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

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

Emergencies in Haiti Gadyen Dlo pilot project started in 2002; Deep Springs began managing in 2008 Jan. 12, 2010: 7.0 earthquake >222,000 fatalities; 3 million 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

Leogane Quake Response Pre-quake program 40 health workers selling Gadyen Dlo 1,500 households with systems Quake response 165 community health workers (CHWs) trained (125 new CHWs) in Jan 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)

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

Partners include: Bulk distributionsHousehold programs Responsibility for chlorine production Deep Springs Responsibility for delivering chlorine to users, training users, ongoing M&E Partner (Deep Springs provides train-the-trainer sessions) Deep Springs (through local distributors and supervisors) Number of people reached since start of cholera 2,273,859 individuals 525 million liters treated Estimated 2,800 deaths averted – (P&G assumptions) 307,390 individuals (66,824 HHs) have systems, receive ongoing M&E Cost recovery Full cost recovery Deep Springs subsidizes promotion and M&E Financial contribution from users Free to households Households pay $1.25 for bottle refill; distributors make margin Post-Cholera Distribution Channels

Observations of Bulk Distributions Bulk distributions reached large scale: DINEPA / UNICEF project aimed to distribute 500,000 bottles of Gadyen Dlo chlorine for free in high-risk zones as part of Phase 3 of national cholera response strategy Initial adoption was much weaker than in household programs: CDC analysis (364 households) who were targeted in northwest dept. (distributions conducted by local political leaders) 50.3% received a 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

Bottles of chlorine sold in Jolivert Household sales (avg. bottles per month) Bulk sales (avg. bottles per month) Total sales (avg. bottles per month) Pre-cholera 62 months Aug ‘05 to Sept. ’ Post-cholera 24 months Oct ‘10 to Sept. ‘ ,717

Tests conducted (n) % tests with positive chlorine residual % reported Gadyen Dlo use + positive chlorine residual Pre-quake: Gadyen Dlo sales Aug (internal data) 3847% Quake response: free tablets Feb (Lantagne) %N/A Mar. – Sept (internal data) 1, %N/A Post-cholera: Gadyen Dlo sales Oct , 2010 (Lantagne) %22.4% Nov – Mar (internal data) 1, %48.0% Nov – Mar (internal data) %46.2% Leogane Household Program

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 Gadyen Dlo) similar to pre-quake levels Despite larger total sales relative to pre-quake due to expansion to new households, income generation for health agents and program cost recovery remain challenges Will / when will free chlorine no longer be available? Will those currently using free products convert to buying Gadyen Dlo or stop treating water?

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

Conclusions for Other 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

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 Gadyen Dlo sales Trainings on selling product vs. health education Importance of incentives (positive and negative) for sales Impact of free distributions on long-term use and program financing Importance of having a national policy on free distributions and executing / enforcing the strategy

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