Where there is water, there is life

1. Adoption of Household Chlorination in Emergency and Development Contexts in Rural Haiti Michael Ritter Where there is water, there is life

2. Our Approach • Deep Springs International is a non-profit organization that incubates social enterprises in Haiti under the brand GadyenDlo (“Water Guardian”) • GadyenDlo system is a Safe Water System which consists of a 5-gallon bucket with spigot and lid along with a bottle of locally produced 0.7% sodium hypochlorite solution • Users add 1 capful to 5 gallons of water and keep refillable bottle in the home; community health workers or technicians sell refills and conduct chlorine residual tests • Deep Springs supports the GadyenDlo social enterprise by strategic planning, technical expertise, networking with partners, and subsidies to fill the gap between sales revenue

3. Emergencies in Haiti • GadyenDlo pilot project started in 2002; Deep Springs began managing in 2008 • Jan. 12, 2010: 7.0 earthquake • >222,000 fatalities; 3 million affected • Leogane: >80% buildings destroyed • October 2010: first cholera case confirmed • Since the first case (first 24 months): • 600,885 cases and 7,568 deaths • “One of the largest epidemics of the disease in modern history to affect a single country”–Pan-American Health Organization

4. Leogane Quake Response • Pre-quake program • 40 health workers selling GadyenDlo • 1,500 households with systems • Quake response • 165 community health workers (CHWs) trained (125 new CHWs) in Jan. 2010 • Free distributions (Jan. – July 2010): • 15,200 containers distributed • 1.7 million chlorine tablets distributed • Current program reaches 19,740 households (over half of population of Leogane)

5. Cholera Response • After earthquake, increased chlorine production capacity in response to quake and in preparation for future disasters • Cholera outbreak resulted in dramatic increase in demand for chlorine among households, government, NGOs • Continued to sell refills directly to households through existing channels (local health agents and distributors) • Developed new distribution channels: bulk sales to NGOs and government

6. Post-Cholera Distribution Channels Partners include:

7. Observations of Bulk Distributions • Bulk distributions reached large scale: DINEPA / UNICEF project aimed to distribute 500,000 bottles of GadyenDlo chlorine for free in high-risk zones as part of Phase 3 of national cholera response strategy • Initial adoption was much weaker than in household programs: CDC analysis (364 households) who were targeted in northwest dept. (distributions conducted by local political leaders) • 50.3% received a bottle • Of those who received: • 82.7% reported treating; 51.8% had positive chlorine residual • Sustained adoption even weaker than initial adoption: Deep Springs has production capacity to continue to serve these HHs, but currently provides promotion, M&E and distribution point to <5% of HHs in bulk distributions

8. Bottles of chlorine sold in Jolivert

9. Leogane Household Program

10. Observations from Leogane Program • Tapping existing local networks allows quick scale-up AND high adoption • Free distribution in response to quake achieved 10-fold expansion and increased correct use from 47% to >80% • Increased adoption of HWT products in general has been sustained, but brand-specific use (% using GadyenDlo) similar to pre-quake levels • Despite larger total sales relative to pre-quake due to expansion to new households, income generation for health agents and program cost recovery remain challenges • Will / when will free chlorine no longer be available? • Will those currently using free products convert to buying GadyenDlo or stop treating water?

11. Qualitative Findings • Qualitative data collected in July – August 2012 • 12 focus group discussions (users); 30 in-depth interviews (distributors) • GadyenDlo distributors have difficulty selling in presence of free chlorine • Free products more of an issue in densely populated areas • Areas like Leogane more wary of outside aid than other areas • Distributors who are compensated based on HH visits still conduct visits and education with those who use other products; motivated by improving health of community and do less brand promotion

12. Conclusions for Other Contexts • Local chlorine production and distribution can be rapidly scaled up if technical knowledge exists prior to emergency • Working with existing, trusted local networks leads to greater correct use in short-term as well as greater sustained use • Rapid scale-ups in emergencies may require more top-down management, but local management early in response leads to more sustainable results • Establishing and strengthening these networks could serve multiple goals of disaster preparedness as well as long-term sustainable programs

13. Key Issues • Matching distributors (and their motivations) with goals for each phase • May not be one network which is most effective for all phases; may require changing individuals in these roles • Health agents were more effective than political leaders in delivering and promoting adoption in emergency • Entrepreneurs more effective than health agents in GadyenDlo sales • Trainings on selling product vs. health education • Importance of incentives (positive and negative) for sales • Impact of free distributions on long-term use and program financing • Importance of having a national policy on free distributions and executing / enforcing the strategy

14. DeepSpringsInternational.org