
the likely level of funding to make realistic plans.
In some situations, however, a donor will give funds based on a
general plan; the proposal could be written and submitted earlier
and the detailed planning can be accomplished when funds are
available and the project team is working. In this case, you will
need to study the rest of this manual to learn about Safe Water
System projects before writing the proposal, but would not need
to make all the decisions described until afterwards.
Some countries have a clear need for a Safe Water System
project, a promise of funding, and an infrastructure suitable for
distribution of the products and education of users. Some
countries have only one or more of these building blocks and
must obtain the missing elements. It may be necessary to
investigate the need for a project and the best target area. It
may be necessary to investigate whether the project may make
use of an existing infrastructure or will need to build one. If there
is clear need and infrastructure, the project team will need to do
research on the most feasible approaches, and then estimate
funding needed.
It may be necessary to investigate to find donors and estimate
the possible levels of funding. Perhaps the most feasible option
is to identify NGOs with a water or health focus that are working
in the target population, and try to work with them in developing
a proposal. Some donors that have supported Safe Water
System projects are listed on the next page:
15
DONORS THAT HAVE PROVIDED FINANCIAL OR IN-KIND
SUPPORT FOR HOME TREATMENT AND SAFE WATER
STORAGE PROJECTS (as of August 2000):
United Nations agencies:
PAHO
Government agencies:
CDC
JICA
USAID
Non-governmental organizations:
Bibosi Institute
CARE
Caritas
GTZ
Population Services
International
Project Concern International
Rotary International
Private sector:
Coca Cola Foundation
Equipment and Systems
Engineering
Exceltech International Corp
Los Alamos Technical
Associates
Millipore Foundation
Procter and Gamble
Western Union
Woodruff Foundation
Some proposals are written with great uncertainty about funding.
In this situation, you will need to investigate the options de
scribed in steps 5.0-8.0 and get estimates of what the different
options might cost in your country or area. The extent of the
target area (number of households targeted) could also vary.
You may then write a proposal that describes a project with
certain parameters and funding required, or you may describe
different options that are possible at different funding levels.
It is often easier to get a small amount of money rather than fund
a large project. It may be possible to target specific donors for
certain aspects of the project that appeal to them. In this way,
you may be able to piece together several donations into one
16
you may be able to piece together several donations into one
complete project. In Bolivia, for example:
• Rotary International and the Procter and Gamble Fund
purchased a mold to produce the vessel
• Exceltech International donated a hypochlorite generating
machine
• USAID donated money for implementation activities
• Bolivian municipalities and NGOs subsidized the distribution
of vessels and disinfectant solution to impoverished villages.
PSI
Vw
CDC
Mg:"
ya—
DSHD
CIARO
Where funding for a large project is unlikely, it may be possible
to fund (for a few hundred or a few thousand dollars) a regional
conference to review the situation in the district, region or
country. A local university may agree to host the conference, and
potential donors would be invited. The working group from the
meeting may outline a modest proposal and seek money for a
demonstration project. When a small demonstration project is
funded and implemented, the working group gains expertise,
self-confidence and credibility. Funding for the next stage is then
easier to obtain.
Annex B provides guidance on points to address in a project
proposal. Before the proposal-writing team begins to write a
proposal, they should:
• study this manual to become familiar with the components of
a Safe Water System project and the activities involved
• study the background information gathered in step 1.0
• identify potential donor organizations that fund this type of
project
17
• meet with potential donors to determine their interests and
needs; if you are reasonably sure that they are interested,
find out as much as possible about the type of proposal and
the level of detail they will need
• estimate the level of funding to request
Then the team can draft the proposal using available information
and formulating plans as progress is made. If a detailed proposal
will be required, the project team will continue with planning and
decisions as described in this manual until sufficiently detailed
plans are developed for the proposal.
In Madagascar and Kenya, some communities were implement
ing CARE community mobilization projects. When people in
those communities identified improved water quality as a priority
need, project personnel applied for funding from the CARE CDC
Health Initiative for a household Safe Water System project. The
Safe Water System activities were able to build on the commu
nity interests and resources already in place. They received the
funding.
In Ecuador, some hypochlorite generating machines were
present in the country but were not in use. When El Nino dis
rupted the water supply and many families were left without safe
drinking water, this disaster presented an opportunity to look for
funding to train staff and put the existing equipment into use.
Funding was obtained initially from the Embassy of the Nether
lands, and was then augmented by USAID, and the project was
successfully implemented in 5 provinces to relieve disaster
conditions. Good results and the recognition that the country had
insufficient potable water coverage led the Ministry of Public
Health to create a National Program for Household Water
Disinfection.
In Peru, a donation was obtained from an NGO for a pilot
project, and then a loan was secured for an expanded project.
In Zambia and Bolivia, small field trial studies were conducted
to determine if the household use of disinfectant and special
water storage vessels could improve water quality and decrease
diarrhea. When these proved successful, PSI wrote proposals to
USAID for funding small pilot social marketing projects in dis
crete regions of the country, and USAID funded these projects.
18
ASSEMBLE TEAM TO DO THE PROJECT
4.0
Tasks:
Consider possible roles of government, NGOs
and the private sector for this project
-> Identify potential donors, implementers, and
evaluators
Select a core team to do the project
Establish a management committee
Add to the team later, according to need and
interest
Roles of government, NGOs and the private sector
Implementing a business-like project is usually outside the scope
of government services and is better done by the private sector
or an NGO. Even when government is not involved in the
implementation, its support of the project and collaboration with
non-governmental organizations remains critical. Government
involvement can provide credibility and strengthen implementa
tion by offering access to government resources, and promoting
the project through existing public health networks.
Projects implemented by NGOs require government support,
donor funding, and motivated, well-trained staff with good
technical back up. Non-local NGOs also need a plan for eventu
ally turning the project over to local institutions.
19
The private commercial sector often has the capability to provide
high quality products, an efficient distribution system, and
marketing through advertising.
Partnerships of private and public sectors aim to involve the
private sector from the start in a commercially viable operation
that makes products widely available at affordable prices. The
process aims to ensure success with market research, a market
ing strategy and a promotional campaign and involves the
following steps:
• forming partnerships between donor, NGO, public and
private sector partners
• developing consumer-oriented market research
• developing a marketing strategy including a business plan,
monitoring and evaluation
• producing/procuring materials
• launching and monitoring a promotional campaign
• expanding project to additional groups and areas
NGO involvement focuses on complementing and expanding the
reach of the commercial sector during the market development
phase and concentrates later on the poorest populations who are
unable to procure products through the private sector.
Consider a range of possible organizations for a range of roles:
• Product registration and certification: Roles for the
Ministry of Health are to register and certify the products,
give their seal of approval, provide existing data, collect
epidemiological information, and assist with promotion of the
project. Include representatives from Ministry of Health
water/environmental departments and from diarrheal disease
control staff.
• Data on water coverage: A key role for the government
ministries responsible for water is to provide information on
populations, their water sources, and quality of water
sources. Depending on the division of responsibilities in the
government, they may also have a role in certifying products
and monitoring water quality.
• Donors: Possible donors include USAID, World Bank, non
governmental organizations, foundations, bilateral and
20
multilateral donors, Rotary Club or other service organiza
tions, and the private sector. Consider trying a sponsorship
program with a private company in which the company buys
“advertising,” for example, paying to put logo on water
vessel. Local government/municipalities may share some
costs and health workers.
• Importation of supplies: Organizations with tax-free status,
such as embassies, donor and UN agencies, can help save
money through customs duty waivers if supplies need to be
imported. Rotary and Lions Clubs may be able to advise
about import procedures.
• Implementation: Implementors’ roles include production,
behavior change, promotion, education, sales, and distribu
tion. Possible implementers include non-governmental
organizations such as Population Services International
(PSI) and CARE, private business (such as bottle manufac
turers), municipalities, and workers at public health clinics.
Organizations with experience with Safe Water System
projects include PAHO (in Peru, Bolivia, Ecuador), PSI (in
Bolivia, Zambia, Madagascar), and CARE (in Kenya, Mada
gascar).
• Distribution: Potential outlets for distribution of products
may include health facilities, hospitals, shops, supermarkets,
church groups, schools, cooperatives, community groups
and local companies. Government, non-government or
commercial organizations that distribute medical supplies
may assist with distribution. (See step 6.0.)
• Storage: Local companies, NGOs, and government offices
may be able to provide secure storage space for supplies or
space for disinfectant production.
• Training: Suitable trainers may be found in the Ministry of
Health, universities, development agencies, or non-govern
ment organizations.
• Behavior change: An NGO that specializes in behavior
change through social marketing may be available to design
a strategy and materials for promotion and education. It may
also provide workers to carry out particular tasks such as
developing a brand name and logo, designing promotional
posters and other materials, and organizing a kick-off event.
21
Universities are another potential source for theoretical and
practical information about behavior change methods.
Advertising agencies may be employed to do marketing
research with the implementing agency and help design
promotional campaigns and materials. Some may donate
services or discount their rates for a public service project.
• Promotion: Health facilities and workers can promote use of
Safe Water System products. Other organizations, such as
schools, community groups, and drama groups, can be
involved in education and promotion. Local media may give
space to promotional and educational messages. Advertising
agencies are expert in promoting products.
• Educational materials: Behavior change expertise, health
education expertise and facilities for producing educational
and promotional materials may be available from the Ministry
of Health, educational institutions, non-governmental organi
zations, advertising agencies, or private business.
• Evaluation: Social scientists from universities and from
government can help to design community, participatory, or
operational research on aspects of implementation. Help in
designing evaluation and monitoring or help collecting data
may be available from local universities, medical schools,
NGOs, and local health departments. International agencies
or universities may help with external evaluations.
Although coordination with various organizations is more time
consuming than working alone, the advantages of this approach
include:
• potential to reach different groups in the community through
different channels
• access to diverse skills and resources
• greater likelihood of sustainability. The chances of
sustainability increase if a project has support from a broad
range of organizations and is integrated into existing local
structures. Existing community structures and committees
are more likely to survive in the long run than those estab
lished specifically for a project.
Consider staffing needs for the project. Review activities
planned. Decide what type of staff will be required for each
activity and estimate how much time will be needed. For example:
22
• Research will require a
trained researcher to
assist with design,
planning and analysis,
and field workers to
collect data.
• Behavior change,
education and promo
tion will require special
ists in behavior change,
health education and
communication to
develop strategies.
Design and implementa
tion will require, for
example, specialists to
develop messages and
materials, an artist to develop posters, field workers to
pretest messages and materials, trainers for field workers
and door-to-door promoters, someone to work with commu
nity drama groups.
• Production will require a
technician to set up
production, train produc
tion staff, and supervise
quality. It will also require
production staff to run
and maintain equipment,
bottle the disinfectant,
and keep records of
production.
• Distribution and sale
will require staff to provide information, demonstrate water
treatment, and record sales activities.
• Management and administration will require staff for tasks
such as stock-keeping, financial control, procurement of
supplies, training, supervision, analysis of monitoring data
and writing reports.
23
Select a core group of organizations to work on the project. Then
establish a project management committee composed of repre
sentatives of the organizations. When several organizations are
involved in implementing a project, each with different roles, it is
important to have a management committee to oversee and
coordinate.
In Madagascar, for example, the team included:
Social marketing implementation: PSI
Community mobilization: CARE
Research: CARE/CDC
Production: PSI
Overall management: CARE
Behavior change: PSI/CARE
Distribution and Sale: PSI
CARE
Catholic Relief Services
Commercial sector
Product Certification: Ministry of Mines
Endorsement: Mayor of Antananarivo
24
5.0
DECIDE ON PRODUCTS
Tasks:
Choose a production method for disinfectant
(sodium hypochlorite)
Choose vessel for water storage
Choose process or product to use if water is
turbid
Choose bottles for disinfectant solution
A Safe Water System project enables households to disinfect and
store essential quantities of household water in safe containers.
The products (“hardware”) of a Safe Water System include:
• disinfectant solution and its container
• a vessel for safe water storage in the home
• a filter, if local water is turbid
CLARQ
l
w
Project planners must decide how these products will be manufactured
or obtained. There are a variety of ways to produce a disinfectant
solution, and there are many different safe water storage vessels.
25
5.1
Choose a production method for disinfectant
The disinfectant should kill or inactivate pathogens that are likely
to be present in the water sources of the target population. An
ideal disinfectant should:
• be reliable and effective in killing pathogens under a range of
conditions likely to be encountered
• provide an adequate residual concentration in the water to
assure persistent disinfection during water storage
• neither introduce nor produce substances in concentrations
that may be harmful to health, nor make the water unsuitable
for human consumption or aesthetically unacceptable
• be safe for household storage and use
• have an adequate shelf life without significant loss of
potency
• be affordable for users
There is no perfect water disinfectant that will work optimally
under all circumstances. Each has advantages and disadvan
tages.15 However, in our experience, demonstration projects
have identified chlorine, specifically 0.5% to 1% sodium hy
pochlorite solution, as having the best overall characteristics for
both production at the local level and convenient dosing for
household water disinfection. It is also extremely inexpensive to
produce, making it an affordable option for economically disad
vantaged populations. Sodium hypochlorite solution at this
concentration is also safe, with evidence that ingestion of
sodium hypochlorite at 10 times greater concentration causes no
lasting damage.16
Sodium hypochlorite has two disadvantages that must be
addressed. The first is the issue of taste. Some populations
object to the taste of chlorine, which may decrease use of
disinfectant. Behavior change interventions should be designed
to address the issue of taste (see section 7.0). In Zambia, one
approach was to teach people to associate chlorine taste as an
indicator of the safety of drinking water. In Bolivia, an approach
was to teach people to treat water in the evening for the following
day, so that the taste would dissipate. The second disadvantage
is the potential for degradation of chlorine concentration during
storage, particularly in hot climates. This problem can be miti
gated by alkalinizing the solution and by storing it out of sunlight
26
in opaque containers in the coolest possible place. In hot cli
mates, the shelf life can be as little as 1 month, but with alkalinization, the shelf life can be increased to 4 months or more. In
cool climates, the shelf life is greater than 6 months. Shelf life
must be determined in each new region because of variations in
source water and climate.
Another concern about chlorination of water is the health effects
of trihalomethanes. Trihalomethanes are disinfection byproducts
that are formed when hypochlorite is used to treat water with
organic material in it. Research suggests that, over a lifetime,
the risk of bladder cancer increases with chronic consumption of
trihalomethanes. In populations in developing countries, how
ever, the risk of death or delayed development in early childhood
from diarrhea transmitted by contaminated water is far greater
than the relatively small risk of bladder cancer in old age.
There are alternative safe and effective ways to produce sodium
hypochlorite solution:
a) local production from water and salt with a low cost
hypochlorite generator that is simple to operate
b) production by an existing local or multinational business in
country
For the Safe Water System, we have decided against using
dilute solution of calcium hypochlorite from High Test Hypochlo
rite (HTH) powder because of the caustic, hazardous nature of
the highly concentrated (70%) powder. Also, in most countries,
HTH must be imported, and storage can be difficult, particularly
in hot, humid conditions.
Another option that is not recommended is to promote use of a
locally available commercial bleach to treat water in the home
because experience has shown that this approach leads to
problems with acceptance. Bleach bottles often display instruc
tions to use bleach to whiten clothes and clean toilets, which
deters people from using it to treat drinking water. Another
problem with commercial bleach is that it may contain additives
or impurities and that concentration can vary, which makes it
more difficult to provide dosing instructions. It is best to create a
new product especially for treating drinking water.
27
Each of the preferred options for production of disinfectant
solution is described below.
a)
Local production from water and salt with a low cost
hypochlorite generator that is simple to operate
Using this method, an arrangement can be made to produce
hypochlorite in the community. Devices are available from
several manufacturers that are designed to reliably produce
hypochlorite solutions through electrolysis of ordinary salt and
water (3% salt solution).7'15117 Most of these devices, called
hypochlorite generators, use electricity from an electrical grid,
but solar powered hypochlorite generators can also be used.
A suitable place is required to operate the machine and store
solutions. A two-person team should be trained to operate and
maintain the device and to monitor the hypochlorite concentra
tion. (See Annex C.)
There is a range of sizes and capacities of hypochlorite genera
tors. Different models can produce as little as 10 liters (enough
for 40 families) per day up to a maximum of 400 liters (for 1600
families) per day. Running 12 hours per day, an electric-powered
hypochlorite generator can produce enough disinfectant solution
28
to treat water for about 8,000 families (40,000 - 48,000 people)
every 2 weeks.
Once production starts, the disinfectant can be produced inex
pensively by a community worker. In Zambia, disinfectant sold
for approximately $0.20 for a month’s supply for a family of 6
people. In Madagascar, disinfectant sold for $0.30 for 2 month’s
supply, and in Kenya, for $0.20 for 2 month’s supply. These
prices did not take into account the cost of marketing and
distribution. Local production has been employed in Bolivia,
Peru, Ecuador, Zambia, and Madagascar.
As the water project expands to reach additional communities, it
may be necessary to obtain additional generators to meet
increased demand and train more workers to produce and bottle
disinfectant.
b) Production by an existing local or multinational
business in country
With this method, a business such as a bleach manufacturer
produces a disinfectant product of a specified concentration. If
an existing business can produce a suitable disinfectant, the
manufacturer is likely to have in place procedures for quality
control, bottling, labeling, and distribution. When the project is
ready to expand, the manufacturer can quickly increase produc
tion. This method has been used in Kenya.
Problems may arise, however, because the manufacturer, rather
than the project administrators, will control price and production.
Business usually requires a certain profit margin, which may
make the disinfectant price too high for intended users. There
may be increased transportation costs, depending on the dis
tance between the manufacturing plant and the communities that
purchase the product.
29
GO
o
Figure 4: Comparison of methods for production of disinfectant solution
Disinfectant
production
options
Cost of
solution
Local job
creation
Cost of
transport
Quality
control
Efficiency of
bottling,
labeling
Start-up
costs and
staff
training
Ease of
scaling up
Control
over
product
price
Distribution
Local
production
with
appropriate
technology
Low
Good
Low
Good
Good
High
Good
Good
Network
must be
developed
Production by
existing
company
Depends on
negotiation
Depends
on size of
project
Higher
Good
Good
Lower
Depends on
capacity of
company
Poor
Existing
distribution
network
5.2
Choose bottles for disinfectant solution
Disinfectant is put into bottles that are then distributed to outlets
and sold to households. There are several issues to consider in
the choice and design of a bottle.
A --iS
• Returnable or non-returnable bottles?
Returnable bottles can save project costs and result in a
lower price for consumers. When the contents of a return
able bottle are gone, the consumer returns the empty bottle
to a sales outlet and gets a discount on a new bottle. Bottles
are sent back to the production point to be cleaned, rela
beled and refilled. Returnable bottles reduce the likelihood
that empty bottles will become solid waste (although this has
not been a problem yet because people tend to reuse nonreturnable bottles for other purposes when the disinfectant
bottle is empty).
Non-returnable sealed bottles have been preferred by social
marketing NGOs because they facilitate quality control and
make operations logistically simpler.
• Color
The bottle should be opaque to extend shelf life.
• Size
The bottle should not be so small that new ones need to be
bought too frequently; nor should it be so large that the
supply of disinfectant lasts longer than its effective shelf life.
Many projects have found that a 250 ml bottle works well, as
31
this is approximately the amount that an average household
uses in 2 to 4 weeks. Up to 500 ml volume is satisfactory in
cool climates. In hot climates, the shelf life is reduced, and
500 ml of disinfectant may begin to lose its strength before it
is used up.
• Paper label to be attached or labels to be silk-screened
(painted) on bottle?
The bottle must have a clear label that identifies its contents
and provides instructions for use in households. Silkscreened labels wear off in time, so if bottles are to be
returnable, paper labels may be more practical.
• Measuring cap
The bottle’s cap should be used to mea
sure the correct amount of disinfectant to
add to the quantity of water in the recom
mended water storage vessel. Therefore
the size of the cap and instructions for its use
must be designed with the water storage vessel in
mind. The dose must be determined using the locally
available disinfectant with the locally available water in the
vessel recommended by the project because different waters
require different doses of sodium hypochlorite for adequate
disinfection. This is best accomplished via trial and error,
measuring free chlorine levels one half hour after dosing. A
qualified person can start by adding 1/2 or 1 capful, then
measuring the chlorine level, and then continuing to add
increments of 1/2 or 1 capful to the vessel until the correct
chlorine level is achieved in the stored water. A free chlorine
level of 0.5 to 2.0 mg/L is optimal. A cap should facilitate
measuring the correct amount of disinfectant for the water
storage container. For a 20-liter water vessel, the dose of
disinfectant will likely be between 5 and 10 ml, so a cap size
of approximately 2.5 to 10 ml will work best.
• How to produce or procure the bottle
The project may be able to use a locally produced bottle of
appropriate size with an acceptable cap to which a label can
be applied. However, there can be problems with locally
32
produced bottles. Sometimes bottles are proprietary and are
therefore not available for the project. Also, available bottles may
be used for other products such as chemicals, and consumers
may mistake one for the other.
Another option is to manufacture a unique bottle. A unique bottle
has advantages in that it can be developed to meet the exact
specifications required (size, shape, cap) and consumers will
come to recognize it. A mold to produce a bottle is expensive
(for example, $8000 was the cost in Bolivia), but once produced,
the project cost per bottle may become less expensive.
5.3
Choose a vessel for water storage in the home
Virtually every type of tank or container imaginable has been
used for household water storage. Unfortunately, most do not
adequately protect water from contamination. Many are open
without lid or cover. Used 55-gallon oil drums and open plastic
and metal buckets are commonplace.
Many people obtain or buy previously-used containers because
they are cheaper. However, sometimes these containers have
held poisonous substances such as pesticides. Families have
become ill or have even died after drinking water stored in them.
Studies have shown that even if water is microbiologically safe
when put into such containers, it can be quickly contaminated
during storage and use, primarily by contact with human hands
or contaminated utensils that are used to withdraw water. Dust,
animals, birds and insects can also contaminate water when the
vessel is inadequately covered. Under these circumstances,
even when water is initially disinfected, the subsequent contami
nation is often so great that it nullifies the disinfectant. Water
stored in wide-mouth vessels (which allow stored water to be
dipped out with hands or utensils) is much more likely to be
contaminated than water in vessels that must be poured. Many
studies have shown the importance of a suitable household
water container to prevent waterborne diseases.1'18'21
33
Typical containers used for household storage that are often kept
uncovered and do not adequately protect water include:
In many countries, clay pots are popular water containers with a
j
.
Buckets
(plastic
or metal)
55 gallon
oil drums
clay pots
cooking
pots
history of use that goes back generations. Many families prefer to
use clay pots because they are porous and permit evaporative
cooling. They are also accustomed to the taste of water in clay
pots. In such cases, it may be difficult to convince people to
change to a different type of container. In Kenya research
suggested that clay pots may be reasonably effective storage
containers, if kept clean, if people avoid touching water when they
dip it out (in some countries, spigots are placed in clay pots to
avoid this problem), and if the water is chlorinated when it is put
into the pot.
Commonly used vessels for household storage which may
adequately protect water if clean and used correctly include:
CDC and PAHO have designed a 20-liter, plastic vessel with a
,
T""
jerry cans
plastic bottles
picnic coolers
narrow mouth, lid, and faucet. Recently, the design was improved
with assistance from Procter and Gamble. This vessel has been
field tested in Bolivia and Zambia with good results. PAHO Peru
and PAHO Ecuador have employed containers with similar
characteristics in their projects. Oxfam has designed a bucket
with a tightly fitting lid, a smaller opening in the lid, and a spigot.
34
Below are desired characteristics of a container that will prevent
contamination of contents and facilitate disinfection of water:
1. Appropriate shape and dimensions with a
volume between 10 and 30 liters so that it
is not too heavy, fitted with handles to
facilitate lifting and carrying, with a stable
base to prevent overturning. If possible, a
standard sized container should be used
because then dosing can be standardized.
20 liter vessels have worked well in earlier
studies. If children often carry water, the
vessel will have to be smaller or the child will
need to collect water in a smaller container and
pour it into the safe storage container.
2. Durable material, resistant to impact and oxidation, easy to
clean, lightweight, and translucent. High-density polyethyl
ene (HOPE) is often the most appropriate material that is
readily available. HOPE should be specially treated with
ultraviolet absorbers, or exposure to sunlight over time will
damage the plastic and vessels will crack.
3. An opening large enough to facilitate filling and cleaning but
small enough that even a child cannot easily insert a hand
with cup or other utensil to dip out water. The inlet should
be fitted with a durable screw-on lid, preferably fastened to
the container with a cord or chain. A diameter between 6 to
9 cm is optimal.
4. A durable spigot or spout for pouring that is resistant to
oxidation and impact, closes easily, and can discharge
approximately one liter of water in about 15 seconds.
5. Instructions for use of the container, disinfection of con
tents, and cleaning the interior, permanently affixed to the
container on material that does not deteriorate when wet or
moist.
6. A certificate that indicates the container complies with
requirements of the Ministry of Health or an equivalent
appropriate authority.
35
co
oy
Figure 5: Comparison of possible vessels for water storage
Vessel
Durability
Easy to
clean
Lid
Faucet
Cleaning
inside
Volume
Ease of dosing
with
disinfectant
Cost
Distribution
costs
CDC vessel
Good
Yes
Yes
(durable)
Yes hand
can fit in
opening)
20 liter
Very easy
(standard
volume)
Moderate
to high
Higher (may
require import)
Acceptable
local jerry can)
(narrow mouth)
Fair
Yes
Usually do
not have
faucets
Usually
not
Variable
Can be more
complicated
(variable volume)
Low
Lower because
they are
locally available
Oxfam vessel
Good
Yes
Yes
Yes
14 liter
Very easy
(standard volume)
Moderate
to high
Lower (will
require import)
In most countries, the choice is between obtaining or manufac
turing a specially designed vessel with all or most of the charac
teristics above or promoting use of a locally available vessel that
has some of the desired characteristics.
A vessel that is already available in communities will cost less
but may be less effective. A specially designed vessel will always
have more of the desired characteristics.
Typically most locally available vessels lack most of the desired
features. Many local vessels:
• have a mouth which is too narrow (difficult to clean)
• have no top to keep out contamination
• do not have a faucet
• are less durable
• vary in volume
Education on how to properly disinfect water is much more
complicated if households have vessels of different design and
volume. Mistakes adding the correct amount of disinfectant are
likely. If the vessel is smaller than the standard and the dose is
therefore too much, a bad taste results. If the vessel is larger
and too little disinfectant is added, the water is not effectively
disinfected.
Education on how to clean vessels must be tailored to the type of
vessels used. If the opening of the vessel permits the entry of a
hand, then the vessel can be cleaned with soap or detergent and
water. If the opening is too narrow for the entry of a hand, then
instructions for cleaning must be adapted to local conditions.
This is one method that has been used:
• Pour 1-2 liters of water into container
• Add double the usual dose of sodium hypochlorite
(e.g., 2 capfuls instead of one)
• Add detergent
• Add hard rice grains or gravel
• Agitate vigorously
• Pour out solution
• Rinse
37
The vessel is more suitable if it has more of the desired charac
teristics. Sometimes no local vessels are acceptable (only
buckets are available). If only buckets or other “unacceptable”
vessels are available and production or importation of a specially
designed vessel is not feasible, an alternative strategy would be
to locate or develop a secure cover for the bucket. Promotion
and education would address keeping the bucket covered and
being careful not to let anyone’s hands touch the water. In
Madagascar, this situation occurred in the early stages of the
project (before special vessels were obtained). Promotional
material stressed the importance of keeping the buckets covered
and pouring, rather than dipping, the water.
HI
Foniba fanipiasana ny Sur'Eau raha seau no hitehirizana rano
Anmitio w> wwiin'ilnj wau
fcno nmo m
voafatra jo
Arohy tram m raw <10 nnmy
Kail tehiafa nvv nandraraluna
SuiTau.
1 _______
30 minitra
Ai.traho at \ ao aikity scou ny
mno itmpiaiaiin.
Inside of Brochure from Madagascar
How to assess possible household water storage vessels:
If your project is considering recommending a local vessel,
search the community for possible vessels in common sizes that
are widely available and used in the area. Then assess each for
the characteristics discussed above. Use a worksheet such as
the one on the next page to help make a systematic comparison.
There is a blank copy of this worksheet in Annex D. On the next
page is an example showing how the worksheet was completed
by some planners comparing a specially designed vessel and
three particular vessels that are commonly available in their
project area (earthenware jug, a plastic jerry can, a 10-litre
bucket with lid).
38
Figure 6: Example Worksheet for Assessing Possible Household Water Storage Vessels
Specially designed
vessel
Common earthenware jug
Plastic jerry can
Bucket with lid
Volume: standard,
10-30 L, marked
Standard 20 liters
Varies - 20-40 liters
Variable
Standard 10 liters
Design
Easy to carry, stable
Familiar, difficult to carry, stable
Easy to carry, stable
Easy to carry, stable
Plastic durable & easy
to clean
Breakable, porous, holds pathogens,
durable in households that take care
of them
Cannot see inside - gets
discolored
Easy to clean
Material
Inlet with screw-on
lid; no access to
dip with hands or
cup
Yes
Some have lids placed on top.
Dipping is usual practice
Yes
Usual practice is to dip
Faucet or narrow
mouth to pour water
Faucet
Not usually, but in some countries
clay pots are made with faucets
Narrow mouth
Wide mouth
Access to inside for
cleaning
Yes - hand can reach
in to scrub
Access to clean
Difficult to clean inside
Access to inside for
cleaning
Can be designed as
part of vessel or
disinfectant bottle
Depends on site - if clay pots have
a standard size, dosing will be
easier; very difficult to design dosing
if widely variable volumes
Can design as part of
disinfectant bottle for two
standard volumes of jerry
can --but measuring
mistakes possible
Can design if bucket of
standard size. Difficult if
bucket sizes vary
Characteristics
Device for
measuring
disinfectant
w
co
-u
o
Figure 6: Example Worksheet for Assessing Possible Household Water Storage Vessels - continued
Characteristics
Specially designed
vessel
Instructions for use,
disinfection and
cleaning affixed
Certification of MOH
Cost
Other comments
Performance in field
trials
Overall assessment
Common earthenware jug
Plastic jerry can
Bucket with lid
Can be standard for
standard volume; can
affix before sale
Must provide apart from clay pot
Labels can be produced for
households, but must be
affixed by owner
Labels can be produced
for households, but must
be affixed by owner
Can be obtained and
distributed with vessels
Difficult to certify used items already
in the home
Difficult to certify used items
Not recommended for
storage, therefore not
certifiable
Expensive but lasts long
time
Cheap, already present in homes
Typically less expensive
than special vessel; limited
safe life; accessibility varies
by country
Attractive, novel, status
item
Familiar, widely available
Likely to be purchased
used; may be unsafe-need
to assure that it is not
contaminated
Used correctly, get
improved water quality
and decreased diarrhea
Recent studies suggest that can
maintain chlorine residuals for up to
24 hours.
Performed OK in Zambia if
had a lid
Best choice if can obtain
for project
If other alternatives unfeasible, it
may be possible to develop safe
practices with clay pots.
Has drawbacks but
acceptable if no other
options
Cheap, accessible
Familiar, widely available
Not tested
Not ideal, but acceptable
if there are no other
options and if a good,
well-fitting lid is available
Whether a specially designed vessel can be used in a project
depends on whether quantities of such a container are manufac
tured regionally or locally, and whether the project can afford to
pay for them. Shipping a vessel long distances from point of
manufacture to users may cost as much as the vessel itself.
Therefore, local or regional manufacture of a specially designed
vessel is important. Refer to the web site of the U.S. Centers for
Disease Control and Prevention (www.cdc.gov/safewater) for the
most current information on manufacturers of vessels and molds.
In Bolivia, a specially designed vessel was manufactured for
$4.00. In South Africa, the specially designed vessel sold for
approximately $4.00. Oxfam sold their vessel for approximately
$3.50. See section 9.0 for more information on production of
vessels.
Important decisions are based on the type of vessel used. For
example, the dosing of disinfectant depends on the volume of
the vessel. Educational materials will need to address advan
tages and disadvantages of the vessel. The manufacturer’s
cooperation will be important to attach promotional information to
vessel surfaces and to correct any problems identified after
vessels are being used.
5.4
Choose process or product to use if water is turbid
In areas where water is turbid, pretreatment to filter out sediment
can improve the aesthetic quality of water and increase the
efficiency of disinfection, and, in some cases, reduce the degree
of microbial contamination.22 The simplest method is to filter
water through locally available, inexpensive cloth such as sari
cloth (Bangladesh), or chitenge (Zambia). To make a filter, fold
the cloth over a number of times, enough to remove turbidity yet
optimize flow. Do a trial with local cloth and local water. The use
of the cloth will need to be added to educational messages,
especially on the label of the disinfectant.
In some regions with extremely turbid water, it may be difficult to
adequately filter water with cloth because the cloth can become
clogged with organic material. In such regions, it may be neces
sary to teach people to let water settle overnight and then decant
the cleared water into a new container. Alternatively, other filter
systems such as slow sand filters could be considered, although
cost and complexity are potential drawbacks.
41
Filtering Water with Cloth
Using a Settling Technique
I
42
DECIDE ON METHODS OF DISTRIBUTION
6.0
Tasks:
Consider possible methods for distribution includ
ing systems or infrastructures that already exist
Assess the possible distribution methods for the
project
-» Select the methods of distribution and plan them
in more detail
The project will need to make water disinfectant and safe stor
age vessels available and easily accessible to target households.
This will require procurement, storage and distribution of both
products.
Factors to remember when planning for distribution are:
• What geographical area will be covered?
• What systems or infrastructures for distribution already
exist?
The most common options for distribution are:
A. government systems
B. non-government systems
43
C. commercial sector
D. social marketing
These systems may be used singly or in combination. Whatever
system or systems are selected, education and promotional
activities are also necessary to create demand for the products
and ensure that households know how to use them correctly.
Planning a strategy for behavior change is described in section
7.0. The system of distribution and the behavior change meth
ods must be planned to work together.
Similar steps are involved to plan and implement a project
through any system:
• procure products
• establish price
• plan distribution through recognized, reputable and conve
nient sites
• work out logistics of transportation and distribution
• prepare educational materials
• train or inform staff at outlets
• manage flow of products and money
• plan for emergency response
• evaluate
6.1
Consider possible methods of distribution including existing
systems or infrastructures
A. Government Systems
Distribution can be organized through government systems in
one or more different ways:
• adding distribution of Safe Water System products onto a
distribution infrastructure that is already in place, for ex
ample, for supplying government health centers
• an ‘ad hoc’ approach using government vehicles to deliver
products from central government stores to more peripheral
government offices, health centers or other outlets
• establishing a separate distribution system specifically for
water vessels or disinfectant or both
44
Government distribution systems can usually distribute large
volumes of supplies rapidly and into distant areas that are
underserved. However, they require functioning vehicles and
staff. Some governments may not have financial and manage
ment resources to maintain them. Using a government system
for distribution of Safe Water System products may divert
resources from other health service activities and may not be as
sustainable as private sector distribution.
In Ecuador, a project was initiated by PAHO in response to
flooding from El Nino with funding from the Embassy of the
Netherlands. Sodium hypochlorite production sites were located
in clinics run by the Ministry of Public Health.5 The disinfectant
solution was distributed to local neighborhoods by Ministry of
Public Health personnel. Additional funding was provided by
USAID. This project was later incorporated into the Ministry of
Public Health as a funded program. Now street vendors are
receiving training in the use of this method and are preparing
food and drinks with safe water, which enables them to be
accredited by the Ministry of Health. This method was also used
to provide safe water to victims of recent volcano eruptions.
B. Non-government Organization (NGO) Systems
Non-government organization (NGO) systems may approach
distribution in one of two ways:
• NGOs implementing a Safe Water System project may
organize their own distribution system.
• NGOs that focus on distribution activities, for example
supply of essential drugs, may distribute Safe Water System
products.
A distribution system organized by an NGO for its own project
may work well but may be expensive and unsustainable when
donor support is discontinued. If the NGO is small, it may be
limited to a small geographical area.
Relying on a larger NGO, such as CARE or PSI, has the advan
tage of using existing distribution structures and may be more
credible and sustainable. This approach requires obtaining
permission from the appropriate authorities to distribute Safe
Water System products and finding a way to cover distribution
45
costs. Sustainability of the project depends on the sustainability
of the NGO. In Western Kenya, CARE used this approach.
CARE distributed water disinfection products to villages in its
Water and Sanitation for Health Project, using community
volunteers as distribution agents. CARE also incorporated an
element of social marketing into this project (see below).
Distribution through a combination of government and NGO
systems is a common traditional approach for distribution of
health products. Products are given away or sold through NGO
clinics, government health centers and health posts, private or
public pharmacies, etc.
The advantage of a traditional distribution system is that it may
reach some individuals who may not be served by commercial
channels. It also ensures lower initial costs than private sector
approaches.
In Peru, the Panamerican Center for Sanitary Engineering and
Environmental Sciences (CEPIS—an office of PAHO), ADRA (a
7th Day Adventist-supported NGO), and the Ministry of Health
joined together in a GTZ -funded project to provide their unique
version of the Safe Water System to communities in 5 regions of
the country.7 Distribution was organized by committees elected
by community members.
C. Commercial Sector
Commercial sector distribution involves distributing vessels and
disinfectant through existing commercial distribution systems
and retail outlets. In most areas there are large or small estab
lished companies that can capably manufacture a product. They
can also distribute the product through commercial channels that
are appropriate for a locality. When the private sector makes a
product widely available and prominent, people use it. This
approach requires a market of consumers with sufficient demand
for the products or a demand-creation campaign. Product prices
must be low enough to be affordable and high enough to include
sufficient profit margin to motivate distributors. Use of a com
mercial sector arrangement is generally sustainable.
46
If a project chooses to work with the private sector for distribu
tion, it is important to arrange an agreement from the outset so
that private companies do not price the product above the reach
of the target population.
In Zambia and Madagascar, the commercial sector was used
by PSI who sold the products to commercial wholesalers for
distribution through retail outlets.1112 PSI also used social
marketing methods (see below) to increase demand for and
promote correct use of the Safe Water System products.
D. Social Marketing
Social marketing is a particular
approach to distribution and
promotion. It uses commercial
marketing methods including the
concepts of market segmentation,
consumer research, and communi
cation to create demand for a
product or service. The main
differences are:
• Social marketing aims to
increase the acceptability of a
product or idea to meet a
social need, whereas commer
cial marketing aims to sell a
product to maximize profit.
CIARO
• Social marketing usually involves subsidy in pricing a prod
uct, or of its distribution or promotion, whereas commercial
marketing involves no subsidy.
Social marketing is based on research into what potential users
know, want and do, and makes use of the best mix of existing
channels of communication to give simple, repeated and attrac
tive messages. It means finding out about potential users, and
considering “positioning”, in other words, what will motivate
these potential users to buy a product or use a service. Develop
mental testing ensures that brand name, product images and
educational messages are appropriate, understood and effective.
47
Social marketing may include aspects of commercial distribution
combined with incentives, subsidies, management or advertising
inputs from the public sector or an NGO. The aim is to support
distribution systems in the short term while demand is created
and until a market is well established. Subsidizing distribution
costs and/or introducing price controls may ensure the price is
kept as low as possible while providing distributors a reasonable
profit. These approaches seek to enable shops or other outlets
to sell to the community before a commercial system is estab
lished. Once people learn about and use the products success
fully, the hope is that they will continue to want the products so
significant demand will be created.
Social marketing, like traditional marketing, involves deciding on
the best mix of four factors, sometimes called the four “P”s:
• Product - includes decisions about brand development,
quality, packaging, logo, size and market positioning to
interest the target population so they will use the products.
• Place - includes decisions about distribution channels and
outlets for vessels and disinfectant, and coverage.
• Price - includes decisions about affordable prices, subsidies,
credit terms and cost recovery goals.
• Promotion - includes decisions about communication
channels, advertising, personal selling and sales promotion,
promotional materials and events.
The four “P”s are interdependent. For example, distribution and
outlets (“Place”) will be linked to advertising and sales promotion
(“Promotion”). Demand is affected by “Price,” as well as by
branding and advertising (“Product”), and by education on use
and benefits (“Promotion”).
“Product” issues are discussed in sections 5.0 and 7.0, “Place” is
discussed in this section, “Price” in section 8.0, and “Promotion”
in section 7.0.
48
Social marketing:
• is expensive as it requires start-up funding, marketing
expertise, and training for outlet managers and sales agents.
• may focus on urban and periurban populations and may
miss rural or marginalized populations.
• can be very effective, combining the advantages of private
sector marketing with knowledge and experience of tradi
tional health care delivery.
• generates enthusiasm about a product.
• includes a system of distribution that ensures the product is
accessible and sells at a low price (not free) so the product
will be valued and used.
An important balance to achieve in social marketing projects is
that between coverage (health impact) and cost recovery (finan
cial sustainability).
Alternatively, if financial support is more limited, elements of the
social marketing approach could be used in other types of
distribution systems. For example, a project could use consumer
research to develop a product brand and advertising for disinfec
tant that could be distributed and promoted through a govern
ment or NGO system of outlets.
In Homa Bay, Kenya, CARE hired a social marketing consultant
to help market disinfectant and safe storage practices to popula
tions in rural Western Kenya (social marketing). The products
were distributed by community health workers (government
system) and sold in local stores (commercial sector) as well as in
clinics and hospitals run by the Ministry of Health.
As the examples in this section show, existing Safe Water
System projects use more than one distribution system. Any
project would be wise to explore all potential distribution options.
Different options offer unique advantages, and the likelihood of
project sustainability and success is enhanced by having many
different types of distribution outlets.
49
6.2
Assess alternate distribution methods for the project
Consider the possible
distribution systems
(government, NGO,
commercial and social
marketing) and focus
on those which seem
most appropriate.
Investigate community
structures that could be
involved in implementa
tion. Then list some
possible methods in each system. For example, in the govern
ment system, specific methods could include distribution by
health centers and health posts. In the NGO system, specific
methods could include sale of products to consumers at the
clinics of a particular NGO, or distribution of the products by an
NGO that distributes food and agricultural goods to villages. In
the commercial sector, the products could be distributed through
an existing network of pharmacies, or a bleach manufacturer
could market them in small retail shops. Another option would be
for a commercial company or an NGO to establish a network of
door-to-door sales persons who are paid a small incentive for
sales of the product.
In reality, no one model will be used exclusively. A mix is typical,
as exemplified in Madagascar, where the project used social
marketing, government certification of the products, NGOsponsored community mobilization, and commercial sector
distribution. In both Ecuador and Peru, a combination of NGO
and government distribution systems was used.
To assess possible distribution methods for the project, use a
worksheet such as the one on the next page to help you make a
systematic comparison of the options. There is a blank copy of
this worksheet in Annex D. Possible criteria for assessing and
comparing options are written across the top of the table.
In the left column, list possible distribution methods. Then
assess each according to these criteria and any additional
criteria that you want to add. The example on the next page
shows how the worksheet was completed by some planners
considering four particular options, in their area.
50
Figure 7: Example Worksheet to Assess Possible Distribution Methods
0) 7; -0 \
0) o X '
n
2 S'”
t3
3 a, o
r» I ? ® X
Ms
cn
Possible Distribution
Methods
Project
cost
Demand
creation
Product
recognition
Effectiveness
of distribution
Accessibility
of product for
consumers
Product
price
Control
over
product
price
Potential for
sustainability
Government & NGO
combination - adding
l onto existing
'distribution system for
UNGO clinics,
•< I
j government health
OJ
o centers, health posts
Lower
Low
Low
Good - may
reach
underserved
areas
High where
government
and NGOs
work
Lowest
High
Moderate to
low
NGO - establishing
new NGO-sponsored
network of outlets for
distribution of vessels
and disinfectant
High
Moderate
Moderate
Depends on
number and
placement of
outlets
Depends on
number and
placement of
outlets
Medium to
high may be
low if NGO
subsidizes
price
High
Low
Commercial Sectorusing network of
established
pharmacies, shops for
household items
High to
moderate
High
High
Good but may
not reach
underserved
Low
High
Low
Moderate to
high
Social Marketing -health centers and
shops provided with
marketing materials;
door-to-door sales
High
High
High
Good, but may
not reach some
underserved
populations,
especially in
rural areas
Will require
special
targeting to
ensure that atrisk
populations
have access
Low
High
Moderate to
High
o'
Though the final choice will probably be a mix of systems, the
worksheet will help make apparent the strengths and weak
nesses of each method. An important consideration will be
whether a method will use an established infrastructure (such as
government health centers) or the system will need to be devel
oped (such as door-to-door sales persons). Development of any
new system requires considerable planning, resources and effort.
6.3
Select methods of distribution and plan them in more detail
Select a method or combination of methods that will be able to
best achieve project objectives within the budget. Then plan the
methods in more detail, that is, plan for actual distribution sites
and persons who will sell vessels and disinfectant. For example,
specify names of health centers, pharmacies and shops, and
plan how to identify and train door-to-door sales people.
Lack of community support and poor communication between a
project management committee and the community are common
reasons for project failure. Careful planning with community
representatives can help. Identify common goals and address
issues where there are differences in views as early as possible.
Identify key people who could be involved in the project and
develop their roles with them.
It may be helpful for project planners to interview prospective
distributors about characteristics of their system, such as:
• distribution area
• site of population covered
• type of outlets
• number of outlets
• other products distributed
• distribution costs
• frequency of distribution
• distribution capacity (i.e., number of vehicles, number of
units of product they can carry in a given period of time)
• do they have issues with product exclusivity
52
Caution: The project must pay close attention to distribution.
Insufficient follow-up after initial distribution in one project led to
failures in some regions. Also, the project grew too large for the
capacity of the implementing agency to fill demand. Households
obtained initial supplies but when the disinfectant was used up,
they were unable to replace it. The education campaign was too
short to persuade the target population of the relationship
between the consumption of contaminated water and diarrhea.
53
7.0
PLAN STRATEGY FOR CHANGING
BEHAVIOR
Tasks to do:
Conduct formative research
Identify the specific target population for behavior
change
Plan the positioning (e.g., brand name product
with logo to appeal to mothers)
Plan key messages
Select methods for behavior change and the
communication channels
Specify communication materials needed
A Safe Water System project must:
• present to the target population a compelling reason to try
the Safe Water System
• create a demand for the products
• change the behaviors of the community to include use of
the Safe Water System.
The Safe Water System requires ongoing use to be effective.
Initially, there may be good participation in terms of purchasing
a container and a bottle of disinfectant. However, for the
system to have a health impact, households must purchase
and properly use the disinfectant on an ongoing basis.
55
Success depends on the degree to which the intended target
households can be convinced to change their behavior, specifi
cally to:
• acquire the products (vessel and disinfectant)
• try using the Safe Water System, and use it correctly
• use it consistently over time.
Traditional practices of water storage and use may be difficult to
change for many reasons:
• Families may not consider the problem of diarrheal diseases
as serious as other diseases like fever or measles and may
not be motivated to use a product designed for preventing
diarrheal diseases.
• Because diarrheal diseases are seasonal, the perception of
risk may vary by season. (This was seen in Zambia, where
sales peaked during the rainy season and dropped in the dry
season.)
• Safe Water System products may seem costly.
• The new behaviors may seem inconvenient.
Behavior change is complex. There are different theories and
strategies for bringing about a behavior change in a population
that have been used with varying success. Behavior change is
always the result of a combination of factors. Changing the
behavior of a community in a lasting way is slow and can be
difficult.
Health education alone is not sufficient to bring about behavior
change23, but it can be an important contributor by raising
awareness of waterborne diseases and how to prevent them.
Promotion, using social marketing techniques, can also be an
important influence to purchase and use a product.24 Motivational
interviewing can greatly increase effectiveness as this type of
communication helps to bring about and support internallymotivated change in people.25 Community mobilization has great
potential for inducing behavior change because the community
defines its problems and the programs it wants. This creates a
powerful demand even before the project is implemented.11
Safe Water System projects have used health education, com
munity mobilization, social marketing and motivational interview
ing. Of these methods, health education, when used alone, has
56
proven to be least effective, but it remains an important supple
mentary element to each of the other approaches. Experience
has shown that if implemented well, each of these methods can
have a significant influence on the behaviors of purchasing and
using disinfectant solution correctly and storing water safely.
What is Education or IEC (Information, Education, and
Communication) ?
Educational activities aim to increase knowledge in the target
population. When planning the educational component of a
project, sometimes people use the term IEC, which stands for
information, education and communication, to indicate that a
broader range of activity is envisioned than just traditional
classroom instruction or a health worker telling a group of
mothers what they should do.
Defecackmes humanas y animates
que llegan a las rias y pozos
2
Personas
recogen agua en
En resumes, muchas
enfermedades se
transmiten de una
persona a otra de
la siguiente forma:
3
Las personas toman esta agua
contaminada
Las personas se enferman despues de |
haber tornado esla agua contominada |
In a Safe Water System project, educational activities:
• are usually implemented through interpersonal communica
tion with health workers or sellers of the products, print
materials distributed in health centers or outlets, street
theater, and video presentations.
• generate awareness of the problem of diarrheal diseases,
the severity and particular risk to young children, and the link
with contaminated water.
57
• provide information about preventing diarrhea by disinfection
and safe storage of water.
• teach households how to use the vessel and disinfectant
solution, and inform people where to obtain the products.
• are best planned using results of formative research on the
target population’s knowledge, attitude and practice.
See Annex E for some example educational materials. Although
educational activities are necessary to provide a knowledge base
about the problem and practical solutions, they have not been
shown to be effective when used alone. The manner and meth
ods that are used to convey educational information can be
extremely influential in laying a foundation for people to choose
behavior change. When individuals decide on their own to
change, it is much more likely to endure. Motivational interview
ing (see below) is a potent communication strategy that can
enhance IEC activities and promote the initiation and mainte
nance of behavior change.
It is important to coordinate IEC activities with other activities
that are already being conducted by other agencies. IEC mes
sages should be consistent with educational messages of other
agencies to avoid confusion in the target population. If other
agencies are delivering inaccurate messages that will conflict
with Safe Water System messages, then tactful efforts should be
made to correct erroneous messages.
What is Promotion? Why is it Needed?
Since information alone is seldom enough to change behavior, it
is advisable to employ other approaches to increase the possi
bilities that people will try and will continue Safe Water System
behaviors. Behavior change can be increased when promotional
activities supplement educational activities.
Promotional activities:
• aim to stimulate individuals to sample new products and
behaviors and to continue using those products.
• use messages specifically formulated to encourage the
target population and deliver those messages through
channels that will be effective with the population.
58
• are based on research on the population and reasons for
their behaviors. (See explanation of principles of social
marketing in section 6.1).
• motivate potential users to buy the products and assist them
in using the products correctly and consistently. This requires
more than giving factual information about diarrhea, water
disinfection and storage.
Promotional methods used in social marketing persuade people
to use products for reasons that are tangential to the main
reasons for the implementation of the project. For example, the
main reason for a Safe Water System project is to prevent
diarrhea. Social marketing may imply however, that women who
use the Safe Water System are better mothers, trend setters, or
smarter. Marketing research can determine how best to appeal to
potential consumers.
Educational activities are an important partner to promotion
because they provide the knowledge needed to understand
promotional messages. Education can help to facilitate behavior
change by giving people the knowledge to understand the
problem, find and purchase the products, and use the products
correctly, once they decide to do so. Both promotional and I EC
messages can appear on the same materials, such as brochures
and posters.
What is Motivational Interviewing?
Motivational interviewing
involves an interpersonal
communication method that is
grounded in health behavior
theories, decision-making theory
and motivational psychology.25
It is very useful to enhance IEC,
promotional activities and
community mobilization efforts.
The empirical evidence supports
motivational interviewing. It is effective in different cultures in
producing internally-motivated changes in a range of health
behaviors. However, training in motivational interviewing re
quires a person experienced in the method. In Zambia, it was
used successfully to strengthen the initiation and sustained use
of the Safe Water System.13
59
Motivational interviewing incorporates the theoretical model of
the stages of change, which conceptualizes change as a process
that people move through at different levels of readiness.26 The
stages are:
• Precontemplation: The person is not ready to consider
change or is unaware of any need to change.
• Contemplation: The person is ambivalent, both considering
change and rejecting it.
• Preparation: The person is open to changing and may be
preparing to make a change.
• Action: The person is actually engaging in actions with the
intention of bringing about change.
Offering advice or suggestions for taking action to a person who
is not ready for change can be premature, inappropriate, and
ineffective. A more person-centered, stage-based approach such
as motivational interviewing has been shown to be more power
ful in bringing about sustained changes in behavior.
Motivational interviewing is effective in moving people through
the stages of change and towards initiating health-promoting
behaviors. The method of motivational interviewing involves:
• listening carefully
• reflecting back certain themes that the person talks about,
• eventually eliciting a person’s own reasons for change, and
• helping the person define the personal resources that are
the most relevant to accomplish that change.
One of the goals is to create awareness in the person of their
behavior and how it may be at odds with their desired goals.
Motivation for change comes from within the person and can be
a result of this discrepancy. It is emphasized that responsibility to
initiate the change, as well as to maintain it, lies with the person.
Another goal is to support an individual’s self-confidence that he
can succeed in his change efforts. So, while there are certain
strategies and tools involved, the defining feature of motivational
interviewing is a style of communicating in a partnership rather
than in an expert role.
In Zambia, the Safe Water System project successfully trained
community members from a wide range of experience and
educational levels (including community health promotion
60
volunteers, health professionals, and social scientists) to do
motivational interviewing. Training involved didactic instruction,
role-plays, exercises, and practice.27 Following the training, it was
important to devote time to supervision, guidance and encour
agement in the field. See Annex F for more information about
training staff in motivational interviewing.
What is Community Mobilization?
Community mobilization is a process by which the community
defines their own problems, decides which are higher priority,
and organizes itself to address the priority problems.
In Madagascar, CARE used this method in its Household
Livelihood Security Program (MAHAVITA) to help communities
form a community organizational structure to diagnose and
analyze problems as described below:
Stage 1: Eligible communities were selected as potential
participants in the project. Community leaders were informed
about Programme MAHAVITA. If the community decided to
participate, their leaders signed a memorandum of under
standing with MAHAVITA personnel outlining their collaboration.
Stage 2: The community was mobilized to identify community
facilitators and form a project committee (‘Structure de
Development’). The facilitators received special training from
CARE teams with special skills in communication or social
work. The committee then identified resources available to
them such as resource persons, influential individuals,
61
local community organizations, and outside organizations. All
community members were informed of the committee and its
activities.
Stage 3: The committee facilitators led the members
through a participatory needs assessment and problem
analysis of the current situation of the community. The
committee studied the history, geography, demographics,
existing structures, and socio-economic activities of the
community. They identified principal problems faced by the
community, including problems faced by different sectors of
the community. They then analyzed the causes and effects
of the problems.
Stage 4: The committee transformed the results of the
problem analysis into a community development plan. The
committee and community members began planning strate
gies and exploring possible interventions by analyzing
opportunities that existed for the community (such as NGOs
working in the community or available government pro
grams). They determined goals, objectives, activities for
projects, and indicators to measure progress.
Stage 5: The committee approached potential partners,
such as service providers and NGOs, with their community
development plan. Contributions included donated time,
funding, technical assistance or services. As resources were
acquired, implementation of projects began.
Programme MAHAVITA personnel assisted neighborhoods with
each stage of this process to increase the likelihood of success
and incorporated the Safe Water System into the process. The
Safe Water System intervention helped to accelerate community
participation, boosted confidence in the process, and provided
an economic incentive (that is, income generated through sales
of Safe Water System products). The success of this project led
CARE to expand it to other regions of Madagascar. By working
through this process with some success, communities achieved
a sense of empowerment that stimulated the community to
continue efforts to improve its condition.
62
Steps in Developing a Strategy for Behavior Change
Regardless of the methods that will be used in the strategy for
behavior change, there are some general principles and steps
that are involved in planning all of them. Those steps are:
• Conducting formative research (in addition to research
described in section 1.0). This is the foundation for selecting
methods and for planning every aspect of each method.
Formative research is most effectively done by people with
experience in doing such research, so the research group
should be selected with care. Formative research will serve
as a baseline by which results can be measured, so monitor
ing and evaluation activities must be coordinated with
formative research (see section 11.0).
• Identifying the specific target population for the behav
ior change.
• Planning positioning (that is, product identification, brand
name, logo, etc).
• Planning key messages. These are the key messages to
convey, regardless of how messages will be conveyed.
• Selecting methods for behavior change and communica
tion channels. These are methods that the project will use
to affect the behavior of the community. Possible methods
might include education, promotion, social marketing,
motivational interviewing and community mobilization. If a
marketing approach will be used, selection of a marketing
consultant or advertising agency is an important part of this
process.
Communication channels are specific ways that behavior
change methods are implemented. Possible channels
include, for example, posters, radio spots, house-to-house
visitors, community meetings, labels on disinfectant bottles,
local drama.
63
• Specifying communication materials needed. These are
the exact materials needed to implement the methods
planned. They include advertising and promotional materials,
educational materials, training for implementers, video, radio
spots, etc. Both promotional and IEC messages can appear
on the same materials.
The strategy for education and promotion in your project will
depend on the level of funding, staff, method of distribution and
other resources available. The extent of effort devoted to re
search and design will vary depending on resources and the size
of the target population.
If a project has a generous budget and qualified staff, a substan
tial effort may be made to implement promotional activities, train
staff to deliver education and incorporate motivational interview
ing in interpersonal interactions, and support ongoing implemen
tation of educational activities. If the project’s budget or other
resources are very limited, educational activities might be limited
to a smaller target population and facilities used regularly by that
population, such as health centers and outlets that sell the
products. Promotional activities might be limited to only a few
community activities. Perhaps the most attractive feature of
community mobilization is that it can be accomplished with a
small budget.
In any case, all the planning steps described in this section are
done to some extent, in coordination with the plans for produc
tion and distribution.
7.1
Conduct formative research
Conduct formative re
search in order to develop
an effective strategy for
behavior change. Earlier
assessment (described in
section 1.0) should have
identified gaps in people’s
knowledge about diarrhea
and safe water practices
that need to be addressed by educational activities. Further
research on cultural and language issues, and knowledge and
64
beliefs about diarrhea and water, will enable the project to
develop a meaningful product brand and effective promotional
messages. The priorities of the community members and their
ways of getting projects done will determine much about how the
project will be undertaken.
Behavior change methods to motivate households to change can
be only as good as the information they are based on. Formative
research seeks to:
• find out from people themselves what will motivate behavior
change
• find out what advantages people see in adopting new
practices
• identify obstacles that need to be overcome
• find out who in the household makes decisions about
purchasing household products and water treatment and
storage and who influences those decisions
• identify media channels that reach specific audiences
Some information on current practices was gathered in the
assessment in Step 1.0; depending on the completeness of that
information for the target population, more or less investigation
may be needed. Specific information needed is listed in Figure 8.
Annex G lists some possible methods of research and provides
some examples of formative research tools. Local authorities
can characterize a town’s social institutions, subgroups and
occupations. Other research methods include:
• survey of knowledge, attitudes and practices as regards
water in the home and the link with diseases
• focus groups
• cohort studies for disease problems
• structured observations
• structured interviews
65
Figure 8: Formative Research Needs for Planning for
Behavior Change
Knowledge and attitudes toward the desired behaviors:
- What do people know about safe water storage and disinfection?
- Why do people practice or not practice certain behaviors (obtaining Safe
Water System storage container; keeping stored water safe from contami
nation by hands, animals; regularly cleaning water storage container;
purchasing disinfectant, etc.)?
- What behaviors might need to be addressed by a promotional campaign?
- Are special water vessels affordable?
- Is ongoing use of disinfectant solution affordable?
- What previous experience do people have with water disinfection
products? With other water treatment practices, such as boiling?
- Are any subgroups currently using disinfectant or special water storage
vessels? Why do they do this? Why do other subgroups not do this?
- What are peoples’ attitudes toward treating water with disinfectant?
- In what ways are the recommended water storage and disinfection
practices inconvenient or difficult for households to carry out?
Responsibility for water in the household and related purchases:
-
Who decides about making household purchases?
What kinds of purchases do different household members make?
Who controls the household budget?
Who takes care of water in the home?
Who takes responsibility for water treatment?
Who influences the household decisions about purchases?
Who influences the person with responsibility for water treatment?
Incentives and barriers:
- What are existing knowledge and perceptions about diarrhea?
- What positive perceptions does the population have about using Safe
Water System vessel and disinfectant solution?
- What are the barriers to use of the Safe Water System? - cost of vessels,
cost of disinfectant solution, difficulty obtaining vessel or disinfectant,
seasonality of income, negative attitudes toward disinfectant (e.g., dislike
of taste of chlorine, distrust of treatment of water)?
- What is important to individual (rank, acceptance, being a good mother,
etc.)?
Channels of communication:
- What channels reach each specific audience? (Channels can include
media and opinion leaders that you want to influence)
- Which of these channels are credible for this sort of message? What are
the costs to use each listed channel?
66
7.2
Identify specific target audiences
Based on findings of
formative research,
identify particular
subgroups (e.g.,
mothers of small
children) that will be
J:
target audiences for
behavior change. Also !
identify individuals who ■“
influence that target
group (e.g., community
leaders and opinion leaders) so that they may also be targeted
with education and promotion. These main groups in the com
munity should be targeted by different methods through different
communication channels.
Specific target groups overlap and may include:
• individuals who make decisions about household purchases
and about water storage and treatment
• mothers of young children and other household members
who have influence over mothers, in order to decrease
diarrhea rates in young children
• specific groups, individuals or opinion leaders in a commu
nity who, after becoming informed, then decide to change
their own behaviors. This, in turn, can influence behavior
change in the community as a whole.28
• groups not typically targeted, such as men, who may divert
family resources to other uses
7.3
Plan positioning (e.g., brand name product with logo to
appeal to mothers)
To “position” the Safe Water System means to present it in a
way that will motivate potential users to buy the products and
use them (that is, change specific behaviors related to water
disinfection and storage.) An effective approach to positioning
includes developing a brand name, logo and packaging graphics
for the vessel and disinfectant. This is strongly recommended
regardless of the other methods and extent of promotion
planned. Potential advantages include:
67
• Brand names are highly desirable to help
create a unique identity for the products
AGUA
and project. A brand name improves
product identification in the target
population.
• Branding can increase the perception of
quality and value, create a positive and
desirable image, and encourage people
to try the product. In projects in Bolivia,
Zambia, and Madagascar, having a
branded hypochlorite solution specifically
promoted for water disinfection helped
avoid the problem of bleach being
CDC PSl
identified by potential users as a product
used for other purposes, like whitening clothes or cleaning
toilets.
• Although information, education and communication can
provide people with information about the benefits of safe
water, advertising a specific brand prompts them to translate
this knowledge into behavior change.
• Advertising a particular brand of vessel or disinfectant helps
to promote safe water vessels and disinfectant in general.
Experience with other products such as condoms suggests
that promoting one brand has a “halo effect”, boosting sales
of all types of condoms. In Zambia, a commercial bleach
manufacturer began advertising its brand as a water purifica
tion product in response to RSI’s successful social marketing
campaign to promote Clorin.
• Experience shows there is a high demand for subsidized
products and that demand decreases as prices increase.
Promoting branded products may help to maintain demand
at higher prices. (Consider this in planning for cost recovery;
see section 8.0.)
■l^o™
OARO
USE PURIFIED WATER
FOR DRINKING
7.4
Plan key messages
Messages should address a few feasible
and relevant target practices or behaviors
that will be the objectives of the behavior
change strategy. For example:
BUT ALSO FOR...
HH
*
WASHINQ HANDS
SM
*
WASHING FRUITS AND
*
WASHING COOKING
UTENSILS
I
VKGETABLCS
gg
Do not putClorinM
tn wll»
Do "O’ put CloHnW
tw bucfcot*
• Buy a vessel
• Buy disinfectant
68
Do no! oxpoBo Clorin j
__
• Add appropriate amount of disinfectant to each container
of water
• If water is turbid, use a cloth filter and/or a settling technique
to clarify water before treating
• Replace disinfectant when it is gone
• Use the vessel correctly to store water and protect it from
contamination
• Do not put or let anyone put hands or other utensils into
water
• Clean the vessel periodically
• Use safe water to wash hands, wash produce, and clean
cooking utensils
Messages should address important knowledge that initial
assessment and formative research found lacking in specific
target audiences. For example:
• The risk of diarrhea for young children; the link between
contaminated water and diarrhea
• The possibility of preventing diarrhea by disinfection and
safe storage of water (the Safe Water System)
• Information about how to obtain and use the Safe Water
System vessel and disinfectant solution
• Where to purchase an approved water vessel and disinfec
tant solution
• Price of the water vessel and disinfectant
Advertising messages highlight qualities desired by target
population. For example:
• Be a super mom
• Be the first in your neighborhood to use the Safe Water System
• Smart mothers use the Safe Water System
• For healthier, beautiful children, use Safe Water System
The target population includes households with low income and
they will have limited ability to pay for vessels and disinfectant.
The project will try to keep the price of these products low by
subsidy and other schemes to lower costs. However one of the
goals of education and promotion will be to make the Safe Water
System a priority household expenditure.
69
7.5
Select methods for behavior change and specify communi
cation channels
Based on formative research and decisions about target audi
ences, positioning, and key messages, select several methods
to try to change the identified behaviors. Methods might be
education, promotion, motivational interviewing and community
mobilization. Multiple methods are more effective than one.
Methods should be sustainable and expandable.
Also use information from formative research to select an
appropriate mix of communication channels to reach each
specific audience. For example, reach mothers of young children
through interpersonal communication with health workers,
brochures for distribution at health centers and points of pur
chase for disinfectant, and through video trucks at markets.
• Education could be implemented through channels such as
school teachers, health professionals, and dramas at market
days.
• Promotion could be implemented through channels such as
posters and brochures at outlets where disinfectant is sold,
face-to-face communication with health workers, and video
trucks at markets.
• Motivational interviewing could be implemented by commu
nity health promoters making house-to-house visits or by
health workers interacting with mothers of young children.
• For community mobilization, the key communication channel
is the neighborhood committee or its equivalent.
Potential channels can be categorized as either interpersonal
communication, local media, mass media, and printed materials.
Annex H describes each of these categories and reviews advan
tages and disadvantages of each.
Choose communication channels that are:
• available to the target group
• appropriate for the target group
• acceptable
• cost-effective
70
Using a mix of channels to reach each audience is always more
effective. Education and promotion are most effective when
delivered through a combination of channels, particularly printed
materials along with face-to-face communication to explain the
materials. Printed materials can be taken home and viewed
repeatedly. During interpersonal communication, individuals can
ask questions, get reassurance, etc.
It is important to have educational and promotional materials at
points of sale. Educational materials must clearly describe how
to use the products. Staff and materials at health clinics should
actively promote the Safe Water System and its benefits. De
pending on resources, the project may choose to use additional
channels, such as house-to-house visits by a neighborhood
health committee member or a door-to-door sales person.
For effective interpersonal communications, choose persons who
will be credible to the target audience and will have the time to
carry out the interactions well. Effectiveness of communication
can be greatly increased if staff are trained to communicate
messages, use printed materials, and ensure that messages are
understood. See Annex I for an example curriculum for training
staff who will teach households about diarrhea, use of a disinfec
tant (“Clorin”), and safe storage of water. Improving the effective
ness of interpersonal communication is the area where motiva
tional interviewing has its greatest impact. If motivational inter
viewing is selected as a method, the implementors (people
having interpersonal contact with consumers) will need to be
trained in the particular skills of motivational interviewing. (See
Annex F.)
7.6
Specify communication materials needed (e.g., label with
dosing instructions)
When target audiences, positioning, key messages, channels,
plans for distribution of the products and cost recovery have
been determined, you can make a specific list of materials that
will be needed. These materials could include items such as:
• label on disinfectant bottle and on water storage vessel (See
Figure 9 for guidelines for these labels.)
71
• training and reference materials for interpersonal communi
cations (for example, for health staff who do health education
in the health center, and for neighborhood health committee
members who employ a motivational interviewing style when
making house-to-house visits.)
• posters for display at health centers, schools
• instructional brochures to distribute to consumers who
purchase the products
• point-of-purchase materials to display at sales outlets, such
as posters and counter displays
• reference materials for interpersonal communication by sales
persons at outlets (such as frequently-asked questions with
good responses)
• promotional items with logo, such as t-shirts, drinking
glasses
• video on how to use the Safe Water System and its benefits
to be shown by a projection truck
• script for radio spot
• support materials for drama group
• materials for use at community meetings
Sotfum hypochforile solution 0.5% USP.
Use lot water disinfection. Store away Irom sunliflht and extreme heat.
Instructions tor use:
Measure solution using the bottle lid as shown, and pour it from the lid
Into your water container.
For 2.5 titre container, fill outer rim of the lid
I For 51'he container, fill outer rim of the lid twice.
-
For 20 litre container,
till center ot the bd.
I
sLJ
Close water container, shake container well and wait 30 minutes
before using water.
KEEP AWAY FROM CHILDREN
j
S
c
Produced and distributed by SFH with support from USAID
72
Si
Figure 9: Package Labels
The label on a water storage vessel should include instructions
for:
• proper filling
• disinfecting
• keeping water safe (such as not putting hands or dipper into
the vessel)
• periodic cleaning of the vessel interior
• suggested applications of treated water, including drinking,
hand washing, cleaning utensils and washing produce
The label on the bottle of disinfectant solution should include:
• identification of contents
• instructions for measuring the correct amount for the vessel
• shelf life (when to throw away unused disinfectant solution
and get more)
• how to keep disinfectant safe, out of the sun, out of the reach
of children
Below are some examples of educational and promotional
channels and materials that have been used in different projects.
Annex E includes some example materials.
Point-of-purchase information: Signs, stickers, and place cards
are used to identify outlets and agents where water vessels
and disinfectant solution are sold. If prod
ucts have a brand name, the brand name is
promoted on these materials. Brochures or
leaflets and counter cards provide simple
instructions on how to use the products.
Sales persons in shops or health workers in
health centers use these materials to help
teach families how to use the products.
Posters promote the Safe Water System with simple messages
about the importance for preventing disease.
Peer educators: Educators are recruited through neighborhood
health committees, or already established community health
workers are trained to do household or small group education
73
on the Safe Water System. Peer educators can provide educa
tional information much more effectively if they are trained in
skills of motivational interviewing.
Small group activities: These are presentations at health
centers, churches, schools or other appropriate community
forums, organized by neighborhood health committees and
conducted regularly.
Interpersonal: Health workers at
health centers and clinics
educate potential users and
support the Safe Water System.
Sales persons at stores and
house-to-house visitors educate
potential users as part of their
sales efforts. These individuals
can also be trained in motiva
tional interviewing to increase
the effectiveness of their
communications.
Schools program: Seminars are
held to teach teachers about
diarrheal diseases and home
water treatment and to encour
age them to include this informa
tion in their curriculum. Presen
tations are then held in schools
to educate students and their
parents. Teachers keep Safe
Water System vessels in their
classrooms. Day to day children
take turns adding disinfectant and they all enjoy a supply of
safe drinking water at school. When children learn how to
disinfect water and keep it safe,
they can help their families do
the same at home.
Promotional materials: If
products are branded (that is,
identified with a brand name as
part of a social marketing
project or commercial
74
distribution system), branded items such as drinking glasses,
cups, t-shirts, stickers and pens may be used to promote
awareness of the Safe Water System vessels and disinfectant
solution.
Mobile video unit: This is a vehicle that is equipped to show
video on a large screen. It travels from place to place to be
seen by potential users in different neighborhoods, at schools,
markets, festivals, and other public gathering places. Video is
most effective when it is accompanied by an educational/
promotional presentation and interaction with an audience.
Special events and local
media: Clean water fairs are
staged at critical times of the
year, such as at the begin
ning of the diarrhea or
cholera season. Sales
agents and health workers
make presentations and sell
vessels and disinfectant
solution. Songs, dance,
drama, and contests make
these a major event for the
community and draw large
crowds. Local performers deliver essential messages through
drama and jingles. Quizzes and competitions involving the
crowd reinforce messages.
Small media and outdoor
advertising: Posters,
billboards, brochures and
leaflets are used to promote
UNL-.
|> -Tii
the benefits of using the Safe
Water System. These
all war tong
materials should use lowliteracy pictorial images and
be written in local languages.
Local radio, TV or print
media (such as newspapers) are used if they are accessible to
households in the project area. (Note that problems of supply
and credibility are created if mass media advertise the products
in a wider area than they are available.)
75
In Zambia, the Clorin project was launched with a public event in
which local children performed Safe Water System skits and
local dignitaries made speeches. Local print and broadcast
media covered the event. Subsequently, Clorin signs were
painted on walls outside of health clinics. Brochures were
distributed at local events and points of sale. Peer educators
developed humorous water safety skits that were performed in
markets and at other public gatherings. Community health
workers were trained to educate their neighbors about causes
and prevention of diarrhea and correct use of Clorin. Clorin
T-shirts were given away at public events. A video was produced
and taken around the country in mobile video units to show to
different communities. Clorin billboards were painted in strategic
locations.
PS
.11
76
8.0
PLAN FOR COST RECOVERY
Tasks:
Decide on an approach to cost recovery
Set the prices of water storage vessels and
disinfectant
Plan any subsidies or special payment methods
Plan how funds will be managed
|CLARO NO ES CARO!
Bid6n CLARO
5
Solucidn CLARO
ClBo
■ El Biddn. si se culda
blen. dura mds de
10 ados.
■ Medio lltro de
poderosa Solucidn.
Possible approaches to cost recovery include:
• Providing vessels and disinfectant free of charge - all funding is
covered by donors or government
• Recovering the costs, or part of the costs, of some project
components - some funds are generated through sales of
products
• Recovering all costs - all costs of the project are repaid through
sale of products. This requires sale of large volumes of the
products at higher prices.
In a Safe Water System project, the products are low cost items, and
the project is conducted in settings with low household incomes.
Consumer ability and willingness to pay are critical factors that depend
on how much money people have and how much they want to spend on
safe water.
77
8.1
Decide on an approach to cost recovery
Cost recovery plans will depend on the objectives of the project in
terms of coverage and sustainability, and the source, amount and
timeframe of funding available. Consider feasibility, advantages
and disadvantages of different cost recovery schemes.
• Providing vessels and disinfectant free of charge —
Providing products free of charge is likely to result in higher
coverage and distribution to the people who are poorest and
most in need. However, experience has shown that people do
not value items as much when they are given away free.
Donation of vessels and disinfectant to families may result in
little use initially and no sustained use. Donation is also
expensive and unsustainable in the long term. An exception
to these recommendations is in disaster settings where sale
of any items would not be possible.
• Recovering the costs of some project components —
Most Safe Water System projects decide to try to recover
some costs. This is usually done by selling products at prices
that generate funds to offset some of the project costs. An
advantage of charging for products is that if a product has a
cost, people feel it is more valuable. A disadvantage is that
some people cannot afford to buy the product. However, this
can often be compensated for by some creative payment
methods. Also, demand creation, through such techniques as
social marketing or community-based promotion, can induce
people to buy a product they might otherwise feel they cannot
afford.
Usually, the original donation is used to cover the costs to
establish production of water storage vessels and disinfec
tant, and also initial project costs such as promotion and
education. Then by establishing a pricing and a payment
collection system for sale of products, the project can gener
ate some revenue. If the project can recover some or all of
the ongoing costs of producing and distributing the disinfec
tant and perhaps vessels, the supply will be more sustain
able. In Zambia, for example, the project recovered 80% of
production costs for the disinfectant; this did not include
marketing costs.
78
• Recovering all costs — With full cost recovery, a project
receives a donation that is placed in a revolving fund. All
expenditures for supplies, distribution, promotion, monitoring
and management are recovered through sales of the prod
ucts. Theoretically the project can sustain itself into the future.
The disadvantage of full cost recovery is that the necessary
price of the products is likely to make them unaffordable,
except for relatively wealthier members of the community,
and result in low demand. Because of this possibility, full cost
recovery may be less likely to succeed.
In Bolivia, for example, in the CLARO project, full recovery of
the cost of 20-liter water vessels led to an initial surplus in the
revolving fund, but the project subsequently saw a decline in
sales. The CARE project in Western Kenya managed to
procure inexpensive, locally-produced hypochlorite solution,
used locally available containers, and had low marketing
costs. In these ways, this project attempted to achieve full
cost recovery from products that were affordable to their
poorest clients.
In summary, donation of vessels and disinfectant to families is not
recommended because it is unlikely to result in sustained use
(except in the case of disasters). Full cost recovery requires
higher product pricing. Therefore, it is recommended that a Safe
Water System project plan some sort of partial cost recovery. To
improve the success of any cost recovery scheme, the project
needs to plan for:
• a well-implemented behavior change strategy to make the
home water treatment system a priority household
expenditure
• creative financing schemes to help poorer families purchase
the products (see 8.3 below)
• diligent collection of sales revenues to achieve sustainability
8.2
Set the prices of water storage vessels and disinfectant
Issues to be considered include:
■ the amount people are able and willing to pay (depends on
availability of cash, seasonality of income in agricultural
79
economies, seasonality of disease, and also factors such as
peoples’ priority for expenditures, perceptions about diarrhea
and water safety, local practices, and effective promotion and
education)
■ the proportion of costs that needs to be recovered from sales
■ the price needed to balance coverage with cost recovery in
line with the project’s health and financial objectives. If prices
are set too low, high coverage may be achieved but less
revenue will be generated. If prices are set high, coverage
may be low initially but effective promotion can usually
increase demand. Also, most projects find that it is easier to
lower prices than raise them; rising prices can cause
resentment and drop out.
■ any changes expected in the local market in the future
Balancing affordability and incentive
Set low prices that most families can afford. Market research
determines consumers’ ability and willingness to pay for special
vessels and disinfectant solution. Where products will be sold
through the private sector, they must be priced so that distributors
and sellers are motivated to distribute, promote and sell them.
Prices should allow sales persons (such as health promoters) to
earn a small commission for sales. Health centers and commer
cial outlets should receive income from sales. These incentives
can be extremely effective to stimulate sales. As a guide to an
appropriate profit margin, look at margins on products of a similar
price and life span.
Pricing special vessels
For specially designed water storage vessels, the price objective
may be to recover as much as possible of the manufacturing
costs (and the cost of shipping, if significant), plus a distribution
margin (some projects have used 25%). If this price is too high for
consumers, a pricing option such as price subsidies (for example,
through the use of coupons) or credit terms may be established to
lower the price or cash outlay.
80
Options include:
■ sale at full price
■ sale at subsidized price
■ sales on credit
■ barter
■ payment in kind (e.g., vessel in exchange for work, see
Figure 10).
One method to estimate a feasible price for the special vessels is
to determine what people pay for the vessels they currently use,
or other similar household items such as plastic washbasins. If the
special vessel has a price like other commonly-used containers,
people will be more likely to purchase it.
Because a vessel is a high-priced item in comparison with
disinfectant and can be too expensive for some consumers, some
successful projects have sold vessels at a subsidized price and
disinfectant at a break-even price.
Pricing disinfectant
For disinfectant, the price objective may be to recover manufac
turing and bottling costs, plus a profit margin. It is best to sell
disinfectant at a break-even price with perhaps a slight profit,
depending on local packaging costs. The break-even price may
not include support for sale and distribution.
To set a price for disinfectant, first calculate the cost to produce
one bottle of the disinfectant, including salt, electricity, operator
and bottler, bottle, label, and transportation. Add a percentage
markup, depending on your project’s plans for distribution, such
as a margin to cover costs of transportation, a profit for retailers,
or an incentive for volunteers involved in promotion and sales.
To determine if this price will be reasonable, calculate what the
cost would be per household per year. Then compare this with
annual household income. (However, data on average household
income is often difficult or impossible to obtain.)
For example:
Price of one bottle of disinfectant = cost to produce and bottle
plus 30% retail markup =
Annual cost per household = Price of one bottle X (number of
bottles needed by average household per year) =
81
Average annual household income = per capita average annual
income X average household size =
Annual cost of disinfectant per household / Average annual
household income =%
In Zambia, the cost to produce one bottle of disinfectant is $0.20.
There is a 25% retail markup, so the price of one bottle is $0.25.
Annual cost per household = $0.25 X 12 bottles = $3.00
Average annual household income = $370 X 6 persons in the
household = $2220
Annual cost of disinfectant per household/average annual house
hold income = 3/2220 = 0.1%
It is unlikely families will buy disinfectant if its cost exceeds 2% of
the average annual household income.
One method to estimate a feasible price for the disinfectant is to
determine what people currently pay for household products they
currently use for cooking fuel or hygiene, such as charcoal, wood,
soap, or laundry detergent. If the disinfectant is priced like other
commonly-used household products, people will be more likely to
purchase it.
If it is possible to sell disinfectant in returnable bottles, the unit
cost of disinfectant may be lowered substantially. The pricing of
returnable bottles and bulk disinfectant will need to include a
much higher profit to compensate disinfectant vendors who
purchase in bulk and then refill containers returned by consum
ers. Alternatively, empty bottles can be collected by vendors and
returned to the manufacturing location to be cleaned, relabeled
and refilled.
8.3
Plan any subsidies or special payment methods
Discuss with community representatives as early as possible the
projected costs of vessels and disinfectant. Also discuss their
perceptions of the costs and whether subsidies or special pay
ment methods are needed. Ask them which payment methods are
most promising in the target communities.
82
Subsidy
Subsidy is one way to increase the affordability of products, but it
may be a short-term option because it relies on external donor
support. Subsidy can make vessels affordable to poorer members
of the community and increase demand. However, it may result in
increased purchases only in the short term, with demand falling if
and when the subsidy is removed.
Subsidies may target particular groups or areas. The issues to
consider include who should benefit and how to ensure that the
target group receives the benefit and not others. For example, the
project may target homes with children and sell them the vessel
at a reduced price. A potential problem with subsidized projects is
that poor households may purchase the vessel at the subsidized
price and then resell it at the regular price to earn the difference.
This possibility defeats the purpose of the subsidy, which is to
increase access to the poor.
Another approach is to sell a basic vessel for a low price and a
more expensive vessel with special features, such as insulation,
for families who want and can afford it. Profit from the more
expensive vessel can help cover the costs of producing the basic
vessel, thereby keeping its price low for the neediest families.
PAYMENT METHODS
Cash purchase of a water storage vessel is too expensive for
some people. Spreading the cost is one way to make vessels
more affordable. Possible payment schemes include:
■ sale for a single
payment
■ sale with
installment
payments
■ payment in kind
(for example,
water vessel for
work project)
■ employer or
community
credit schemes.
83
To date, water projects have all sold vessels for a single payment.
One project sponsored a “Water Vessel for Work” project in which
some individuals worked on a community improvement project,
such as building a health post or community center, digging
drainage ditches to remove standing water, or planting a commu
nity garden. When the project was completed, participants were
“paid” a vessel and disinfectant. This approach allowed families to
obtain a vessel with no cash outlay, but the vessel had value
because it was earned. (See Figure 10.)
Administration of credit schemes is not easy and can be time
consuming, but may be considered where the infrastructure is
already in place and operational.
Figure 10: Steps of a Water Vessel for Work Project
1. Meet with the community to
• introduce products,
• determine interest and motivation, and
• define community improvement projects in which many
can participate.
2. Obtain funding from local government, NGOs:
• for vessels and disinfectant, and
• for project materials.
3. Define work day. Purchase products and materials.
4. On work day, register participants, assign tasks, and verify
participation for entire work day.
5. Upon project completion, distribute vessels and solution.
Suggested projects:
Build or improve health posts, community centers,
or schools
Dig drainage ditches to remove standing water
Prepare, plant, weed, and cultivate a community
garden
Build desks and chairs for school or community
center
84
8.4
Plan How Funds Will Be Managed
Important decisions include whether the project or other institu
tions within the community will manage the money and how it will
be handled. Management needs to ensure accountability for
funds and supplies. Financial controls are required to prevent
misuse or theft. To achieve sustainability, management of funds
must include diligent collection of sales revenues. Lenient pay
ment policies will lower cost recovery and sustainability.
Issues to consider include:
• capacity of different organizations, groups or individuals for
management of funds
• sustainability of the procedures
• security of funds and supplies
Project management of funds - Some projects have estab
lished their own system of collecting funds generated from
product sales to community members or retail outlets or through
health facilities. Experience shows that allowing health facilities to
retain some revenue can improve staff motivation and service
quality.
Project management of funds has several potential drawbacks:
• The project may not have the capacity for the work created by
managing funds.
• The community is not involved.
• The system is only as sustainable as the project.
• The project may not be able to receive payment for supplies
at the time of hand-over if outlets or individuals do not have
funds to pay up front. Collecting money in arrears can be
difficult.
Project managers also need to consider the safety and security of
project staff, who may be expected to transport funds generated
from product sales.
Community management of funds - Some projects work with
community organizations, such as women’s groups, neighbor
hood health committees, and community pharmacies, that can
85
buy and sell products, bank funds generated, and use the funds
for resupply. The ability of local health centers or neighborhood
committees to manage inventories and collect and manage funds
will vary widely. Commercial retail stores and shops will have
these abilities. Although community involvement can potentially
increase sustainability, any project considering this approach
needs to consider carefully the experience of community
committees:
• Policies must be clearly defined, written down and understood
by all members of the committee, project and community to
avoid misunderstandings.
• Procedures to control money handling, banking and access to
banked funds must be established to prevent theft.
• In anticipation of the end of external support, systems must
be created to enable the community to use funds generated
to procure and distribute new supplies.
The most important policies to define are the roles and responsi
bilities of the project, the committee and its individual members,
and how the income generated will be used.
Procedures to control money handling can reduce the risk of theft
of community funds. Procedures can be quite complex and time
consuming, and outside regulation of village committees may
sometimes be required. But they can also be quite straightfor
ward, such as requiring signature of both a neighborhood health
committee member and an appointed health worker to withdraw
funds from the bank. Some projects have found that women are
more trustworthy in handling revenue and managing funds.
86
PREPARE FOR PRODUCTION,
PROCUREMENT AND DISTRIBUTION OF
PRODUCTS
9.0
Tasks:
Set up production of vessels or procure vessels
Set up production of disinfectant bottles, caps
and labeling or procure a source
Set up production of disinfectant or procure a
source of supply
Set up distribution system for products
-> List the activities and desired outputs (quantities)
, IL
If
*
9.1
Set up production of vessels or procure vessels
If the project plans to sell a specially-designed vessel, the options
available (as of August 2000) are:
• CDC vessel (Africa): Purchase from Megapak,
Johannesburg, South Africa. Contact gtpage@.nampak.co.za.
• CDC vessel (Bolivia): Purchase from PROSIN, Telephone
591-2-782498, Fax 591-2-782400. Contact
Yale@mail.zuper.net or prosin@ceibo.entelnet.bo
• CEPIS vessel (Peru): Purchase from PBEX S.A., Los
Calderos 120, Urb. Vulcano, Ate., Lima Peru, 51-1-348-3835,
51-1-348-0278
87
• Ecuador vessel: Purchase from Plasticos Ecuatorianos.
Contact alarconf@gye.satnet.net or katty@gye.satnet.net
• Oxfam vessel: Contact: psherlock@oxfam.org.uk
If the project plans to manufacture a special vessel in a country
without current production, the project needs to obtain molds for
making the vessel, spigot and lid (estimated cost for 3 molds was
$100,000). The first step is to identify a factory that will have the
capability to manufacture the vessels and to determine the
machinery they use. Most blow-molding machines produced after
1990 are capable of producing the special vessel, but the molds
will need to be made to suit the particular machine that will be
used. After molds are made, they are shipped to the factory,
installed and tested. If a project chooses this option, it should
request technical assistance from CDC (safewater@cdc.gov).
If, instead of a specially-designed vessel, inexpensive, locallyproduced or locally-acquired jerry cans are selected as the vessel
of choice, then the use of these containers can be promoted.
Alternatively, the containers can be purchased by the project and
distributed to target areas.
9.2
Set up production of disinfectant bottles, caps and labeling
or procure a source
If the project plans to manufacture a unique bottle for disinfectant,
this will require a mold for the bottle and one for the cap. The
mold used to make a small bottle in Bolivia cost $8000. Often a
mold can be designed locally so a locally available cap, such as
for a soda bottle, will fit the bottle, eliminating the need for a new
mold for the cap.
If the project plans to use a locally available bottle, make arrange
ments with the manufacturer to procure a supply (and re-supplies) of the bottle. One potential problem with this approach is
that the local producer might not be able to keep up with demand.
This happened in Madagascar.
Labels for the bottle should be carefully designed as a part of
planning for education and promotion. Options for applying labels
to the bottles include:
88
• silk-screening the labels directly onto the bottles, or
• printing a paper label and gluing paper labels onto the bottles
Explore the options available locally. Decide how the bottles will
be labeled and what tasks to contract out to local printers. If the
labels will be printed on paper and applied to the bottles, be sure
to test the paper and glue before large quantities are produced.
9.3
Set up production of disinfectant or procure a source of
supply
Obtain the necessary equipment and set up for hypochlorite
production (see Figure 11). The manufacturer of the hypochlorite
generator will provide detailed information on the use of their
equipment.
Below are four different hypochlorite generators with information
for contacting the manufacturers.
AquaChlor
Equipment and
Systems Engineering
Miami, Fla. USA
Jotoma1@shadow.net
Telephone (305) 378-4101
Sanilec
Exceltec International Corp.
Sugar Land, Texas USA
Exceltec@sanilec.com
http://www.sanilec.com
Telephone (281)240-6770
Clorid
Av. Gonzalez-Suarez 4-121
y Octavio Diaz
Cuenca, Ecuador
http:// www.clorid.com
clarid@cue.satnet.net
Telephone 593-7-801652
Dip Cell
Magneto-Chemie B.V.
Calandstraat 109
3125 B.A. Schiedam
Netherlands
Telephone: 31-10-262-0788
31-10-262-0201
89
Figure 11: Requirements for installation and operation of
hypochlorite generators
Hypochlorite generator
• information on operation and maintenance from the
manufacturer
• space
• a room exclusively for installation and operation of the
equipment
• cement floor at least 2x2 meters
• ventilation - windows opposite each other for circulation
and for release of hydrogen gas
• locking door
Electrical source 110-220 volts, 20 amps from battery or solar cell
Water source
• piped preferable; well is acceptable
• close to equipment
• clear (filter if turbid)
Salt source
Store in room in covered plastic container, away
from walls, windows and floor
Operators
At least two, trained to operate and maintain
equipment, bottle disinfectant, keep records, follow
distribution procedures
Materials
• three 100 (or 200) liter barrels with lids. Cut 15 cm circular
hole in one lid. Place plastic spigots 5 cm from bottom in
2 places.
• wooden benches to hold barrels
• chairs
• table for labeling bottles
• plastic bottles (250 ml recommended)
• preprinted labels or silk-screened bottles
• storage space for bottles, supplies
• sodium hydroxide (alkalizing agent to extend shelf life of
sodium hypochlorite solution)
• measuring device that tests concentration of sodium
90
Figure 12 lists steps for producing hypochlorite solution on a
routine basis. Before routine production can begin, however,
a critical step is trial production. Trial production includes
producing a batch of solution, assessing the chlorine concen
tration of the solution produced, and making adjustments in
the manufacturing procedure as needed. This process must
continue until batches of solution with the desired concentra
tion of chlorine are produced reliably. Trial production may
take one or several days, and requires the assistance of an
experienced person.
The steps of trial production are:
• Follow the procedure for production of hypochlorite
solution. (Refer to Figure 12, steps 1 through 10.)
• After the machine has operated the prescribed number of
hours, determine concentration of chlorine produced
(see Annex C).
• If the concentration is less than 0.5%, this result is likely to
be explained by one of three factors that determine
hypochlorite concentration: salt concentration, time of
machine operation, and current flowing into the solution.
Make adjustments to at least one of these factors to obtain
the desired concentration of 0.5% - 1.0%.
- Increase the time of operation of the machine in incre
ments of 1 hour until desired concentration is reached
- Increase the concentration of salt by 10% (e.g., if 3 kg is
used initially, then use an additional 0.3 kg).
- Check the amperage produced by the machine (most
machines have digital or graphic indicators of amperage).
If amperage is less than the level recommended in the
operation manual for the machine, contact the manufac
turer for recommended adjustments.
• When optimal time of machine operation and salt concen
tration is determined, this procedure should be recorded
and used for each production cycle.
• Test concentration of hypochlorite after each round of
production so adjustments can be made as necessary.
(See Annex C.)
91
Figure 12: Procedure for Production of Hypochlorite
Solution (manufacturer will provide detailed information)
STEPS
1. Mix completely 3 kg salt in 100 liters water in a barrel (or 6 kg
in 200 liters)
2. Cover with lid with hole
3. Place cell in solution
4. Connect cable of cell to rectifier
5. Connect rectifier to power source (wall outlet or battery)
6. Turn on rectifier - set for 12 hours
7. Make sure amperage does not exceed 20 - check hourly.
If amps increase, turn down amperage on rectifier
8. When finished, immediately remove cell from solution
9. Remove lid with hole and replace with lid with no hole
10. Place cell in container with fresh water after use
11. Test concentration of finished product (see Annex)
12. Maintain register of each production: date, time on, time off, kg
salt, liters of water, final concentration, number of bottles filled,
operator name
Maintenance
Clean cell in 5% solution of acetic acid (vinegar) at least once a
week by submerging cell in vinegar for 1 hour
Safety precautions
Fuse (circuit breaker)
Goggles, gloves, and apron for operators
No smoking around equipment
Barrels and spigots should be polyethylene as metal parts
will corrode rapidly
To enhance shelf life of bleach
Add NaOH to finished solution, aiming for pH of 11 to 12
If no pH meter available, add 60 gm NaCH/100 liters of
disinfectant
Packaging bleach
Plastic 250 ml bottles, opaque, with 2.5 to 10 ml cap.
Add label with dosing instructions in pictures
Store bottles in cool place away from sunlight, out of reach
of children
Determine local shelf life and discard bleach not sold 3
months before expiration
92
After successful trial production is accomplished, test the disinfec
tant in local water to determine the necessary dose. The dose will
depend on the turbidity of the water.
The procedure is as follows:
• Fill vessel with local water (it is best to use the type of vessel
recommended by project)
• Add Vz to 1 capful of solution to the water
• Agitate the container and let it sit for 30 minutes
• Test treated water for free chlorine concentration
• If concentration is between 0.5 and 2 mg/liter, dosage is
adequate
• If concentration is less than 0.5 mg/liter, add disinfectant
solution. Double the previous dose (e.g., if it was !4 capful, add
another % capful). Keep adding these same increments of
solution until target concentration of chlorine is reached.
• If concentration is greater than 2.0 mg/L, then start process
over, beginning with the initial test dose in a vessel of fresh,
untreated water.
• Continue reducing dose until target concentration is reached.
State the correct dose in educational materials including on the
label for the bottle. The best dose is one that can be measured
with the cap of the disinfectant bottle (so that everyone has the
same measuring device), is simple,
and can be used in as many locally
INSTRUCTIONS
available containers of different sizes
as possible.
In Zambia, for example, the disinfec
tant bottle had a cap with a central
cup and a surrounding rim. The
instructions said to measure the
correct amount of disinfectant to treat
a 2.5 liter water vessel by filling the
outside rim of the cap once. To treat
5 liters, fill the outside rim 2 times; for
20 liters, fill the central cup.
For 2 $ Utro contains Mil
outer r«m o» ttw i»d
For $ Hire container hll
outer rim of the IhJ twice
Outer rim~|
ienter ot lid
In Madagascar, the instructions
were to use % capful to treat 10 liters
of water and to use one whole capful
93
for 20 liters. One problem faced there was that disinfectant was
shipped to a cyclone-affected disaster area where the only
available water source was turbid river water. The dose recom
mended for the relatively clear water in the capital city was not
adequate for the turbid river water at the disaster site. The dose
had to be adjusted for the local water and educational material
altered to reflect this change.
Train staff at each production site. Training should include opera
tion and maintenance of the equipment that produces disinfectant,
safety precautions, measurement of hypochlorite concentration,
product safety, record keeping and reporting. (See Annex C.)
9.4
Set up distribution system for products
In section 7.0, the project planned for behavior change, using
strategies such as community mobilization, promotion, and
education. Materials included items to be displayed at points of
sale and materials to explain use of the products to families at
house-to-house visits and community meetings.
In section 8.0, the project planned pricing of the products and a
system for cost recovery.
Next, to set up the distribution system, as described in section
6.0, identify and contact specific retailers, government health
centers or other health facilities, and other organizations that will
sell the products (e.g., neighborhood health committees). Plan
the network of distribution (how products will be transported to
sellers, how health centers and other sellers will be re-supplied)
and flow of money. For example, list the exact procedures for
sellers to turn in revenues and receive a commission for vessels
or disinfectant sold.
Finally, the project will need to train health center staff, neighbor
hood health committees and agents, commercial retailers, service
club participants and NGO representatives who will be involved in
the sale of water storage vessels and disinfectant solution. (See
sections 10.4 and 10.9 on planning and implementing training for
staff.)
94
9.5
List the activities and the desired outputs (quantities)
List the activities including a statement of the quantities that the
project plans to achieve. These should be the main activities and
level of effort required to achieve of the objectives specified in
step 2.0. For example, see Figure 13.
Figure 13: Production and Distribution Activities to
Lead to Achievement of the Objectives
To achieve the following objectives:
1.
Increasing access to the intervention (products)
1.1 Sell 20,000 bottles of disinfectant in first 3 months
1.2 Sell 1,000 water storage vessels in first 3 months
The project will implement the following activities:
1.
2.
3.
4.
5.
6.
Place disinfectant and vessels in 60 retail shops and
demonstrate consistent supply
Place disinfectant or vessels in 10 health facilities
Train 30 community-based distributors (such as commu
nity volunteers)
Produce 1500 liters of solution per month
Produce 100% of batches of solution with free chlorine >
0.4%
Review sales records.
95
10.0 PREPARE TO IMPLEMENT THE
BEHAVIOR CHANGE STRATEGY
Tasks:
Develop brand name and logo
->
Develop key messages
->
Make detailed plans to implement methods for
behavior change
Plan training of staff to implement behavior
change methods
Develop communication materials and training
materials
List activities and desired outputs (quantities)
Arrange use of channels selected
->
Pretest messages and materials
Produce and distribute materials
-> Train persons who will implement behavior
change methods
Plan additional behavior change interventions, if
possible
97
Use information from formative research (see 7.1) to develop plans
and materials to carry out the behavior change strategy. Effective
messages, materials and other behavior change interventions will
increase demand, purchase, and use of appropriate water storage
vessels and disinfectant. Developing effective materials requires
pretesting them with the target audience to find out whether they
create the desired effect and revising them accordingly.
Developing an effective behavior change strategy and its compo
nents, such as brand name, logo, messages, materials, etc.,
requires special skills. It is recommended that the project works
with specialists to undertake this development. Individuals who
have the skills and experience to contribute in this area may be
found in HIV/AIDS health education within the MOH, in private
firms or advertising companies within the country that have
produced effective marketing campaigns, or in NGOs with
substantial behavior change activities. In Kenya, for example,
CARE hired a marketer who had worked in the private sector. He
appreciated the opportunity to apply his skills to a socially useful
product.
10.1 Develop brand name and logo
Development of the brand name and logo to position the Safe
Water System positively for the target population is a very
important step. Having a brand name and logo can be very
beneficial because it gives people an easy way to identify the
products. The best brand names are simple, catchy, and evoke
healthy images in the minds of the target population. When the
brand name and logo are completed, they should be incorpo
rated in the various promotional and educational materials.
98
10.2 Develop key messages
Use appropriate language, terms and local dialect to ensure that
messages are relevant to the audience and can be understood
by them. If a new term is needed, it may be necessary to intro
duce the new term and teach what it means in educational
messages. Prepare educational and promotional messages in
pictures and words. The pictures should be understandable
without the words, so that illiterate people in the target population
can also understand the message.
Formative research provides information on:
• local language and terms - to decide on wording of
messages
• current knowledge about diarrhea
• positive perceptions about water disinfection and storage
• negative perceptions and barriers to address in messages
The project must decide which positive perceptions to reinforce
and which benefits to emphasize in promotion, according to local
circumstances. Some messages may need to address negative
perceptions (e.g., about chlorine) or barriers to use of the Safe
Water System. Negative messages or warnings tend not to work
as well as positive messages. Messages must give information
the audience wants and needs but does not know. Promotion can
be effective by associating use of the Safe Water System with a
status and lifestyle that people aspire to have.
Develop messages that fulfill specific educational and promo
tional objectives and that are:
• easy to understand - simple, using appropriate language and
local terms
• easy to remember - simple, conveying only 1 or 2 ideas
• positive — conveying positive benefits of products in a way
that encourages use
• specific and action-oriented, not general
• accurate, feasible and relevant
• sensitive to existing cultural beliefs
• attractive and interesting
• conveyed in pictures that can be understood without words
(particularly important for messages about how to use
products)
99
The actual messages will depend on findings of the formative
research and the behavior change objectives. The box below lists
some common messages.
Figure 14: Key Messages or Topics for Education and
Promotion
Diarrhea
How water is contaminated
• Animal and human feces on the open ground get washed
into water sources (surface water, shallow wells)by rain
• Sewage is dumped in surface water sources
• Crossed connections are accidentally made between
sewer and water lines
• Cracks or holes in water pipes allow surface contami
nants (animal and human feces) to get into water lines
(particularly when there are power outages which shut off
pumps and create negative pressure which sucks surface
contaminants into the water lines)
• People with fecally-contaminated hands touch water
stored in wide-mouthed containers such as buckets
How drinking contaminated water causes diarrhea
• Microbes that cause diarrhea are present in feces. These
are ingested when a person drinks contaminated water.
• Microbes are too small to see. Clear water can be very
contaminated.
The problem of diarrheal disease in our community
• Use local data that is meaningful, for example, the
number of episodes of diarrhea in children under age 5 per
month in the community, the percentage of children who
die of diarrheal diseases annually
Young children are at particular risk of diarrhea, which can be
very severe in infants and toddlers.
You can prevent diarrhea by using the Safe Water System.
Protect your family from diarrhea by using the Safe Water
System.
Acquiring vessels and disinfectant
Where to go to get disinfectant and a vessel
Get a safe water storage vessel
What disinfectant.is; it is safe
Buy 'disinfectant and always use it
Prices of the vessel and disinfectant
How long disibfectant lasts in the bottle; when to discard
How to obtain more disinfectant
100
Figure 14: Key Messages or Topics for Education and
Promotion (continued)
Treating water
How the intervention works
Disinfectant kills microbes in water within 30 minutes
Storage container keeps new microbes out of water
Cloth filter removes dirt from water so disinfectant is more effective
Allowing water to settle and separating the clear water makes disinfec
tant stronger.
The correct amount of disinfectant to use in recommended containers.
How to measure and add the correct amount of disinfectant to water
Wait 30 minutes to allow the disinfectant to work and then drink
Always treat water before drinking it, or using it to wash or prepare food
Storing water
Use the vessel correctly to store water and protect it from contamination
Do not put your hands or let anyone else put their hands or utensils into
water
Clean the vessel at least once a week
Uses of treated water
Drinking
Washing hands
Washing produce
Cleaning cooking and eating utensils
Storage of disinfectant bottle
Out of reach of children
Indoors, in a dark cool place
Benefits of water treatment and safe storage
Your family, particularly children, will stay healthier and will have less
diarrhea if you use disinfectant and a safe water storage vessel.
Shows that you are a better mom
Shows that you are a smart mom
Shows that you are a trend setter
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101
10.3 Make detailed plans for implementing the methods for
behavior change
Describe the methods selected for behavior change and make
detailed plans for each. Plans should include channels and the
numbers and types of staff needed to implement the methods.
Plan where, when, how often staff will implement the methods,
and produce a list or schedule.
For example:
• In both the Central and Northern districts, project will
conduct informational meeting for teachers and distribute
materials to them by (date). Teachers will do educational
activities in the schools at least once weekly.
• Project will distribute promotion and education materials to
outlets by (date) in the Central district and (date) in the
Northern district. Shopkeepers will do education and
promotion on an ongoing basis.
• In the Central district only, house-to-house visitors will be
selected, trained in motivational interviewing (specify date,
location and trainer), and will make house-to-house visits in
their assigned areas according to a schedule developed at
their training (to visit each house twice monthly).
• In both districts, posters will be hung in market places and
in government offices by (date).
• In the Northern district, a local drama group will be con
tacted and their help enlisted by (date); local drama group
will perform once weekly at market days plus at community
mobilization meetings in the towns of Adaba and Cristo on
(dates).
• Project will distribute educational and promotional materials
to 8 health centers in the Central district by (date) and 4
health centers in the Norther district by (date).
• The project will conduct 4 training sessions for health center
staff in the Central district and 2 sessions in the Northern
district (specify schedule). Health center staff will teach
102
mothers about the Safe Water System at well-baby clinics
each week. Health center staff will teach mothers of children
who come with diarrhea about the Safe Water System.
10.4 Plan training of staff to implement behavior change methods
Key steps in organizing training in any project are:
• Decide who needs training
•* Develop a training curriculum and materials, if not already
available
• Identify suitable trainers
• Develop a plan to implement training, and consider whether
this training can be integrated into other training activities
List the types of staff that will be involved in the project and list
the tasks that they should perform. Assess their need for training.
Everyone will need to be informed of the tasks that they are
expected to do. Some will need further training to provide new
skills. Staff will require training for their role in distribution of
products as well as their tasks related to behavior change
methods. Training may include oral instruction, written instruction,
review of reference materials, discussions, demonstrations,
practice exercises, and practice on the job.
' I
1
1
For effective interpersonal communications, the project must train
staff about the Safe Water System and its use, and how to use
printed materials. Effectiveness of communications can be greatly
increased if staff are trained how to communicate effectively and
ensure that messages are understood. For example, a group of
community volunteers received training in a behavior change
technique known as motivational interviewing (see Annex F for a
103
description of the training). Prior to training, 1% of the target
population used disinfectant in their water compared to 2% of a
neighboring community. Three months after the community
volunteers received training, 78% of the target population had
detectable chlorine residuals in their stored water, compared to
4% in the neighboring community.(Quick-unpublisheddata)
10.5 Develop communication materials and training materials
Develop text, artwork and layout for the materials needed. This
may include point-of-purchase signs, stickers and cards to
identify outlets and sales persons; brochures with instructions on
product use and benefits; posters to promote the products and
benefits.
Develop video. Video development includes writing a script,
filming, editing a film, and adding narration and graphics.
Develop specifications for and list messages that may be included
in wall paintings or murals. Then commission community artists to
do the paintings.
Write newspaper stories or advertisements.
Design small group activities such as presentations and demon
strations for community meetings, club meetings, etc. This
includes writing scripts and instructions, and designing visual
aids.
Produce radio spots, including writing scripts, taping a speaker,
adding music, and editing.
104
Figure 15: Characteristics of good educational and
promotional materials29
A useful flyer, visual aid
or brochure
A good logo
• Simple, not cluttered
• Explicit and not abstract, the
audience should understand it
immediately
• Related to the key benefits of
the Safe Water System, a
symbol of the idea
• Positive, uplifting, conveys the
idea of results
• Easily reproducible
• Works in different sizes and
settings
• Dramatizes the overall tone of
the behavior change strategy
Carries the information most likely
to be forgotten
Uses visuals to tell the story, not
just words
Shows people performing key
behaviors
Uses images attractive to the
audience
Concise
Maintains same tone as overall
behavior change strategy
Organized so that it favors a
logical action sequence
Designed for easy use as a visual
aid
Matches graphic and language
skills of specific audience
An effective radio spot
An effective public poster
• Dramatizes a single idea
• Attracts attention from at least
ten meters away
• Uses visuals to carry the
message
• Memorable
• Models the behavior when
ever possible
• Shows how the product
benefits people
• Consistent with tone of overall
change strategy
•
•
•
•
Presents one idea
Begins with an attention getter
Is direct and explicit
Repeats the key idea at least
two or three times
• Asks listeners to take action
• Makes the audience feel part of
the situation
• Maintains the same tone as the
overall change strategy
105
Training materials may be needed in addition to the educational
and promotional materials for the community described above.
Training materials should prepare staff to do their specific tasks in
the Safe Water System project. For example, shopkeepers may
need:
• a description of how they should promote the Safe Water
System to customers, including main points to describe
• frequently asked questions and how to answer them
• instructions for keeping records of sales
• instructions for reordering stock of disinfectant and/or vessels.
Training materials may also describe how shopkeepers should
display posters and other point-of-purchase materials and sug
gest how to use the pamphlet when talking with customers.
Training materials are most effective when they are simple and
focus just on behaviors that the person is supposed to do.
Some participants in the project will not need written training
materials but will be trained by another person. In this case,
prepare a trainer’s outline of points to address and exercises to
do with the group, to show them how and have them practice
carrying out their tasks correctly. See Annex I for an example of a
plan for a training session.
10.6 List the activities related to behavior change and desired
outputs (quantities)
List the activities and outputs (quantities) that the project plans to
achieve. These should be main activities and level of effort
required to achieve the objectives specified in step 2.0. See an
example in Figure 16.
106
Figure 16: Sales and Behavior Change Activities to Lead to
Achievement of the Objectives
(This example is for illustration only. Actual implementation plans will be much
more detailed.)
To achieve the following project objectives:
1.1
1.2
Sell 20,000 bottles of disinfectant in first 3 months
Sell 1,000 water storage vessels in first 3 months
2.1
70% of target population will recognize the brand name of the Safe
Water System products (vessel and disinfectant) after 6 months
30% of households will report use of approved water storage
vessel and disinfectant after 6 months
25% of households will have knowledge of correct dose of
disinfectant after 6 months
25% of households will have observed safe water storage practices
after 6 months
10% of households will have measurable residual free chlorine
levels >0.2 mg/liter after 6 months.
10% of households will have no detectable E. coli colonies in
stored water
2.2
2.3
2.4
2.5
2.6
The project will implement the following activities:
Production and Sales
1. Produce 1500 liters of solution per month
2. Produce 100% of batches of solution with hypochlorite concentration >0.5%
3. Train 30 community-based distributors (such as community volunteers)
4. Place disinfectant and vessels in 60 retail shops and demonstrate consistent
supply
5. Place disinfectant or vessels in 10 health facilities
Education and promotion
6. Design and produce 20,000 information brochures
7. Hold informational meeting in 10 communities per month
8. Train 10 community health workers to deliver education methods per day
9. Design and broadcast one advertisement on the radio 3 times per day
10. Conduct educational event in 4 schools per month
11. Produce video and show it to 3 communities per week
12. Observe health facility staff providing education to mothers once per week
107
Figure 16: Sales and Behavior Change Activities to Lead to
Achievement of the Objectives (continued)
Community mobilization
13. Establish neighborhood committees in 3 communities in first 3 months
14. Have 3 committees work through participatory process in 3 months
15. Have 3 communities organize themselves for the project in first 3 months
Motivational interviewing
16. Train 10 trainers in first 3 months
17. Each trainer trains 5 additional trainers in 3 months
18. Each of 50 trainers trains 10 volunteers in 3 months
19. Each volunteer conducts motivational interviewing intervention in 10 community
households in 3 month period
10.7 Arrange use of channels selected
Arrange use of channels as planned in step 7.5.
Seek radio time that may be donated by government stations or
purchased time from commercial stations. Arrange for air time on
stations that the target audience listens to and schedule broad
casts at times the target audience listens.
Arrange for use of a video projection truck. Schedule where and
when the truck will visit different communities, markets, busi
nesses, etc.
Arrange with the local newspaper to print advertisements or
notices on certain dates.
Arrange for interpersonal communications through health staff,
shop keepers, sales persons. This includes distributing materials
to them and training them how to communicate the messages
(see 10.10 below).
108
10.8 Pretest messages and materials
It is essential to pretest
messages and materials
with members of the
community to be sure
they convey the mes
sage clearly and have
the positive effect
intended. Pretest pic
tures as well as words to
be used in promotional
messages. Pretesting can avoid expensive and time-consuming
mistakes.
Pretesting can be done through in-depth interviews or focus
group discussions with a sample of the target audience. It is
important that the interviewers listen carefully to the participants’
impressions of the materials and NOT tell them what the mes
sages are. If the participants do not understand something, the
interviewer should record that and not explain until the interview
or focus group is over. This method enables an unbiased assess
ment of how well the materials convey the intended message.
Pretesting should check the following:
• Presentation: Do people like the words and pictures?
• Attention: Does the message hold the audience’s attention?
• Comprehension: Does the audience understand the in
tended messages and products?
• Personal relevance: Does the audience perceive the
messages to be made for them or made for other people?
• Believability: Does the audience perceive the message and
its source to be credible?
• Acceptability: Is anything (words, pictures, implications)
offensive or culturally inappropriate?
Frequently the same material is presented in two or more for
mats, so that people can choose the one they prefer. Arrange to
actually observe people using the materials or products. For
example, if a brochure teaches how to add the disinfectant to
water, it is best to ask women to actually perform these tasks,
using instructions in the brochure. In this way one can observe
whether women can actually follow the instructions.
109
Based on feedback from pretesting, revise the messages and
materials. Revision may involve changing text or illustrations,
eliminating a particular element such as distracting sound effects
in a radio spot, combining parts of two different materials, or
actually beginning from scratch with a new idea made evident by
the tests. Pretest again with a sample of the target audience to
see that the modifications have improved the materials in terms of
the audience’s comprehension and other criteria listed above. If
new materials are developed, they should be pretested before
being produced in final form.
In Madagascar, for example, the original draft of an instructional
brochure showed a close up of a hand holding a cap of disinfec
tant and pouring it into a bucket. Mothers were confused by the
brochure and could not understand the picture. When this picture
was replaced by a drawing of a woman holding and pouring the
capful of solution, understanding improved. Also, in this draft
brochure, the different steps of treatment were numbered. Step 3
showed the woman pouring a half capful, the recommended
dosage, into her container. Several people, when referring to the
brochure, poured 3 half capfuls into their containers, mistakenly
interpreting the number 3 as the number of capfuls to use. This
problem was corrected by using arrows to point from one step to
the next, rather than numbers.
10.9 Produce and distribute materials
Estimate the number of copies of different materials needed for
distribution to the target population (e.g., brochures, point-ofpurchase displays, posters, videos). Print the needed quantities
and distribute them to health facilities and other outlets, health
staff, marketing staff, organizations such as neighborhood health
committees, and warehouses that will resupply outlets. Also
provide sufficient quantities for training sessions.
110
10.10 Train persons who will implement the behavior change
methods
To prepare for implementation of the educational and promotional
activities:
• Train health staff to use educational materials to teach the
target population about products and behaviors.
• Train pharmacists, shopkeepers, volunteers and other
persons who will sell products about the messages to tell
customers, use of sales brochures and other point-of-pur
chase materials, procedures for managing money from sales,
and procedures for restocking supplies.
• Hire and train promotional workers (e.g., communicators,
video projection truck drivers) how to communicate mes
sages, and how to answer likely questions from families.
• If plans include use of motivational interviewing, train the
selected staff in those skills (see Annex F).
Training should include information, examples and practice. The
trainer should:
• describe the task and give necessary information about it
such as tools and supplies needed, when to perform it, and
main steps.
111
• demonstrate himself or show the learners an example of
someone doing the task correctly.
• ask the learners to practice the task (or part of the task) so
that they gain experience.
• watch carefully and give additional help as needed until every
learner can perform the task. People learn better and remem
ber longer how to do a task that they actually perform, as
opposed to only hearing about it or seeing someone else
perform it.
10.11 Plan additional behavior change interventions, if possible
Consider planning additional methods to increase demand for
products and behavior change, if possible. Below are some
methods used in Safe Water System projects so far:
• use of volunteers for door-to-door sales (Zambia)
• payment of commissions/incentives for sales (Zambia)
• home visits by health workers to reinforce messages (Paki
stan, Madagascar, Kenya, Zambia)
• use of Safe Water System in schools to teach school children
(Equador, Bolivia)
• branded items such as drinking glasses, cups, t-shirts,
stickers and pens to promote awareness of water system
project-approved vessels and disinfectant solution.
112
11.0 PLAN MONITORING AND EVALUATION OF
THE PROJECT
Tasks :
For monitoring
-> Identify activities/indicators/outcome measures to
be monitored
Decide how the findings will be acted on
-> Identify sources for monitoring data and data
collection methods
Schedule monitoring
Design and pretest simple forms and question
naires for recording information
For evaluation
-> Review project objectives and relevant project
activities in terms of expected effects
-> Identify indicators/outcome measures to evaluate
Determine sources of data for evaluation and
data collection methods
-> Plan for data gathering including schedule and
staff
113
Monitoring and evaluation are crucial to effective management of
a Safe Water System project. There are many examples where
information from monitoring or evaluation led to a significant
change in a project that, one can see in retrospect, was essential
to success. If a problem had not been identified, or not been
identified until later, the project would have failed. In Pakistan, for
example, ongoing monitoring of a project identified a problem with
vessel breakage 6-12 months after distribution. On analysis the
problem was due to ultraviolet light degradation of the plastic. The
solution was to add UV light absorbers to the plastic of future
vessels. In Madagascar, the project expanded from the city into a
rural region affected by a cyclone. The only water source was a
river with very turbid water. The dose of disinfectant recom
mended for clear piped water in the city was inadequate for the
river water in the rural project. The solution was to double the dose.
Monitoring requires ongoing data collection during project
implementation. Purposes of monitoring include:
• measuring progress of activities during implementation, using
indicators, which usually relate to quality or quantity and a
particular timeframe.
• highlighting which activities are being carried out well and
which less well.
• providing information during implementation about specific
problems and aspects that need modification.
• enabling managers to decide about allocation of resources
and to identify training and supervision needs.
Evaluation requires data collection before and after a given
period of project implementation. Purposes of evaluation include:
• assessing whether the objectives have been achieved.
• looking at overall strengths and weaknesses.
• guiding design of future phases or follow-up projects.
To plan for monitoring and evaluation, specify the information that
will be needed, how it will be used for decision making and how
progress and impact will be measured. Plans for monitoring and
evaluation should be developed at the same time and integrated
with plans for the whole project. At the beginning of the planning
process, decide how monitoring and evaluation data will be acted
on. Ensure that each piece of data collected has a purpose so
114
that monitoring and evaluation is a meaningful practice that
advances the project’s goals and objectives.
To plan for monitoring:
11.1 Identify the activities/indicators/outcome measures to be
monitored
First review the project objectives (these were specified in step
2.0) and the activities planned (in steps 9.0, 10.0) to achieve the
objectives. Monitoring should allow the project to determine what
activities are occurring, not occurring, or not working out as
planned, so that corrections can be made along the way. The
project may monitor an activity, or some indicator of the activity.
For example, one activity to monitor is:
• Place disinfectant and vessels in 60 retail shops and demon
strate consistent supply
This activity could be
monitored by reviewing
records of shipments of
disinfectant to all 60
shops. Or an indicator
could be monitored, such
as presence of disinfec
tant on the shelves during
a survey of a sample of
retail shops. Monitoring
will need to be more
intensive in the early
stages of the project.
Once the project is
established and running
well, monitoring frequency can be reduced.
Limit the items to be monitored to a manageable number that will
provide the most useful information for the pilot project, and that
will not require excessive personnel time and project money.
115
11.2 Decide how the findings will be acted on
It is important to assure that only useful data is collected so effort
is not expended on activities that do not contribute to the project.
The best way to do this is to think through how each piece of
monitoring data will be acted upon. For example,
• If production of disinfectant solution is insufficient to meet
demand, then the project can purchase new hypochlorite
generating machines, or if a company is making the solution,
that company can produce more.
• If the population is not purchasing the disinfectant solution
because the price is too high, the project will have to recon
sider how much to charge for disinfectant.
• If the solution is not being purchased because of taste, then
more education and behavior change approaches will be
needed.
• If mothers with a lower educational or income level are not
purchasing disinfectant, the project can undertake an educational/behavior change campaign targeting this group.
• If vessels are not being purchased because of the price, then
the price will have to be changed, or a locally-produced,
cheaper vessel can be recommended.
11.3 Identify sources for monitoring data and data collection
methods
To monitor some indicators, new data collection systems may
need to be established, whereas, for others, existing data sources
will be sufficient. For example, systems for recording sales of
vessels and disinfectant at shops or other outlets may need to be
established. Alternatively, it may be simple to track invoices which
are already collected by businesses for all of their sales. Specify
where monitoring will be done, that is, in the whole project area or
in a sample of outlets. Keep surveys limited in scope as they are
labor intensive and relatively expensive. Surveying a small
sample of shops, or doing a focus group, may be sufficient as a
simple monitoring check of whether certain activities are getting
done, or whether products are available in the target area.
116
Decide what methods of data collection will be used to measure
the selected indicators. Possible methods include:
• Routine reports, such as
- Records from chlorine production site about volume pro
duced and distributed (see Annex C)
- Reports from sales outlets of bottles sold
- Overall sales by community and region
• Supervisory visits to health facilities that are promoting and
selling the products
• Survey of outlets in target area (can include interview with
staff, examination of records of sales, observation of sales
behaviors, inventory of stock)
On the next page is an example of planning for monitoring. The
project objectives and activities are listed, along with the data
source and method of data collection for monitoring each activity.
117
Figure 17: Example: Plan for Monitoring
00
Objectives:
1.1 Sell 20,000 bottles of disinfectant in first 3 months
1.2 Sell 1,000 water storage vessels in first 3 months
Activities to monitor___________________
Production and sales
1. Produce 1500 liters of solution per month
2. Produce 100% of batches of solution with
free chlorine > 0.5%_________________
3. Train 30 community-based distributors
(such as community volunteers)
Data Source
Method of data collection
Disinfectant production records including
concentration of batches and volumes bottled
4.
Survey of outlets and health facilities in target
area
Review of production records;
Visit to validate concentration
testing_________________________
Visit to trainers/administrative office
to review training records
Observation of training session to
confirm agenda__________________
Bi-weekly visits to outlets and health
facilities to inventory stock on shelves
Sales reports
Review sales reports
5.
6.
7.
Place disinfectant and vessels in 60 retail
shops and demonstrate consistent supply
Place disinfectant or vessels in 10 health
facilities___________________________
Sell at least 5000 bottles per month
Sell at least 300 vessels per month
Records of training sessions conductedand
attendees
Observation of training session
Objectives:
2.1 70% of target population will recognize the brand name of the Safe Water System products (vessel and disinfectant) after 6 months
2.2 30% of households will report use of approved water storage vessel and disinfectant after 6 months
2.3 25% of households will have knowledge of correct dose of disinfectant after 6 months
2.4 25% of households will have observed safe water storage practices after 6 months
2.5 10% of households will have measurable residual free chlorine levels >0.2 mg/liter after 6 months
2.6 10% of households will have no detectable E. coli colonies in stored water
Activities to monitor__________________
Education and promotion
1. Design and produce 20,000 information
brochures____________________
2. Train 10 community health workers to
deliver education messages in each of 3
communities
Data Source
Method of Data Collection
Invoices from printing company
Review invoices
Training records
Observation of training sessions
Review of records
co
Activities to monitor__________________
3. Hold informational meeting in 10
communities per month______________
4. Design and broadcast one advertisement
on the radio 3 times per day
Data Source
Meeting minutes
Method of Data Collection
Review of records
Review of advertisements drafted/ produced
Review broadcast schedule
Broadcasts
5. Conduct educational event in 4 schools per
month_____________________________
6. Produce video and show it to 3
communities per week
Training plans and schedule
7. Observe health facility staff providing
education to mothers once per week
Community mobilization
8. Establish neighborhood committees in 3
communities in first 3 months
9. Have 3 committees work through
participatory process in 3 months
10. Have 3 communities organize themselves
for the project in first 3 months_________
Motivational interviewing
11. Train 10 trainers in first 3 months
12. Each trainer trains 5 additional trainers
in 3 months
13. Each of 50 trainers trains 10 volunteers
in 3 months________________________
14. Each volunteer conducts motivational
interviewing intervention in 10 community
households in 3 month period
Survey of health facilities in target area
Meeting with designer of
advertisements and
written broadcast schedule
Listen for scheduled broadcasts
Review plans and records of events
conducted_____________________
Review draft and final video
Video projection truck reports of
communities visited_____________
Bi-weekly visits to outlets and health
facilities to observe staff
Drafts of video
Report of communities visited with video
Meeting minutes
Review minutes
Observe meetings
Training reports
Review reports
Observe training
Regular meetings with volunteers
Reports from volunteers
Accompany volunteers on some visits
11.4 Schedule monitoring
Decide on the timing of monitoring activities and draw up a
schedule. Some activities or indicators may require weekly or
monthly monitoring, whereas others may only need to be mea
sured once or twice during a 6 - 12 month pilot project. Some are
important to check early in the project, so that problems can be
quickly identified and solved. For example, if there are problems
producing enough disinfectant to supply outlets, this problem must
be quickly solved. If it is found that vessels are available but
people are not buying them, this problem should be addressed
quickly. Plan to begin data collection while the pilot project activi
ties are implemented.
Identify staff who will conduct monitoring and who will analyze and
interpret the data and schedule their time.
11.5 Design and pre-test simple forms and questionnaires for
recording information
For example, design forms to collect information about sales of
vessels and disinfectant at outlets. When designing data collec
tion, be sure to include all the information needed to monitor the
selected indicators, but do not include extra information that is
“nice to know” but will not be used for decision making.
To plan for evaluation:
11.6 Review project objectives and relevant project activities in
terms of expected effects
Review the reasons for evaluating the project and review the
project objectives. Then describe the project:
• target population
• project activities
• responsibilities of project staff
• resources available to project (persons, transportation, data
managers/analyzers, money)
120
Match project
objectives with
project activities to
be sure enough
activities will be
done to meet the
objectives in the
proposed time
frame. This will
prevent undertaking evaluation prematurely, when there is little or
no chance of measuring an impact. For example, to measure the
health impact of the project, 20 percent of the population will need
to be using the intervention. Until the project has reached this
level of participation, a health impact evaluation will be premature.
11.7 Identify indicators/outcome measures to evaluate
Specify the indicators/outcome measures based on what is
important to know to evaluate achievement of project objectives,
strengths and weaknesses of the pilot, and to plan for future
activities and expansion. Limit the items to be evaluated to a
manageable number that will provide the most useful information
and that will enable you to stay within budget and personnel
limitations of the project.
Evaluation of the behavior of the target population and use of the
products is essential. If use of the products is less than expected,
or declining, the project must figure out the reasons and make
adjustments. Behavior change strategies must be designed,
implemented and modified as needed because these are the key
to an effective project. Repeated project evaluations over time will
permit personnel to determine whether behavior change is
increasing or decreasing in the population. For the project to
succeed new behaviors must be sustained.
11.8 Determine sources of data for evaluation and data collection
methods
Possible sources include:
• interviews with members of target populations
• disease registries in health facilities serving target populations
• accumulation of monitoring results
121
Possible methods include:
• community surveys (baseline and follow-up), which can
include interviewing family members in their homes, observ
ing certain practices, and/or testing samples of water stored
in the home for chlorine residuals or microbiologic quality
• surveys of health facilities and sales outlets, which can
include interviewing staff, observing sales and education
behaviors, and checking stock
• exit interviews with families attending health facilities or
families purchasing Safe Water System products
• focus group interview of sample of target population (to
assess people’s perceptions of product acceptability, taste,
cost and to probe for potential barriers to utilization, such as
cultural factors, education, other priorities)
• review of monitoring results
• special studies and surveys that can assist in understanding
specific operational issues, for example, case control studies
of patients visiting health center with diarrhea and their well
neighbors
• active diarrhea surveillance by home visits (health impact)
If there is a local laboratory that assesses microbiologic quality of
water, the project may choose to assess water quality. However,
these tests can be expensive. Measurement of free chlorine
residuals is a reasonable indicator of microbiologic quality, since
in the presence of adequate free chlorine residuals, it is much
less likely that E. coli are present in the water.
The table on the next page shows a plan for evaluation. For each
objective, it shows indicators to evaluate, data sources and data
collection methods.
122
Figure 18: Example: Plan for Evaluation
Objective_________________
1.
Increasing access to the
intervention (hardware)
Indicator
Data Source
Method of Data Collection
Number of bottles sold
Sales records
Review sales records
1.1
Sell 20,000 bottles of disinfectant in
first 3 months
Sell 1,000 water storage vessels in
first 3 months_________________
Changing water treatment and
storage behaviors
Number of vessels sold
70% of target population will recognize
the brand name of the Safe Water
System products (vessel and
disinfectant) after 6 months
30% of households will report use of
approved water storage vessel and
disinfectant after 6 months
25% of households will have
knowledge of correct dose of
disinfectant after 6 months
% recognition of brand name
Interviews with
target population
Baseline and follow-up surveys of
random sample of target population
1.2
2.
2.1
2.2
2.3
ro
co
% of households reporting use
% of households able to
demonstrate correct dose
2.4
25% of households will have observed
safe water storage practices after 6
months_______________________
10% of households will have
measurable residual free chlorine
levels >0.2 mg/liter after 6 months.
10% of household will have no
detectabe E. coli colonies in stored
water________________________
Improving health
% of households with stored
water observed in
recommended container
% of households with free
chlorine residual >0.2 mg/liter
3.1
Reduce diarrhea rates in target
population by 20%.
% decreased risk of diarrhea in
intervention households
compared to control
households
Interviews with
patients or
caregivers, and
well controls
Active diarrhea surveillance:
periodic (weekly, biweekly) home
visits to obtain information about
diarrhea episodes. Need
comparison group - could be non
users of intervention or selected
control group. Obtain baseline
diarrhea data, and then data
following implementation of
intervention
4.
Achieving satisfaction
4.1
80% of households in target population
will report satisfaction with products
% of households indicating
satisfaction with products
Interviews with
households in
target population
Survey of random sample of target
population
Focus group interviews
2.5
2.6
3.
Home visits to
observe water
storage practices
Water stored in
households
% of households with no
detectable E. coli colonies in
stored water
Baseline and follow-up surveys of
random sample of target population
Home visits to random sample of
population to test stored water at
baseline and then after 6 months of
implementation
11.9 Plan for data gathering including schedule and staff
• Select a data gathering method.
• Consider the purpose of the evaluation, the anticipated start
of project activities, and time required for intended outcomes
to occur. Then specify when to collect baseline data (prior to
project implementation) and when to collect evaluation data
(after an appropriate interval).
• When estimating time and other resources required for the
data collection, also consider:
- the number of project participants (e.g., homes or outlets to
be surveyed), distances between these
- the willingness of participants to provide data, the difficulty
and time required for data collection at each house (e.g.,
testing water samples, interviewing family members,
observation of water handling practices)
• Design and pretest simple forms and questionnaires for data
collection.
• Determine who will collect, analyze, and interpret evaluation
data.
• Also determine who will be responsible for writing report.
Without a written report, the evaluation will not be in a useful
form. The report is essential for progress reports to donor
agencies and can provide justification for future funding.
• Set timeline for data collection, analysis, interpretation, and
report writing.
125
12.0 IMPLEMENT THE PROJECT
Tasks:
-> Produce and distribute vessels, disinfectant and
educational/promotional materials
Launch the pilot project (special event)
-> Supervise and support activities to implement the
behavior change strategy and sell vessels and
disinfectant through distribution systems as
planned; monitor the activities
Continue supplying bottles of disinfectant
Evaluate the pilot project
-> Implement the project on a larger scale
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127
The project should first be implemented as a pilot. This is strongly
recommended in order to test methods and determine what is
effective, before implementing on a large scale. A pilot project
discovers mistakes or weaknesses, and permits adjustments and
improvements, without jeopardizing the larger activity. Also, a
successful pilot can be used to justify increased funding from
donor agencies.
The length of the pilot depends on what you need to learn from it.
A pilot to determine the acceptability to the target audience and
the effectiveness of the Safe Water System can be fairly short,
such as 12 weeks. A pilot of a social marketing approach to
distribution, education and promotion will take longer, to give time
for the messages and distribution to diffuse in the community.
In Zambia, for example, a pilot project lasted one year. It was
successful and was instrumental in helping the Ministry of Health
control a cholera outbreak, which convinced USAID to increase
funding to expand the project to other regions of the country in
the second year.
12.1 Produce and distribute vessels, disinfectant, and educational/promotional materials
• Procure or produce vessels. (See section 5.0.)
• Procure or produce disinfectant. (See section 5.0.)
- Bottle disinfectant (with appropriate label)
- Assure quality/concentration of disinfectant when produced
and when distributed (see Annex C)
- Distribute disinfectant to outlets (clinics, stores, and other
outlets). Provide health facilities and other outlets such as
clinics, pharmacies, NGO clinics, and volunteer sales
people, with an initial supply of vessels and disinfectant.
Monitor to ensure that deliveries are made to outlets in a
timely way and that families who hear of the products and
come to purchase them will not be disappointed.
• Print and distribute educational/promotional materials
Print sufficient quantities and materials for all anticipated
needs during the pilot. It is usually more cost effective to print
a large quantity than to reprint smaller quantities each time
supplies run out. Distribute materials so that they are in outlets
and in the hands of staff who will use them prior to the launch.
128
12.2 Launch the pilot project (special event)
The launch event is a special promotional activity to introduce the
products and outlets in the pilot area and generate excitement
and awareness in the target population. In Bolivia, for example,
the launch included a parade of traditional dancers through the
streets of La Paz followed by a ceremony on stage that included
popular musicians and political figures. In Madagascar, the
launch included a performance by the leading popular singer and
other educational activities.
Timing of the launch is
very important. In some
settings, it is most effective
to first implement some
educational activities to
convey some messages
about diarrhea as a
problem and the need for
safe water. These activities
should make the audience
aware of the link between
diarrhea and unsafe water
and stimulate their interest.
In Pakistan, for example, the project spent a couple of weeks
doing community-based education about contamination in the
drinking water and the diseases it caused, using videotapes, slide
shows, posters, and group meetings. Then the project brought in
the water vessels, demonstrated and distributed them. The initial
2 weeks of focus on the problem effectively increased enthusiasm
for the subsequent intervention.
A launch event might be timed to correspond with a cholera
season or other seasonal increase of diarrhea, a time when
people are especially motivated to avoid disease transmission.
However, a launch event does not have to be expensive. In
Kenya, the launch was a meeting with community leaders to
hand out and discuss information about the Safe Water System.
The community leaders were then asked to take back the infor
mation to their villages. No press was present, but the effort
reached all villages in the project area.
129
12.3 Supervise and support activities to implement the behavior
change strategy and sell vessels and disinfectant through
distribution systems as planned; monitor the activities
Health staff, staff at pharmacies and shops, and volunteers sell
the products as planned. They will require an uninterrupted
supply of the vessels, disinfectant, and educational and promo
tional materials.
Promote and sell the products through different distribution
systems and media channels as planned.
• Use print materials - Health facilities display posters and staff
use brochures when teaching family members about making
water safe. Labels are put on disinfectant bottles. Posters are
hung in places where groups will see them, such as in the
market place, post office, shops.
• Disseminate messages to groups — Radio spots are broad
cast, demonstrations are conducted at community meetings,
audio-visual trucks visit communities to show a video on the
Safe Water System, and drama groups stage promotional
events.
• Implement interpersonal
communication — Health
staff teach clients about
diarrhea and the Safe
Water System including
answering questions and
ensuring clients under
stand how to use the
products. Pharmacists
and shopkeepers pro
mote and teach clients
about the Safe Water
System products as they
sell the products to them.
Neighborhood health
committee representatives trained in motivational interviewing
talk with community members about the Safe Water System
and sell the products to them.
130
It is important to monitor these activities from the beginning to be
sure that the activities are getting underway as planned, that the
products are available for families to buy, that the target popula
tion understands the messages, and that there are no significant
barriers to acceptance. If results are unexpected, conduct analy
ses to determine what went wrong. Solve problems that have
delayed activities such as distribution of products or promotion of
the Safe Water System and make adjustments as needed.
Sometimes rumors are spread about a product, for example that
it causes sterility. If this happens, it is necessary to seek out the
source of the rumor to dispel concerns, and to reinforce educa
tional and promotional efforts in populations affected by the
rumor. Another potential problem is misuse of the products, for
example using the water vessel to dispense alcoholic beverages.
While such occurrences are impossible to prevent, it is important
to disseminate a clear message that the purpose of the products
is to make water safe.
Over time, assess the audience’s response to the messages.
If necessary, adjust messages and the way they are delivered.
Even if the messages are still appropriate, their format and
presentation should change over time so that people do not
become bored and ignore them. Over time, promotion can
emphasize different aspects of the product and the image associ
ated with it. Early in the campaign, messages may emphasize
purchasing a Safe Water System storage vessel and a bottle of
disinfectant solution. Later messages may emphasize the on
going purchase and proper use of the disinfectant along with
improved sanitary practices.
Monitoring and Supervision
Monitoring and supervision are important to ensure that the
activities are carried out as planned. In one project, after exten
sive media coverage, shipment of the disinfectant became
unreliable and people did not have access to the product. Use of,
and demand for, the disinfectant dropped to zero.
131
Some factors that often result in poor motivation and lead to
project failures include:
• lack of clarity about responsibilities
• inadequate transport
• lack of support from supervisors and colleagues
• inadequate incentives, pay and resources
• heavy workload or conflicting tasks
Staff at health centers, pharmacies and shops, and volunteers
who will sell the products need support and supervision. These
individuals were given training and materials to help them teach
about and sell the products. In addition, a visit to their site to
answer their questions and give them encouragement, particu
larly early in the pilot project, can help to increase their effective
ness and motivation.
Strategies for improving supervision and staff motivation include:
• Giving staff clear and detailed job descriptions so that they
know what is expected of them
• Establishing clear roles and allocating responsibility for
supervision, especially if activities are being integrated into
existing health programmes and activities and personnel
already have a range of tasks to carry out
• Holding regular meetings to ensure that staff at all levels are
aware of plans, progress and changes as a result of monitor
ing, and can exchange information about their experiences.
• Investigating and addressing the specific causes of poor
motivation
• Ensuring that staff are paid a salary in accordance with the
job and have the resources to carry out their jobs
• Ensuring that volunteers receive sufficient incentives to play
their expected roles
• Providing staff with incentives for good work, such as bonus
payments, recognition through prizes or awards, in-service
training, or promotion
• Including funds for supervision in project budgets
132
12.4 Continue supplying bottles of disinfectant
Monitor to ensure that production of disinfectant is keeping up
with the need to resupply outlets. If demand exceeds the
supply, consider whether an additional machine is needed in
order to increase the production, or whether the existing
machines could be run more hours each day to increase output.
Determine that there are not large stocks sitting in some outlets
while other outlets run out. If some outlets have stock outages,
help staff at those outlets to anticipate their needs and order
products to restock their shelves in a timely way.
12.5 Evaluate the pilot project
• Meet with community leaders to inform them about the need
for evaluation and to get their approval and cooperation
• Initiate field work; obtain consent from every participating
household
• Collect and store evaluation data as planned
• Analyze and interpret evaluation data
• Review findings with project staff
• Make adjustments in project activities based on findings
• Write the evaluation report
- Organize report around objectives that were evaluated
- Write a summary, purpose of evaluation, methods, results,
conclusions, recommendations
12.6 Implement the project on a larger scale
Each successful Safe Water System pilot project has been
subsequently implemented on a larger scale. This requires
additional funding and partners. Successful projects have been
able to find substantial additional funding. It is important to
document success through project evaluations and reports so
that this information can be presented to donor agencies and
other potential partners. Each effort to expand a project will be
unique, but will probably include the following steps:
• Make adjustments in the project design for the next phase
(going to bigger scale). Slow incremental growth is recom
mended so that supply and demand can be generated evenly
in new areas.
133
• Make needed adjustments in the products, methods of
distribution, communication methods or messages needed to
implement on a larger scale, and any adjustments based on
evaluation of the pilot.
• Obtain funding for increased product volume, distribution,
behavior change strategy.
• Arrange for transportation and storage for increased distribu
tion of products in larger area.
• Establish additional points of sale for vessels and disinfec
tant, including providing promotional and educational materi
als, and training staff.
• Implement distribution, sales, and the behavior change
strategy on a larger scale (e.g., promotion, education, motiva
tional interviewing, community mobilization).
• Monitor and evaluate.
When expanding, consider additional target populations, such as
schools, health clinics, mothers’ clubs, restaurants, or public
places where people must wait (e.g., city offices).
Also consider different applications of the Safe Water System.
Examples of additional applications that have been tried in pilot
projects include:
• street vendors of beverages (Guatemala and Bolivia)8
• preparation of bulk ORS solution in cholera wards, hospitals,
or clinics (Guinea-Bissau, Bolivia)9
• emergency response to natural disasters and epidemics
(Bolivia, Zambia, Madagascar)12
• preparation of infant formula by HIV-positive mothers (Cote
d’Ivoire).
134
Safe Water System projects have been expanded to a national, or
near-national level in Zambia, Madagascar, and Ecuador. A
similar project was expanded to several regions of Peru. Bolivia
expanded to 7 regions of the country, but then reduced the
project due to lack of funding and management problems. These
projects can be contacted for more specific information.
n
Yale@ceibo.entelnet.bo
Changops@telconet.net or
msdinasa@punto.net.ec
makutsa@net2000ke.com
Kenya:
koons@ksm.care.or.ke
Madagascar: Mahavita@dts.mg
cms_psi.mad@simicro.mg
rrojas@cepis.ops-oms.org
Peru:
Bolivia:
Ecuador:
135
ALTERNATIVE WATER TREATMENT
TECHNOLOGIES
A number of water treatment methods that employ simple, low cost
technology are available. These methods include straining; aeration;
storage and settlement; disinfection by boiling, chemicals, solar radia
tion; and filtration; coagulation and flocculation; and desalination. The
following classification is based on Skinner and Shaw.29 The different
methods are presented alphabetically.
Aeration can be accomplished by vigorous shaking in a vessel part full
of water or allowing water to trickle down through one or more perfo
rated trays containing small stones. Aeration increases the air content
of the water, removes volatile substances such as hydrogen sulfide,
which affect odor and taste, and oxidizes iron or manganese so that
they form precipitates which can be removed by settlement or filtration.
Coagulation and flocculation. If water contains fine suspended solids,
coagulation and flocculation can be used for removal of much of the
material. In coagulation, a substance is added to the water to change
the behavior of the suspended particles. It causes the particles, which
previously tended to repel each other, to be attracted towards each
other, or towards the added material. Coagulation takes place during a
rapid mixing or stirring process that immediately follows the addition of
the coagulant.
The flocculation process, which follows coagulation, usually consists of
slow gentle stirring. During flocculation, as the particles come into
contact with each other, they cling together to form larger particles
which can be removed by settlement or filtration. Alum (aluminum
sulfate) is a coagulant used both at the household level and in water
treatment plants.3132 Natural coagulants include powdered seeds of the
Moringa olifeira tree and types of clay such as bentonite.
Desalination. Excessive chemical salts in water make it unpalatable.
Desalination by distillation produces water without chemical salts and
various methods can be used at household level, for example to treat
seawater. Desalination is also effective in removing other chemicals like
fluoride, arsenic and iron.
Disinfection is a way of ensuring that drinking water is free from
pathogens. The effectiveness of chemical and solar disinfection, and to
137
a lesser extent boiling, is reduced by the presence of organic matter
and suspended solids.
Disinfection by boiling. A typical recommendation for disinfecting
water by boiling is to bring the water to a rolling boil for 10-12
minutes. In fact, one minute at 100°C. will kill most pathogens
including cholera and many are killed at 70°C. The main disadvan
tages of boiling water are that it uses up fuel and it is time
consuming.
Chemical disinfection. Chlorination is the most widely used
method for disinfecting drinking water. The source of chlorine can
be sodium hypochlorite (such as household bleach or electrolytically generated from a solution of salt and water), chlorinated lime,
or high test hypochlorite (chlorine tablets). Iodine is another excel
lent chemical disinfectant that is sometimes used. Iodine should not
be used for extended periods (longer than a few weeks). Both
chlorine and iodine must be added in sufficient quantities to destroy
all pathogens but not so much that taste is adversely affected.
Deciding on the right amount can be difficult because substances in
the water will react with the disinfectant, and the strength of the
disinfectant may decline with time depending on how it is stored.
Solar disinfection uses solar radiation to inactivate and destroy
pathogens present in water. Treatment consists of filling transparent
containers with water and exposing them to full sunlight for about
five hours (or two consecutive days under 100 percent cloudy sky).
Disinfection occurs by a combination of radiation and thermal
treatment (the temperature of the water does not need to rise much
above 50°C). Solar disinfection requires relatively clear water
(turbidity less than 30NTU). More information on solar disinfection
is available on the website www.sodis.ch.
Filtration includes mechanical straining, absorption and adsorption,
and, particularly in slow sand filters, biochemical processes. Depending
on the size, type and depth of filter media, and the flow rate and physi
cal characteristics of the raw water, filters can remove suspended
solids, pathogens, and certain chemicals, tastes and odors. Straining
and settlement are treatment methods that usefully precede filtration to
reduce the amount of suspended solids that enter the filtration stage.
This increases the period for which a filter can operate before it needs
cleaning or replacing. Coagulation and flocculation are also useful
treatments to precede settlement and improve still further the removal
of solids before filtration.
138
Storage and settlement. Storing water in safe conditions for one day
can result in the die-off of more than 50 percent of most bacteria.
Longer periods of storage will lead to further reductions. During storage
the suspended solids and some of the pathogens will settle to the
bottom of the container. Water removed from the top of the container
will be relatively clear (unless the solids are very small such as clay
particles) and contain fewer pathogens. The three-pot treatment system
where raw water is added to the first pot, decanted into the second pot
after 24 hours and into the third pot after a further 24 hours, exploits the
benefits of storage and settlement.
Straining. Pouring water through a clean cotton cloth will remove a
certain amount of the suspended solids or turbidity. Special monofila
ment filter cloths have been developed for use in areas where Guinea
worm disease is prevalent. The cloths filter out the copepods which are
intermediate hosts for the Guinea-worm larvae
The following tables (Figures 19 and 20) describe the systems currently
promoted for household treatment in developing countries, the advan
tages and constraints of each system, and costs. Figure 19 also indi
cates whether published reports of lab tests or field trials of household
applications are published in the epidemiologic or environmental
literature. Promotion and education are essential elements for the
successful implementation of any of these systems. The costs given in
Figure 20 do not include the costs of promotion and education leading
to behavior change because the major determinant of these costs is
likely to be the context or setting in which the treatment systems are
being promoted. Promoting household treatment in a setting where
there are trained extension agents and community health promoters is
very different from working in communities and neighborhoods where
there is no institutional capacity.
139
o
Figure 19: Household Treatment Systems - Advantages and Constraints
System
Process
Aeration
Shaking part-full container or some
form of cascade that exposes water
to air
Boiling
Bring water to rolling boil for 10-12
minutes
Ceramic
filters
Water passes (by gravity or siphon)
from outside to inside of unglazed,
ceramic cylinder (often called a
candle). Good quality ceramic has a
pore size of 0.2 microns. Some
candles are impregnated with silver
to kill pathogens. In some systems,
candle filter is preceded by a
polypropylene rope filter to remove
suspended particles or packed with
activated carbon to remove organic
chemicals and tastes.
What is
Removed
Some taste and
odor removal,
oxidizes iron and
manganese
facilitating
removal by
filtration______
Kills nearly all
waterborne
pathogens
Suspended solids
and pathogenic
organisms. In
theory viruses can
pass through 0.2
micron pore but
they are normally
attached to other
material and are
prevented from
passing.
Published
Pub
tests in
lished field
developing
lab-tests
countries
No
No
Advantages
Constraints
Low-cost
component of
iron and
manganese
removal
Limited removal,
normally used in
combination with
other treatment
methods
Time to gather
firewood. Cost of
fuel. Increased
demand for firewood
contributes to
deforestation______
Blind quickly if water
contains suspended
solids. Suspended
solids are removed
by scrubbing candle
and scrubbing wears
away ceramic
material. Candles
are relatively
expensive.
Yes
Yes
Materials
available in
most
households
No
No
Simple and
robust.
Figure 19: Household Treatment Systems - Advantages and Constraints (continued)
Chlorine tablets
Disinfection with calcium
hypochlorite or
trichloroisocyanuric acid
tablets
Inactivates or
destroys nearly all
waterborne
pathogens, oxidizes
organic substances
Yes
Yes
Relatively easy to
distribute and use,
particularly in
emergencies.
Residual effect.
Rapid sand
filters
Use coarser sand and
higher flow rate than slow
sand filters to remove
impurities by
sedimentation, adsorption,
straining, chemical and
microbiological processes.
Disinfection with locally
available chlorine source
(sodium hypochlorite
solution generated from
salt and water or
purchased as bleach),
container with faucet &
narrow neck
Suspended solids
especially after
coagulation and
flocculation.
No
No
Relatively small
and compact.
Inactivates or
destroys nearly all
waterborne
pathogens, oxidizes
organic substances
Yes
Yes
Complementary
package of
disinfection, safe
water container
and hygiene
promotion.
Use a relatively fine sand
and a low filtration rate to
remove impurities by
sedimentation, adsorption,
straining, chemical and
microbiological processes.
Substantially reduces
pathogens
(microbiological is
main mechanism for
removal)
No
No
Pathogen reduction
but not complete
removal. Locally
available materials.
Safe water
system (sodium
hypochlorite
+ safe water
container
+ social
marketing +
education)
Slow sand filters
Not locally available in
many developing countries,
have to be imported.
Expensive for long term
use. Dose depends on
organic material, etc in
water. Available chlorine in
tablet can decline with age.
Adequate contact time
required.______________
Not effective at removing
pathogens. Needs system
for backwashing.
Local supply of
hypochlorite must be
continously available,
strength of hypochlorite
solution and raw water
quality must be relatively
constant, otherwise dosing
must change. Adequate
contact time required.
Only suitable for raw water
with a turbidity of less than
20 NTU. Requires careful
maintenance.
ho
Figure 19: Household Treatment Systems - Advantages and Constraints (continued)
SODIS
(solar
disinfection
+ social
marketing +
education)
Disinfection by UV
radiation & heat through
exposure to full sunlight
for 5 hours in
transparent plastic bottle
Inactivates or
destroys most
waterborne
pathogens
Yes
Yes
“Sorption”
or “catalytic"
filters
Water passes through a
finely ground filter
medium composed of
zeolite or similar.
Impurities chemically
bond with filter medium.
Pore size in medium is
about 2 micron.
Taste, odor,
chlorine, and
suspended solids,
pathogens,
volatile organic
compounds, and
heavy metals.
No
No
Storage &
settlement
Raw water is added to
the 1st pot, poured or
preferably siphoned into
2nd pot after 24 hours,
and into 3rd after further
24 hours
No
No
Pots available in most
households
Straining
Pour water through
monofilament cloth
About 50 percent
of most bacteria
die-off,
schistosomiasis
cerceriae die-off,
significant
removal of
turbidity________
Copepods
(cyclops)
containing
Guinea-worm
larvae, some
turbidity
Yes
Yes
Simple method for
prevention of Guinea
worm. In areas where
copepods harbor V.
cholerae, can reduce, but
not eliminate
transmission.
Uses plastic bottles which
are easy to handle,
convenient for storage
and transportation, and
reduce risk of
recontamination.
Sustainable system that
does require
consumables except for
bottles.________________
Very simple to use small filters are attached
to the cap of a water
bottle. User simply fills
the bottle with raw water
and sucks on a spout in
the cap, drawing the
water through the filter.
Removes nearly all
impurities.
Requires favorable climatic
conditions. Only suitable for
water with turbidity of less than
30 NTU.
Filters are easily blinded by
suspended solids. Small filters
set in water bottle cap have a
limited life being capable of
filtering a maximum of 750 liters
of water before media is used
up. Filters specially formulated
for arsenic removal have an
even shorter life: filtering about
100 liters. Sorption filters are
relatively expensive.__________
Only partial removal of
pathogenic organisms
Cloth must always be used with
same surface uppermost.
Limited removal of other
pathogens.
Figure 20. Household Treatment Systems - Costs
Aeration
Boiling
Imported
items
(shipping
costs and
customs
duties add to
cost)______
None______
None
Ceramic filter
Filter candles
Chlorine
tablets
Rapid sand
filter_____
Safe Water
System
Tablets
Slow sand
filter
SODIS
None
Sorption filter
Filter media
Storage and
settlement
None
Straining
Monofilament
cloth
System
None
Cells for
generating
hypochlorite
None
Initial per capita
Annual
cost* of hardware operating cost
per capita
(5 person
(5 person
household)
household & 10
liters of treated
water per day)
None________
None
Time to
None
gather firewood.
Cost of fuel.
Deforestation.
$1 (replace $5
$5 ($20-25 per
filter annually)
system)______
$6
None
Bucket or other
Time to gather
container for sand
and clean sand
$1.60 (2 plastic 20 $0.60
liter water
containers per
household, $4.00
per container)____
Bucket or other
Time to gather
container for sand
and clean sand
Cost of black paint
None
for used plastic
bottles__________
$7.50 (one filter per $37.50 (replace
person)
filter five times
per year)______
Cost of three pots
Cost of three
pots (zero after
initial investment
for every year
that pots last)
Depends on
Depends on
location
location
*AII cost are estimates based on data in 1999.
143
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a practical new strategy to prevent waterborne disease. JAMA
1995;273(12):948-953.
2Quick RE, Venczel LV, Gonzalez O, et al. Narrow-mouthed water storage
vessels and in situ chlorination in a Bolivian community: a simple method to
improve drinking water quality. American Journal of Tropical Medicine &
Hygiene 1996;54(5):511 -6.
3Quick RE, Venczel LV, Mintz ED, et al. Diarrhoea prevention in Bolivia through
point-of-use water treatment and safe storage: a promising new strategy.
Epidemiology & Infection 1999;122(1 ):83-90.
4Macy JT, Quick RE. Evaluation of a novel drinking water treatment and storage
intervention in Nicaragua [letter]. Pan American Journal of Public Health
1998;3(2): 135-6.
5Chang C, Canizares R. Proyecto desinfeccion de agua a nivel domiciliario en
las regiones costa e insular del Ecuador frente al fenomeno de El Nino.
Guayaquil, Ecuador: Pan American Health Organization, 1998-1999: 1-28.
6Luby SP, Agboatwalla M, Roza A, et. al. Microbiological evaluation and
community acceptance of a plastic water storage vessel, point-of-use water
treatment, and hand washing in Karachi, Pakistan. In: Program and abstracts of
the 47th Annual Epidemic Intelligence Service Conference, April 1998; Atlanta,
GA. Abstract.
7Desinfeccion del agua y alimentos a nivel domiciliario. Lima, Peru: Pan
American Health Organization, 1997: 1-36.
8Sobel J, Mahon B, Mendoza CE, et al. Reduction of fecal contamination of
street-vended beverages in Guatemala by a simple system for water purification
and storage, handwashing, and beverage storage. American Journal of Tropical
Medicine & Hygiene 1998;59(3):380-7.
9Daniels NA, Simons SL, Rodrigues A, et al. First do no harm: making oral
rehydration solution safer in a cholera epidemic. American Journal of Tropical
Medicine & Hygiene 1999;60(6):1051-5.
10Quick R, Mintz E, Sobel J, Mead P, Reiff F, Tauxe R. A new strategy for
waterborne disease prevention. 23rd WEDC Conference 1997, Durban, South
Africa: 340-2.
11Dunston A. CARE, CDC and PSI join forces for safe water project in Madagas
car. HealthCARE, May, 2000, Vol. 2. CARE USA, Atlanta, GA.
144
12Population Services International. Home water chlorination. Maternal and child
health profile, January 1999.
13Thevos AK, Quick RE, & Yanduli V. Application of motivational interviewing to
the adoption of water disinfection practices in Zambia. Health Promotion
International 2000; 15 (3)
14Esrey SA, Feachem RG, Hughes JM. Interventions for the control of diar
rhoeal diseases among young children: improving water supplies and excreta
disposal facilities. Bulletin of the World Health Organization 1985;63(4):757-72.
15Reiff F, Witt V. Guidelines for the selection and applicatin of disinfection
technologies for small towns and rural communities in Latin America and the
Caribbean. Washington, D.C.: Pan American Health Organization, 1995.
16Racioppi F, Daskaleros P, Besbelli N, et al. Household bleaches based on
sodium hypochlorite: review of acute toxicology and poison control center
experience. Food and Chemical Toxicology 1994;32(9):845-861.
17Chang C, Real Cotto J. Manual de produccion de hipoclorito de sodio en sitio
para desinfeccion de agua a nivel domiciliario. Guayaquil, Ecuador, 1999: 1-40.
18Deb BC, Sircar BK, Sengupta PG, et al. Studies on interventions to prevent
eltor cholera transmission in urban slums. Bulletin of the World Health Organi
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19Hammad ZH, Dirar HA. Microbiological examination of sebeel water. Applied &
Environmental Microbiology 1982;43(6): 1238-43.
20Han AM, Oo KN, Midorikawa Y, Shwe S. Contamination of drinking water
during collection and storage. Tropical & Geographical Medicine
1989;41 (2): 138-40.
21Reiff FM, Roses M, Venczel L, Quick R, Witt VM. Low-cost safe water for the
world: a practical interim solution. Journal of Public Health Policy
1996;17(4):389-408.
22Huo A, Xu B, Chowdhury MA, et al. A simple filtration method to remove
plankton-associated vibrio cholerae in raw water supplies in developing
countries, Appl Env Microbiol 1996; 62: 2508-12.
23Quick RE, Gerber ML, Palacios AM, et al. Using a knowledge, attitude, and
practices survey to supplement findings of an outbreak investigation: cholera
prevention measures during the 1991 epidemic in Peru. Int J Epidemiol 1996;
25:872-78.
24Ling JC, Franklin BAK, Lindsteadt JF, Gearon SAN. Social marketing: its place
in public health. Annu Rev Publ Health 1992; 13:341-62.
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25Miller WR, Rollnick S. Motivational interviewing: preparing people to change
addictive behavior. New York, NY: The Guilford Press, 1991.
26Prochaska JO, DiClemente CC. Stages of change in the modification of
problem behaviors. In: Hersen M, Eisler R, Miller PM, eds. Progress in behavior
modification. Sycamore, IL: Sycamore Publishing, 1992: 183-218.
27Thevos AK, Kaona FAD, Siajunza MT & Quick RE. Adoption of safe water
behaviors in Zambia: Comparing educational and motivational approaches.
Education for Health (joint issue with the Annual of Behavioral Sciences and
Medical Education) (in press).
28Rogers EM. Diffusion of innovations. Fourth ed. New York, NY: The Free
Press, 1995.
29Adapted from Communication, a guide for managers of national diarrhoeal
disease control programmes, World Health Organization, Geneva, 1987.
30Skinner, Brian and Rod Shaw, Household Water Treatment 1 & 2, technical
briefs #58 & #59, Waterlines, October 1998 and January 1999.
31Khan MU, Khan MR, Hossain B, Ahmed OS. Alum potash in water to prevent
cholera [letter]. Lancet 1984;2(8410):1032.
32Oo KN, Aung KS, Thida M, Knine WW, Soe MM, Aye T. Effectiveness of
potash alum in decontaminating household water. Journal of Diarrhoeal
Diseases Research 1993; 11 (3): 172-4.
33Miller, WR, Zweben, A, DiClemente, CC, & Rychatarik, RG (1992). Motiva
tional enhancement therapy (MET): A clinical research guide for therapists
treating individuals with alcohol abuse and dependence (DHHS Publication
No. ADM 92-1894). Washington, D.C.: U.S. Government Printing Office.
146
ANNEXES
A. Collecting background data: Sample questionnaire on
148
knowledge and practices........................................
B.
Developing a proposal for a Safe Water System project
154
C. How to test concentration of freshly-produced sodium
157
hypochlorite for quality assurance.........................
•
Hypochlorite Production Record
159
D. Planning worksheets:
•
•
Worksheet for assessing possible household
water storage vessels.....................................
160
Worksheet for assessing possible distribution
methods...........................................................
161
E. Examples of educational and promotional materials
162
F. Training in motivational interviewing.
167
G. Formative research...........................................................
170
•
•
Sample focus group discussion questions about
water treatment and storage................................
Sample focus group discussion guide for
brand name, logo, and slogan............................
172
174
H. Potential channels of communication...............................
176
Example training curriculum from Zambia: Clorin home
water chlorination............................................................
179
I.
147
ANNEX A: COLLECTING BACKGROUND DATA: SAMPLE
QUESTIONNAIRE ON KNOWLEDGE AND PRACTICES
Date of interview/
Index subject study no.
Household no.
Interviewer’s name
J20Q_
Demographic data
1. Name of principal respondent
2. Relationship of respondent to the head of household
a = Husband
b = Wife
c = Son
d = Daughter
e = Other (specify)
3. Name of the village
I WOULD LIKE TO ASK YOU ABOUT THE SOURCES OF INCOME FOR
YOUR HOUSEHOLD
4. What are the main sources of income for the household?
a. Professional technical or managerial job
b. Large scale agriculture
c. Small scale agriculture
d. Sales or services
e. Skilled manual labor
f.
Unskilled manual labor
g- Other
5.
What is the type of the house (Look at the house and circle the
appropriate choice below)
a. The walls are made of mud and the roof is grass-thatched.
b. The walls made of mud and the roof is of iron sheets.
c. The walls are made of bricks and the roof is grass-thatched.
d. The walls are made of bricks and the roof is made of iron sheets.
e. The walls are made of bricks and the roof is made of tiles.
6.
Which of the following things do you have in your house?
a. Beds
Yes
No
Don’t know
[If yes] how many?
b. Bicycle
Yes
No
Don’t know
c. Car
Yes
Don’t know
No
d. Truck
Yes
No
Don’t know
e. Padio
Yes
Don’t know
No
f. TV
Yes
No
Don’t know
Yes
g. Pefrigerator
No
Don’t know
Don’t know
Yes
h. Electricity
No
Don't know
i. Stove
Yes
No
[if yes] Is it
electric
kerosene
gas
Do you keep any animals or birds in your household?
(If yes) record the type and number of animals/birds kept in the table
below. (If no go to question 8)
148
Type of animal/bird
Cows___________
Goats___________
Sheep__________
Pigs____________
Chicken / Ducks
Other
1 = Yes 2 = No
1
2
1
2
1
2
1 ______ 2
Number of animals/birds kept
2 _____ 2
1
2
I WOULD LIKE TO ASK YOU ABOUT THE SOURCE AND HANDLING OF
HOUSEHOLD WATER
8.
From where do you usually collect the water you use in the house? Do not
read the options to the respondent. Mark all the sources that apply
a. Pond or dam
b. Lake
c. Stream or river
d. Well
e. Borehole
Spring
f.
g- Ba in water
h. Water-tap
Other
i.
9.
With what container do you collect the water you use in the household?
(Ask to see the vessel that is usually used to collect water)
a. No container
b. Bucket
c. Jerrycan
d. Barrel / drum
e. Clay pot
f.
Sauce -pan
g- Directly from the tap
h. Other (specify)
10. Do you think this water is safe to drink without any treatment?
1 = Yes
2 = No
3 = I do not know
11. What type of container do you use to store vyater for drinking in the house?
(Look at the vessel usually used to store drinking water) (Do not read,
circle all that apply)
a. No container
b. Bucket
c. Jerrycan
d. Barrel/drum
e. Clay-pot
Saucepan
f
e. Jug
f.
Kettle
g- Bottles
h. Other (Specify)
149
12. What type of water storage vessel does the household use?
See if it is
a. Wide mouthed
b. Narrow mouthed
c. Other. (Describe).
13. Is the water in the storage vessel covered?
1 = Yes
2 = No
14. Do you process this water in any way to make it safer to drink?
1 = Yes
2 = No
3 = Don’t know
15. If yes what do you do to the water to make it safer to drink? (Circle all that
apply)
a. Boil
b. Add bleach
c. Sieve it through cloth
d. Other (Specify)
16. What do you use to get/pour drinking water out of the storage container
(Look and circle all that applies)
a. Nothing
b. Cup
c. Ladle
d. Pitcher
e. Bowl
f.
Bucket
9- Pour water directly from container
h. Other (Specify)
I WOULD LIKE TO ASK YOU SOME QUESTIONS ABOUT THE TOILET
HABITS OF THE PEOPLE IN YOUR HOUSEHOLD
17. What toilet facility do you use? (Do not read the options. Circle all that
apply.)
a. In the bushes or on the ground?
b. In a latrine?
c. Other (specify)______________
18. Can I see the type of soap that you use? (Look at the soap and comment
whether)
1 = Soap available
2 = Soap not available
Observations to be made by the interviewer
Ask to look atjtip toilet facility^nd record
'
- - ''a
19. What-Lpilet facillfy'does 'this household use?
''a. ’ "No' facilities^ t ‘.j
150
b.
k Pit •latrihe:
c.
Other-'J- ■
* ■' ’' ,p'’' ‘ ■
' -
____________
20. Is there water for hand washing near or at the toilet?
1 = Yes 2 = No
Inspect the compound and observe for
21. Are there any visible excreta in the yard? (If no go to 22)
1 = Yes 2 = No
a. Human feces
1 = Yes 2 = No
b. Animal feces
1 = Yes 2 = No
c. Unknown excreta
22. If yes how many stools are observed?
a. Small amount (1-2 feces)
b. Moderate amount (3-4 feces)
c. Large amount (>5 feces)
and In
ZWhiaangawr«> -
//
151
23. Record the names and age of all people who currently live in the household.
No Names
ID No.
152
Age
Sex
1=M
2=F
1
2
Relationship to
head of household
a = Husband
b = Child
c = Grandchild
d = Other relative
e = Not related
abed e
1
2
a
bed
e
1
2
a
bed
e
1
2
a
bed
e
1
2
a
bed
e
1
2
a
bed
e
1
2
a
bed
e
1
2
a
bed
e
1
2
a
bed
e
1
2
a
bed
e
1
2
a
bed
e
1
2
a
bed
e
Check form at the end of the visit
•
Water vessel inspected
•
Water from the household storage vessel sampled
•
Water source inspected
•
Water from the source sampled
•
Toilet facility inspected
•
The compound inspected
[_]
[_]
[_]
[_]
[_]
[_]
Say goodbye to the family after going through the check form above
153
ANNEX B: DEVELOPING A PROPOSAL FOR A SAFE
WATER SYSTEM PROJECT
Many donors have a particular form or list of items to be included in a
project proposal. It is important to follow prescribed guidelines to
provide information that the donor will use to decide about funding a
project.
Before preparing a proposal, ask donors for their guidelines for
proposals. Also contact others who have written successful proposals
for that donor. They may have helpful suggestions on what to include
and how to present it. The Safe Water System is still a relatively novel
idea, so the idea must be sold to the donor.
Below are some elements often required in proposals:
CORE ELEMENTS
A. Title of project
B. Summary:
Project location(s)
Project staff including names and positions of country staff and
external staff
Contact persons - name, phone number, fax number, Email
address
Target population - estimated total population
Duration of the project (years)
Budget - estimated total cost and amount being sought from
this donor
C. Introduction:
Background on the country, region and site of the project,
including demographics, climate, economic situation, political
situation, and major constraints to development efforts
Overview of the project — Who, what, when, where, why and
how
Resources - available human, material and financial resources
and how they can be utilized in this project
How this project relates to ongoing projects or activities (if any)
related to water safety or projects in the area also funded by
this donor
D. Problem statement:
Describe the problem and its causes, morbidity, mortality and
other short-term and long-term effects in the community
154
Describe what the communities, the government, NGOs and
other agencies are doing or plan to do about it
Present any needs assessments undertaken or any relevant
statistics or research findings
Describe the purpose and the rationale for this initiative
E. Project description:
Goals and objectives of the project
Indicators: process indicators and impact indicators (if any)
Main activities
Expected outputs
Describe the project activities, their timing, duration, and
expected outputs
Describe how they relate to the objectives and goals
F. Operational plan:
Describe the intervention strategies
Discuss technical needs assessment, and areas of sustainable
collaboration
Describe how the government (MOH) and communities will
actively participate in this project
Describe interagency cooperation
Discuss possibilities to leverage donor funds
Discuss how the project will strengthen the capacity of local
organizations and communities
G. Project management:
Describe staffing patterns: delineate the number and type of
staff required, and describe how they are to be organized to
carry out project activities and program management with
optimal efficiency
Outline clearly lines of communication and channels for a
smooth and efficient management: technical assistance,
project activities reports, problem solving, mediating
conflicts. This will allow all the various actors to understand
the set-up from the beginning and prevent unnecessary
burden of miscommunications and frustrations.
Describe project main physical requirements: buildings,
vehicles, equipment, project materials and explain briefly
their purpose
Indicate the nature and quantity of any in-kind contributions by
local communities, organizations, host government and other
agencies (if any)
155
H. Monitoring and evaluation:
Describe briefly the information system, how it fits with the
MOH health information system or other government or
commercial information system
Describe necessary baseline studies (if any), how they will be
done, when and by whom
Discuss timing for evaluation
Describe the reporting system: timing and feedback
Describe role of different partners in monitoring and reporting:
local communities, MOH, NGO staff, external staff
Explain how feedback from various partners will be
incorporated into decision making on the project
I. Budget
Cash budget:
Staffing costs
Material and equipment
Vehicle operations and maintenance
Office operations
Training
Evaluation
Travel and lodging
Technical assistance
Indirect costs
In-Kind budget: Material and equipment
Personnel
Other (specify)
Total costs
SUPPLEMENTARY ELEMENTS (OPTIONAL)
J. Innovative aspects of the proposal
K. Capacity building to be achieved
L. Sustainability
M. Leveraging/multiplier potential for additional funding beyond this
donor.
ATTACHMENTS
Maps (country and program area)
Workplan: Detailed project timeline for each month of the project period
156
ANNEX C: HOW TO TEST CONCENTRATION OF FRESHLYPRODUCED SODIUM HYPOCHLORITE FOR QUALITY
ASSURANCE
Materials needed:
•
1 ml pipettes
•
pipetter (for drawing up solution into the pipette)
•
2 100-ml graduated cylinders
•
distilled water
•
colorimetric chlorine comparator (Hach kits, test strips, other colorimeters)
Testing procedure:
Fill both graduated cylinders with 99 ml of distilled water.
Draw up 1ml of freshly-prepared sodium hypochlorite and put it in first
graduated cylinder, mix well.
Draw up 1ml of solution from first graduated cylinder and put it in second
graduated cylinder, and mix well.
Measure the solution in the second graduated cylinder in the chlorine
comparator—the result will be measured in mg/liter.
With this method, the units in mg/liter correspond exactly to the
concentration of the disinfectant produced. (For example, if the solution
from the second graduated cylinder is 0.5 mg/liter, then the sodium
hypochlorite solution is 0.5%.)
Basis of this calculation:
First graduated cylinder:
X mg hypochlorite solution/100ml (99ml H2O + 1ml of hypochlorite
solution) = X mg/IOOml
Second graduated cylinder:
Y mg x 1 ml of solution from 1st cylinder/100ml (99ml H2O + 1 ml 1st
cylinder solution) = Y mg/IOOml
Example:
If the sodium hypochlorite solution is 0.5%, this equals 0.5gm/100ml,
which equals 500mg/100ml. In 1ml, there are 5mg.
Therefore, in the first cylinder, you have:
5mg/100ml (99ml H2O + 1ml hypochlorite solution)
1ml of this solution has 0.05mg of solution.
In the second cylinder, you have:
0.05 mg/IOOml (99ml H2O + 1 ml solution from first cylinder)
The concentration of this solution in mg/liter (which is what is
measured in the chlorine comparators) is 0.5 mg/liter. If you get this
measurement in the chlorine comparator after doing this procedure,
the sodium hypochlorite solution is 0.5 gm/100ml or 0.5%.
157
Alternative Testing Procedure for Sodium Hypochlorite
Concentration (if graduated cylinders are not available)
Materials needed:
•
1 ml pipette
•
1 20 liter container
•
distilled water
•
chlorine comparator
Testing procedure:
Fill 20 liter container (attempt to fill exactly; variation by a few ml will not
appreciably affect results).
Add 2ml of sodium hypochlorite solution and mix well.
Measure this solution with chlorine comparator.
With this method, the units in mg/liter correspond to the concentration of
the disinfectant produced. (For example, if the solution is 0.5 mg/liter,
then the sodium hypochlorite solution is 0.5%.)
Example:
If the concentration of the sodium hypochlorite solution is 0.5%, or
0.5gm/100ml, or 500mg/100ml, in 1ml of solution there are 5 mg.
In 2ml of solution, there are lOmg.
10mg/20 liters = 0.5mg/liter. If you get this measurement in the
chlorine comparator after doing this procedure, the sodium
hypochlorite solution is 0.5 gm/100ml or 0.5%.
158
For quality assurance of bleach production, a form should be used to monitor each production run of sodium hypochlorite. The
following form is a sample:
Hypochlorite Production Record
Date
Operator
Time
machine
turned on
Time
machine
turned off
Salt (kg)
Water
(liters)
Sodium
hypochlorite
concentration
159
pH
No. of
bottles
filled
Comments
ANNEX D: WORKSHEET FOR ASSESSING POSSIBLE HOUSEHOLD WATER STORAGE VESSELS
CHARACTERISTICS
Volume: standard, 10-30 L,
marked
Design
Material
Inlet with screw-on lid; no access
to dip with hands or cup
Faucet or narrow mouth to pour
water
Access to inside for cleaning
Device for measuring disinfectant
Instructions for use, disinfection
and cleaning affixed
Certification of MOH
Cost
Other comments
Performance in field trials
Overall assessment
160
WORKSHEET FOR ASSESSING POSSIBLE DISTRIBUTION METHODS
Possible Distribution
Methods
Project
cost
Demand
creation
Effectiveness Accessibility
Product
of product for
of
recognition distribution
consumers
161
Product
price
Control
over
product
price
Potential for
sustainability
ANNEX E: EXAMPLES OF EDUCATIONAL AND
PROMOTIONAL MATERIALS
HO HAROVANA AMi?J
ARErJM PiVALAHAH;
IHA RANG VOA&EJTAMIOY
I
wr-
Sur Eau
NO AMP! Alt Al NAY
z00°
4,5
|
fiftS
Mahadio rano 100
seau I jerikana ny
tavoahangy Sur’Eau 1
Mora vidy
Mora ampiasaina
______
DSHD
SOLUTION POUR PURIFIER L'EAU
CARE CPC
FANADIOVANA RANO
Fomba fampiasana ny Sur’Eau raha seaii no hitehirizana rano
V
R
Ur'Eau hutreo
30 minitra
Brochure from Madagascar
162
Arohy Burn ny rano »o anaiy
Kau rehcfa ayy ntuidrurah.w»
SOr;E*u.
I
Cuidemas cl retipienke
dondc dlmacenamoi; cl aque
aqua
para heber.
Recpmendacionci
JTr en el uso del cloro
RGUR PUR?
iSHLUD SEGUFV
EE
JeU estar
Lsvemos e! recipienle
lejcHJJak
<le aacntro h*cia aluera
de lol forma qiie
no quede niiWuna
Si ha redbido
impurt/4 en »u interior.
doro en
umos
CACHET
o fundita.
?
coldquelo en
una botella
<d Una vex limp’' •
oKura
conlapa. ®
upio y war
■ipticamotf la
la niedi
niediJa
corrects ne cloro,
llenamo* de agua
Evileiw ipte 1
el recipient.
juegucn cun cl
dunde $e almaicu*
t'l a^uo para Beker.
Manten(a <u retipienlc
Memprc Uwdo
pera que nu enta
ninguiu impwrcu
w X’v prrmih
cn si interior.
quo los animate*
/
ar aecnjUCTi
J
al redpiente
/fl|]
de agna.
>* Ltiliceulhive
del bidta
para soar el egu.i.
J
Podrfan contaminaj
" CLORO DE Ml CENTRO DE SALUD
0® o
■WJAF
UTIUCEMDS EL CLORO PHRlA
TOMRR RCUJ^EIN MICRCB|OS ’
OPS i OMS
NOa>LOQ^
-
“
■
Ud?Bebe sober:
-
-
*
E3
>
El ague dorado sirv
* para:
I’icla e! cloro «n an cvnlm iL
Snlnd cmu v<r i|n« |c> neceMle.
\ji> 1:1 afiiu qn« conaninnncw pnmlc eetar <x>n!aininaila. tlredc
la ntenle de abMloeimieiUn i» pwr a wnna <w alnuictnarU
BeLer
F
•Lil Cloiu <iek» .‘uti«iiiiiir«<*
FCEXTCft
it rxibiAi del ..1.1m
J. S.W
__
• CLOTO DE Ml CENTRO DE SALUO ‘
pilw. o’c. pnrJ.n at
■E3I
Cloro
TRAXSI’OKIH
k
||T‘'|
-*1 Hacer Hielo
L'hhft* urulUpd
t? Ti^CJ
ra imedir d
de cola para
_ JI S"""""
SlKdororawrodMSJlas
®.=«=
IJ' '1-1
mJ ntadir,
*
■ Purifique el aqua | /
"”,n“dom'id'‘k,’“n'v'
Lavar frutas
y legumbr
•.teKX4,
« niiliMr Mfttl
® Hacer jugos
blAopaiBaW
dALMACrXAMIESTG
Y MASirUUCW.
Cloro
Cloro
• I'or ItsMt 4l atfiw «VII Up IIMIWP.
dl Wwtrld ,<«h nxipkiiks aw
±“:.
CL CONSUMO DE AGUA COIWFAMINADA PRODUCE
FNFERMEDADES GRAVES COMO
itros
®C epillarse
los dientes
^Tetwrlque espeyrpor lo men« 30
„ minutoipafajwoefutitizar elagua
deepuet de bater apticado el cloro
nara que ae sxiente « eoneho y luego pas*lo':
^^aoiio recipients y ipfique el tlero^^^
Brochure from Ecuador
163
■■MM
USE PURIFIED WATER
FOR DRINKING
BUT ALSO FOR...
• WASHING HANDS
•
WASHING FRUITS AND
VEGETABLES
KlalWg Wulf WW
giaff© IT© ©aMfe
with...
WASHING COOKING
UTENSILS
Do not put Clorin
in wells
Do not put Clorin
in buckets
Do not expose Clorin
to the sun
CHILDREN
WATER PURIFICATION SOLUTION
drinking water in eloeed
plesac containers (o« 2»
Mrs*. S ktres or 20 Itres)
IM wM prevent contamtnatton caused by teanan
'^Tb. w«tor treated with Cloftn
water purHlceOon solution and I
aiored In closed plastic contain
ers is dean and safe to drink.
Brochure from Zambia
164
I buy
with my other
[
I 'TfPl EVERYDAY
OJ.
ITEMS
Tike. . . MEALIEMEAL
.
|k3,
SOAP
COOKING OIL
-
DISIMBUTED BY SOCIETY FOR FAMILY HEALTH
POBOXSWW
7EL2»-1-2n*43J FAX 28240
EMAIL *MhM«vUai
Poster from Zambia
165
Until now, the only way to make water safe
to drink was to boil it. Boiling requires a lot of
charcoal and can get quite expensive.
Making Your Water
Safe To Drink With
20 L
Ukufika feta, ukwipika amenshi ya kunwa enstiila
yalikofye iyakuyawamtshamo. Ukwipika kulafwaika
amalasha ayengi elyo munshita shimo no lupiya utwingi.
Sangusheni amenshi yenu aya suma ukunwa
musunge no lupiya. Bomfyeni umuti wa Clorin.
Now there is a safe, effective and
affordable way to purify your drinking
water: Clorin only costs K10 for
each 20 litres of water.
K10
20 L
Poster from Zambia
166
Nomba kuli inshila iyakuwamishamo
amenshi yakunwa iyabula ubwafya
ku bumi, iibomba. kabili iyanaka umutengo:
Clorin ishitikwafye K10 pali 20 litres ya
chikunkubiti chamenshi.
ANNEX F: TRAINING IN MOTIVATIONAL INTERVIEWING
Motivational interviewing is described in section 7.0. In Zambia,
volunteer community health promoters who were members of the local
Neighborhood Health Committees were trained to use a communication
approach based on the method known as motivational interviewing
when interacting with community residents to promote the Safe Water
System. Below is some further explanation of the method and training
volunteers to implement it, based on experience in Zambia.
In sessions to train community volunteers to use motivational
interviewing, the trainer describes the theoretical model of the stages of
readiness to change and the methods of working with people at the
different stages. Throughout the training, volunteers are encouraged to
provide examples of their experiences as health promoters working in
the community. The trainer then weaves these examples into the
discussion, exercises, and practice to illustrate the theory and
application of motivational interviewing.
The trainer describes the essential elements of effective brief
interventions and discusses examples provided by the volunteers. The
Miller and Rollnick books25,33 on motivational interviewing use the
acronym FRAMES to describe these elements (Feedback,
Responsibility, Advice, Menu, Empathy, and Self Efficacy):
• Feedback involves non-judgemental sharing of local data on
diarrhea rates, incidence of cholera, and water quality within the
residents’ own community. If needed, education on the causes
of diarrhea and cholera can be delivered, within a motivational
interviewing framework.
• Responsibility for change is emphasized to reside solely within
the community resident.
• Advice is given but permission is requested beforehand. It is
made clear that the views offered are solely the personal ones of
the volunteer. The resident is free to weigh how the offered
suggestions fit within his or her own values and ideas, and to
accept or reject the advice.
• A menu of options for dealing with the problem is also beneficial.
• An empathic style is critical throughout the entire interchange.
• Self efficacy, or self confidence in achieving change, is
supported whenever possible. If someone does not believe
change is feasible, her or she is not likely to even begin to try. It
is very important to support any thought, desire, or attempt at
behavior change by expressing belief that change is achievable
for that person.
167
The trainer describes the tools of motivational interviewing which the
volunteers practice in training:
• use of open-ended questions
• affirmations
• reflective listening, and
• summarizing.
A good portion of the training focuses on developing the tools of
summarizing and reflective listening. Reflective listening is the most
difficult skill. Volunteers need a lot of practice to develop this skill and
some volunteers develop the skill better than others. (A useful strategy
in the field is to use a buddy system whereby volunteers with stronger
skills are paired up with ones with weaker skills.)
The trainer also introduces principles of motivational interviewing:
•
•
•
•
•
expressing empathy
developing discrepancy
avoiding argumentation
rolling with resistance
supporting self efficacy.
Since the principles are closely related to the elements and tools, they
serve as a reminder as well as to unify the ideas.
Another important concept is eliciting change statements from
residents. The trainer teaches this along with summarizing so the
volunteers learn what to reinforce from what is said during an
interaction. Most volunteers can understand this concept, though
implementing it in the field is more difficult.
Throughout the training, the trainer emphasizes the style and spirit of
motivational interviewing which involves an empathic, collaborative
approach and avoids direct persuasion. If the timing and progress are
right, the volunteer can offer an invitation for the individual to consider
the benefits of using the Safe Water System. Volunteers learn that by
working through a resident’s ambivalence, using motivational
interviewing tools and style, and supporting and developing a person’s
ideas about change, it is quite possible that a resident will make a
commitment to adopt the Safe Water System. Subsequent
interventions with the resident can then focus on maintaining the
behavior change.
At the end of the training, the expectation is that the volunteers have
understood the main ideas and have begun to master implementation
168
of some of them, so that they can be more effective than they would be
if delivering health education in the traditional didactic, authoritarian
way. However, they still need further field supervision and guidance by
the trainer.
In two Zambia studies, the rates of use of the Safe Water System were
significantly higher in communities using a motivational interviewing
approach when compared to communities using standard health
education13 or to those using social marketing and health education. 27
These higher rates have been sustained over time.
More work is needed to develop training specifically for motivational
interviewing used in public health interventions in developing countries.
Further adaptation of motivational interviewing, and other brief
negotiation methods based on motivational interviewing, is expected.
Training in motivational interviewing approaches must be provided by
individuals previously trained and experienced in the method.
For further information, contact:
Dr. Angelica Thevos
Department of Psychiatry and Behavioral Sciences
Medical University of South Carolina
67 President Street
PO Box 250861
Charleston, SC 29425
USA
Email: thevosak@musc.edu
169
ANNEX G: FORMATIVE RESEARCH
Formative research is the basis for an effective strategy for behavior
change. Collecting background data for a safe water system project is
described in section 1.0. Additional formative research is described in
section 7.1.
This annex summarizes some major points about formative research
and provides some example focus group discussion guides:
Sample focus group discussion questions about water
treatment and storage (used by CARE Kenya Nyanza Healthy
Water Project)
Sample focus group discussion guide for brand name, logo,
and slogan development (used by CARE Kenya Nyanza
Healthy Water Project)
ABOUT FORMATIVE RESEARCH
Plan of Formative Research
Identify risk practices
Select practices for intervention
Select target populations (e.g., mothers of young children, school
age students, opinion leaders)
Determine most effective and relevant messages for target
populations (e.g., for mothers—“good mothers provide safe water
for kids”; for students—“help kill microbes that cause illness.”)
Determine channels of communication (e.g., radio messages,
street theatre, discussions in schools, health centers, markets)
Design and field test communication and other behavior change
strategies and materials
Formative Research Methods
Site study
Topic: characterize each sector of town/region
Information sources: meet with leaders, women’s groups,
health personnel
Focus groups
Topics: water sources, causes of diarrhea, diarrhea treatment
and prevention, health priorities of community, hygienic
170
practices/excreta disposal, child feeding, access to health
education, animals in compound
Information sources: Women’s groups, opinion leaders,
educators, health personnel (traditional vs. modern),
community organization
Evaluation of health status
Information sources: Epidemiologic data - local government,
health centers/posts, special studies of causes of diarrhea,
case control/cohort studies
Structured observation
Topics: water sources, water treatment practices, water
storage practices, human waste disposal
Information sources: Households
Structured interviews
Topics: water handling, hygienic practices, methods of
communication
Information sources: Health workers, mothers
Knowledge, attitudes, practices, beliefs (KAPB) study
Quantitative study of KAPB re: water handling, diarrhea
prevention, communication sources
Information sources: Households
HINTS:
Cross check data for consistency.
Need political commitment at all levels for project to work.
Formative research team should include outsiders trained in
public health, social sciences, and insiders who know
community.
171
Sample Focus Group Discussion Questions
(Used by CARE Kenya Nyanza Healthy Water Project)
1.
Introductions and statement of purpose of the meeting
Name, occupation, education level, marital status, family size
2.
What are your main service needs in your village?
What are the major health problems in your village?
3.
What do you understand by safe drinking water?
What do you think makes water unsafe for drinking? (at source and
at home)
What can you do to make the water safe?
4.
5.
Once boiling is mentioned
How many of you boil drinking water?
What fuel do you use?
How long do you take to collect the fuel?
How much does the fuel cost you if bought?
How long do you take to light the fire?
How long does the water take to boil?
How long does the water take to cool?
On average how much water do you boil per day?
What do you like about boiling?
What do you dislike about boiling?
If chemicals are mentioned
How did you hear about these chemicals?
Which chemicals are these?
How are they used?
Have you ever tried them?
What do you like about chemical treatment of drinking water?
What do you dislike about chemical treatment of drinking water?
6. What are the qualities of a safe water storage vessel?
7.
172
Show clay pot (20 liters estimated volume)
How many of you use clay pots to store drinking water?
Can water in clay pots be contaminated?
How?
How do you clean the clay pots?
After how long?
How much does it cost?
How long does it last?
What do you like about storing drinking water in a clay pot?
What do you dislike about storing drinking water in a clay pot?
8.
9.
Show common plastic container
How many of you use this to store drinking water?
Can water in this container be contaminated?
How?
How do you clean this container?
How much does it cost?
How long does it last?
What do you like about storing water in this container?
What do you dislike about storing water in this container?
Show specialized container
What do you think about this container?
What special features does it have? (Different from the other two)
Can water in this container be contaminated?
How?
How would you clean this container?
How much do you think it might cost?
How can you make water cool in such a container?
What do you like / dislike about storing water in this container?
Are you willing to buy such a container if it is in the market?
What is the maximum amount of money you can pay for the
container if you were to buy it?
Comparison of the three containers
10. Out of these 3 containers, which one do you prefer for water
storage and why?
Decision-making
11. Who decides on which water storage container to buy for the
household?
Why is he/she the one who makes the decision?
Who decides on the general household expenditure?
EXPECTED DURATION OF INTERVIEW: 1 HOUR 30 MINUTES
173
Sample Focus Group Discussion Guide for Brand Name,
Logo, and Slogan Development
(Used by CARE Kenya Nyanza Healthy Water Project)
1.
Introduction of respondents and moderator
Purpose of discussion.
2.
If a safe chemical for water treatment was available to you and
supposing you were to buy, where would you expect to buy it?
Why?
How much would you pay for it at the most if you were to buy the
chemical to last you one month?
Where do you expect the chemical to have been produced? (Local,
Nairobi or Imported)
3.
Brand Name
Plead out suggested names.
What do you think about that name?
What do you associate the name with?
Does it arouse negative feelings or positive feelings?
Why?
Pronounce it.
Which one do you prefer for a safe water treatment chemical?
(No.1,2, &3)
Why?
4. Logo
Show different logo drawings
What do you think is the meaning of this symbol?
What do you associate with it?
Does it arouse negative feelings or positive feelings to you?
Why?
Which one do you prefer for a safe water storage chemical? (No. 1,
2, &3)
Why?
5. Slogan
Plead different slogans
What do you understand by the following statement?
Does it remind you of any good or bad thing?
Which is that?
Which one do you recommend for a safe water treatment chemical?
(No. 1,2, & 3)
Why?
174
6. Colour
Which colour do you associate with clean drinking water?
Show different colours
Which of these colours do you associate with clean water?
Which one would you prefer for a safe water treatment chemical?
7.
Unsealed & sealed bottles
Which of these two capping systems do you prefer for a safe water
treatment chemical?
Why?
175
ANNEX H: POTENTIAL CHANNELS OF COMMUNICATION
Interpersonal Channels
Interpersonal channels include community meetings,, door to door visits,
health worker/client interactions, interactions between shopkeepers or
other sales agents and their customers, teacher/student interactions
and any other direct communication through project staff or peers.
The advantages of interpersonal channels compared with other
channels include:
• ease of approach for smaller projects
• potential to use locally appropriate terms
• allows selective targeting of specific groups
• high impact in communities
• effectiveness in rural areas where there is greater community
cohesiveness and potential for sharing information by word of
mouth
• message delivery is interactive with the potential for discussion
and clarification of messages
• potential for incorporating novel approaches like motivational
interviewing
• increased efficiency when well-traveled, well-connected
persons in the society are the communicators
Disadvantages of interpersonal channels compared with other channels
include:
• low coverage and low rate of message repetition per person
• relatively high costs per person reached
• if special staff added for a promotional campaign, coverage of
a target population requires large numbers of staff for a short
term campaign or long term staff inputs for a longer campaign;
high salary, training and transport costs
• staff drop out
• less effective in urban areas and among other less cohesive
communities.
Local Media
Local media can include drama, songs sung by traditional musicians,
puppet shows, storytelling, or public announcements by religious
leaders or other local leaders at community gatherings. Local media
can be useful for raising awareness, generating interest and discussion,
and may be effective in improving acceptance.
176
Advantages of local media include:
• communities can easily identify with the source of the
information
• messages can be delivered using the most locally appropriate
language and terminology
• messages delivered in an entertaining way may be better
remembered
Potential disadvantages of local media channels are:
• relatively low audience exposure to messages or repetition of
messages, because dramas or performances may only
happen occasionally
• messages may be missed if people focus on the entertainment
or if the messages are difficult to understand
Mass Media
Mass media include radio, television, video, films and cassettes. These
channels can increase awareness and interest, and convey messages
in a dramatic and meaningful way. Access to mass media is increasing
rapidly in developing countries and radio ownership is high, particularly
in urban centers.
Advantages of mass media include:
• wide coverage
• low cost per person reached
• messages can be focused on a target audience by attaching
them to mass media programs that reach the target audience.
Soap operas on radio and television are especially good
channels for conveying messages because they are ongoing
and provide the opportunity to convey more complicated
messages and repeat them frequently.
• are effective to motivate individuals to purchase and use
products by associating them with a desired lifestyle
Disadvantages of mass media include:
Not everyone has access to mass media (less access in rural
areas, poorer people).
Preparing radio and television spots can be expensive, though
donors or government sponsored stations may give free
airtime.
Message delivery is not interactive.
177
•
Areas and people reached by broadcasts may not correspond
with areas targeted for the project.
Printed Materials
Printed materials include posters, labels on vessels or disinfectant
containers, sales brochures, leaflets, newspapers and newsletters.
They encourage people to take action, convey information quickly and
reach many people.
Advantages of printed materials include:
•
•
Labels, brochures, leaflets are a useful channel for providing
instructions. Even if people cannot read, they generally have
access to someone who can explain instructions to them.
Labels have the advantage of always being available when a
product is used.
Newsletters can be useful to update health workers or sales
outlets about information such as changes in product
availability, progress of the project, and answers to frequentlyasked questions.
Disadvantages of printed materials include:
•
•
•
•
178
Printed materials may not reach people who need them.
Posters must be placed where many people will see them.
Leaflets must be distributed carefully to reach many people.
Printed materials must be re-supplied to clinics, sales outlets,
and other distributors such as neighborhood health
committees.
Some cultures are not used to receiving information in written
form. Some languages and dialects do not have a written
form. Some people are not literate.
Some terms may not be understood. Pictures may be
misinterpreted. (These disadvantages can be overcome with
pre-testing and by combining print materials with face to face
interactions in which terms, pictures and messages can be
explained.)
Unless printed materials are well designed and tested, they
may not convey the intended messages to the audience.
ANNEX I: EXAMPLE TRAINING CURRICULUM
FROM ZAMBIA
CLORIN HOME WATER CHLORINATION GUIDELINES FOR
TRAINING CURRICULUM
FOR CLINIC STAFF, NEIGHBORHOOD SALES AGENTS,
RETAILERS, DRAMA GROUPS
HALF DAY TRAINING
8AM: Opening and Introduction (30-45 minutes)
•
•
•
•
Welcome participants to the Clorin Home Water Chlorination
Workshop
Explain that the workshop will continue until about noon with a
break for tea
Introduce yourself and explain that we will begin with
introductions. Ask participants to give their name, where they
are from, and what they expect to learn from this workshop.
Write responses on the flipchart about what they expect to learn
so that you can come back to it at the end.
Start with yourself. Introduce yourself and explain whom you
work for.
Explain to participants what is SFH.
•
SFH is a Zambian non-government organization dedicated to
improving the health of Zambians by marketing essential health
products to the public and by educating Zambians about
important health concerns. SFH works in the areas of AIDS
prevention, family planning, and child health. For AIDS
prevention, we sell Maximum condoms and Lovers Plus
condoms. For family planning we sell Safeplan oral
contraceptive pills and Prolact vaginal foaming tablets. For child
health we sell POWERCHEM mosquito nets and retreatment
kits for malaria prevention, and Clorin home water chlorination
solution for water borne disease prevention. If they have
questions about products other than Clorin, they can ask at the
end of the training.
Next explain about the Clorin Home Water Chlorination Solution project.
•
The objective of the Clorin home water chlorination project is to
reduce the cases of diarrhea and cholera in Zambia. Clorin is a
chlorine solution that is used to disinfect home drinking water. It
179
kills most bacteria in water that cause disease, including
cholera.
•
The product has been developed largely through the support of
the Centers for Disease Control in the United States. The Clorin
project started in Zambia in September 1998 in 5 pilot sites in
Lusaka and Kitwe. It was expanded to cover Lusaka, Kitwe,
and Ndola in 1999, and now in 2000 it is expanding nationwide.
To date, more than 350,000 bottles of Clorin have been sold.
There has been tremendous demand for Clorin, especially in
the rainy season when cases of diarrhea increase, and when
there are outbreaks of cholera. Clorin has the support of the
Central Board of Health, and is often mentioned as a way to
prevent cholera. In fact, because of this, Clorin has been widely
associated with cholera prevention. SFH in our communications
efforts would like to emphasize that Clorin should be used to
disinfect your water all year round, not just in the cholera
season. This is because diarrhea is a serious problem among
children in Zambia, and diarrheal diseases occur throughout the
year. Far more children die of diarrhea each year than cholera,
which makes it even more important that people treat their
water to prevent diarrhea, especially among children.
Next explain the objectives of today’s Clorin training program. During
the course of today’s training, we will cover the following topics (write on
a flipchart):
•
•
•
•
Review the important facts about diarrhea and cholera transmission, symptoms, and consequences.
Understand what Clorin is and how to use Clorin.
Learn the essential messages to discuss with people in the
communities about Clorin.
Practice communication skills/selling techniques.
Ask the class if they have any questions.
8:30AM: DIARRHEA AND CHOLERA - THE PROBLEM (30 MIN)
Diarrhea Transmission
Objective: Review transmission and signs and symptoms of diarrhea
and cholera.
180
Tell the group that you are going to read a story about diarrhea, and
then discuss it afterwards:
STORY: The clinic director from(name a local clinic) has
just admitted a seriously ill child to the clinic. Mrs.has just
brought her 3 year old daughter Grace to the clinic at 10pm because
she had had diarrhea for the previous 4 days, and was very weak. The
doctor examined Grace and found that she was very dehydrated, and
had a severe case of diarrhea. He gave her some medicine, and
admitted her for further observation. Two days later, Grace was feeling
better and playing. Mr and Mrs.were very relieved, and
thanked the clinic doctor. The doctor gave Mr. And Mrs.
some advice on how Grace and the whole family could prevent
themselves from getting diarrhea and other water borne diseases.
After reading the story, discuss these questions and write all answers
on the flipchart:
1.
How do you think Grace got diarrhea?
Answers to look for:
• Diarrhea can be caused by drinking contaminated water, eating
contaminated food, or from contaminated hands going into the
mouth, or indirectly from not washing hands before eating, after
going to the toilet.
• Cholera is a bacteria that is most often transmitted by
contaminated water.
2.
What signs and symptoms can a person get from diarrhea and
cholera?
Diarrhea - can result in weakness, dehydration
Cholera - severe diarrhea, dehydration
3. What could have happened if the parents had delayed more in
taking Grace to the clinic?
She might have died
4.
If the child has a mild case of diarrhea, what is the proper
treatment?
Oral rehydration solution. If the child doesn’t recover in 2 days,
take the child to the clinic. If people say Clorin is the proper
treatment, explain to them that Clorin is for treatment of water
to prevent diarrhoea and not a treatment for diarrhoea.
If the child has severe diarrhea, take the child immediately to
the clinic. Give lots of fluids (treated water)
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5.
How do you think the parents could have prevented Grace from
getting diarrhea?
Make sure that the home drinking water is treated with Clorin to
disinfect it.
Use a closed container with a lid to store drinking water.
Make sure that Grace washes her hands before eating and
after going to the toilet.
Prevent food from getting contaminated by the cook washing
her/his hands before preparing food, and by covering leftover
food.
6.
What is the best way to prevent Cholera?
Cholera is most commonly transmitted by contaminated water,
so disinfecting your water is the best way to prevent cholera.
Disinfect your water with Clorin, or boil your water.
Use a closed container with a lid to store drinking water.
Good sanitation - use toilets/latrines, keep environment clean.
When people die of cholera, it is because of the severe
dehydration from the diarrhea that is caused by the cholera
bacteria. A person with severe diarrhea should be taken to the
clinic immediately, and also given plenty of fluids (disinfected
water).
7.
If Grace got diarrhea from drinking contaminated water, what are
the ways that the water could have gotten contaminated?
From the pipe, in the well (at the source)
By a dirty water container
By a person scooping water out with an unclean cup or putting
an unclean hand in the water
At the end of the discussion, you should summarize what the
participants have said, and add any information that was not
mentioned. Ask questions of the group that will get them to say the
correct answers.
9AM CLORIN - THE SOLUTION (1 HR)
The Clorin Home Water Chlorination Product
Objective: Participants understand the benefits of Clorin and howto use
Clorin.
Explain to the group that this component of the training is to help them
understand what is Clorin. Hold up the product. Explain that Clorin is a
chlorine solution. Chlorine is a chemical that will kill most bacteria in
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water that cause disease and diarrhea, including cholera. Treating
drinking water with Clorin is one of the best ways to prevent diarrhea
and cholera.
The Clorin is sold for 500 kwacha per bottle. One bottle on average is
enough for a family of 6 people for one month. The clinics and retail
outlets buy Clorin for K350 kwacha. The KI 50 difference is for sales
commission for the clinic sales agents, and trade margin for the retail
outlets (use flip chart to explain if necessary). These prices are
subsidized which means that SFH does not make a profit on them. The
program is funded by donors, and Clorin is sold at a low price so that
we can reduce the diarrhea and cholera cases in Zambia and improve
people’s health.
Next explain that before you demonstrate how to dose Clorin, you will
tell them about how to properly store drinking water. As discussed
earlier, water can be contaminated in several ways. One of the most
common ways that water can be contaminated is by storing water in an
open bucket where people put their hands into the bucket to scoop
water out. A person’s hands can easily contaminate water, even if it is
already treated. So you must store your water in a closed container with
a lid. Pour the water out instead of scooping it out.
Once you have filled your closed, narrow mouth container with water,
you put Clorin into the container according to the directions. Only a
small amount of Clorin is needed to disinfect your drinking water. Can
someone tell me from the brochure, how much Clorin do I put into a 20L
container?
Fill inside ring of the lid with Clorin and pour into
container.
That is correct. You fill the inside ring of the lid once with Clorin and
then pour it into the container with the water. Then you close the
container and shake it. Then you must wait for 30 minutes for the Clorin
to kill all the germs before you can drink it.
Can anyone tell me how much Clorin do I put into a 2.5L container? A
5L container?
Fill outside rim of lid once with Clorin.
Fill outside rim of lid twice with Clorin.
In order for them to understand how to use the product better, let’s
conduct the following exercise:
Split the group in to 3 groups by having them count off 1-2-3.
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Explain to the three groups that this is the situation: Someone from their
neighborhood has just bought this Clorin. They need your help in
figuring out what it is and how to use it. Give each group a Clorin bottle
and one container (different size to each group) and ask them to read
the instructions and put the correct amount of Clorin into the container.
After they have agreed how much to put into the container, switch the
containers until they have tried all three.
Then ask one member of each group to come to the front and correctly
dose one container each. Ask the rest of the group if they are dosing it
correctly.
Ask the group if they have any questions.
Then explain what will happen if they put too much Clorin in the water.
If someone puts too much Clorin in the water, no harm will result to
anybody. The only result of putting too much Clorin in the water is that
you will smell the Clorin, or the water will taste like chlorine. So if
anyone ever complains that the taste or the smell changes after they
put Clorin in the water, what do you tell them?
That they have probably overdosed their water. Explain to them
how to correctly dose it.
Some people ask if you can put Clorin in a well to disinfect the whole
well
No, this does not work. Do not pour Clorin down a well.
10 AM REVIEW OF CONTENT (30 min)
Objective: Review of the content to this point and clarification of any
content that is not clear.
Give everyone a slip of paper, or instruct them to find the blank piece of
paper that is in their folder. Instruct them to write on the paper one thing
they have learned and one question that they have.
Collect the papers, and read them to the class. Ask members of the
class to answer the questions for the rest of the class and answer any
yourself that others cannot answer.
Ask if there is anything else that is unclear, and break for tea.
TEA: 10am - 10-1 Sam
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10:15AM-COMMUNICATION-SELLING Clorin (1 Hr)
Objective: What and how to communicate the benefits and correct use
of Clorin
Divide the group into 2-3 groups of three or four by counting off 1-2-3-4
(not more than three groups if possible). Tell them they are to develop a
short skit that shows what are the most important points to tell a person
when they are selling Clorin to a person. (If the group is for retailers
they should pretend they are going to sell Clorin to a customer. If the
group is a drama, they are pretending they are educating the group
about diarrhea, and trying to convince them to go to buy Clorin).
Tell them that the skit should include what they think are the most
important things that they should tell the customer, such as asking them
if they know how you get diarrhea or cholera, and how to properly dose
water to prevent diarrhea. Tell them to come up with the other important
points that they need to tell the customer. The person playing the
community member or customer is skeptical. This person must think of
all the reasons possible, why they would not want to use Clorin (i.e.
price, never treated water, my water is clean etc)
After the groups have finished, discuss the main points that they want
to talk to the customer about. Ask them to tell you the points, and you
write them on the flipchart.
The main points should be as follows - if any are missing after they
finish telling you what they have thought of, then you should ask them
questions so that they say what is missing:
V Did they ask (not tell): How do you get diarrhea/cholera?
(Discussion of how diarrhea/cholera can be transmitted through
contaminated water and get rid of any misconceptions)
2) Did they ask (not tell): Do you know how you can prevent
diarrhea/cholera? (Discussion of disinfecting water with Clorin,
storing water in a closed container, washing hands before eating,
cooking, and after using toilet, covering food etc)
3) Explain the product - what is Clorin, what does it do, and how do
you use it properly (i.e. Clorin is a solution that kills all germs in
water that can cause diarrhea and cholera. Inner ring once for 20L
container etc, shake and let rest for 30 minutes before drinking)
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4) Explain how to store the water safely (z.e. use a closed, narrow
mouth container with a lid. Pour water out instead of scooping to
avoid re-contamination)
5) Explain that water treated with Clorin is safe for adults and children.
The taste and smell of the water will not change if Clorin is used
correctly.
6) Explain that you can find Clorin in pharmacies, clinics, drug stores,
and supermarkets for only K500.
7) Address any barriers to purchase or use
• Too expensive
(it’s cheaper in the long run than taking your child to the
clinic for treatment. It can save your life by preventing
cholera. It will save you time that you have to take off of
work by taking your child to the clinic. It costs less than one
glass of beer)
• My water is safe because it looks clear and comes from the tap
(Even tap water can be contaminated. The germs are too
small to see, so even if the water looks clear, it can be
contaminated. The city does not treat the water all the time,
and it can get re-contaminated in the pipes anyway)
• I have never treated my water. Why should I start now?
(Has your child ever had diarrhea? It was probably from
drinking contaminated water. Your water can have germs at
any time. You should always treat your water.)
• I only need to treat my water in the rainy season.
(Your water can have germs that can cause diarrhea at any
time of the year. Treat your water with Clorin all year round)
After the discussion, ask one group to perform their skit. Tell the rest of
the class to watch for any of the main messages that were left out.
After the skit, ask the class to point out any messages that were left out.
11:15AM (If Neighborhood Health Committees or Clinics) GO
OVER BOOK KEEPING FORMS (30 min)
11:45AM REVIEW OF EXPECTATIONS AND CONCLUSIONS (30
min)
Objective: Make sure the expectations and objectives of the course
have been met.
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Let’s review the essential messages about Clorin. What are some of the
essential messages that you would want to tell a customer or
community member about Clorin?
•
•
•
•
•
•
•
•
Clorin will help prevent diarrhea and cholera in your family.
Clorin will kill bacteria (germs) in your water that causes
diarrhea, including cholera.
Clorin should be dosed according to the instructions. Inner ring
for 20L container, etc.
Store your water in a closed container with a lid to avoid re
contamination.
Even tap water or water that looks clear can have germs. All
drinking water must be treated with Clorin.
Diarrhea can be a problem all year round. Treat your water all
year round, not just in the rainy season.
Clorin can be found in clinics, pharmacies, drug stores, and
supermarkets for just K500.
Clorin is a prevention against diarrhea, NOT a treatment for
diarrhea. Diarrhea is treated with oral rehydration solution.
Refer to the original expectations and objectives.
Check them off to make sure they have been met.
Ask participants if there is anything that is unclear.
Ask the participants what they thought of the training and if they have
suggestions for improvement or things they would like to know that
were not covered.
Congratulate the participants and tell them that they should go out and
actively try to educate people in their communities about diarrhea and
cholera, and teach them to use Clorin to treat their water all year round.
Thank the participants. Give out certificates.
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