IPA Kenya Maseno Conference

School-Based Public Health

Interventions and Educational

Outcomes

Wilson Odero MD, PhD

School of Public Health & Community Development

IPAK-Maseno University Policy Workshop

July 14, 2011

Kisumu Hotel

Outline

Review of concepts

Relationship between health and

academic performance

Evidence from literature

Examples of public health

interventions

Conclusions

What is Health?

• A state of complete physical, social

and mental well-being, and not merely

the absence of disease or infirmity

(WHO)

• Health is regarded as a fundamental

human right and all people should have

access to basic health care (Ch 4;sec

43(1) Constitution of Kenya)

Public Health

• Public health - is a scientific, social and political concept aimed at improving health, prolonging life and improving the quality of life through health promotion, disease preventionand other forms of health intervention:

• is concerned with the overall health of a community

• Focuses on prevention rather than treatment of diseases

Quality of Life

• Quality of life is a multidimensional

concept which encompasses 5

dimensions:

• physical wellbeing

• social wellbeing

• emotional wellbeing

• material wellbeing

• development and activity

• Health promotion is the process of enabling people to increase control over, and to improve, their health. • Health promotion is not just the responsibility of the

health sector, but involves all sectors that contribute to human development, especially the education sector.

• School health programs comprise all activities in the school environment aimed at promoting and maintaining the health and development of students

• Schools provide a unique opportunity to influence students’ health and their educational achievement

Health Promotion and School Health

Health and Academic performance

• Health and learning are interdependent: • Children who are malnourished, sick and tired tend

to have trouble in learning and performing well in class;

• Conversely, cognition, concentration and cooperation are enhanced when students are healthier

• children who do poorly in school may have more health risks, which adversely affect their learning.

• Academic performance of children impacts on their future health, educational attainment, career choices, income, social status and quality of life

Education and Health

“Good education predicts good health.”• More formal education is associated with lower death

rates.

• The less schooling people have, the higher their levels of risky behaviours such as smoking, alcohol abuse, being overweight, or having a low level of physical activity.

• School completion rate can be a useful measure of educational attainment

• Interventions that reduce school dropouts by improving the health of students can improve educational attainment

Molla M. et al., 2004; Lantz PM. et

al., 1998.

Specific public health interventions

and resources can positively affect both

student health and academic

achievement.

Public Health Interventions

Public health measures

administered at various stages of

human development improve school

attendance, enhance childhood

learning and contribute to improved


Examples of public health interventions

1. Prenatal period – to prevent infections and improve fetal development ANC services

Vaccinations – tetanus toxoid

Prophylactic treatment – IPT for placental malaria (using SP), ARVs (Nevirapine) for HIV

Iron/ folate supplementation - to prevent anaemia; Vitamin A – to prevent eye infections

Prevention of infections – ITNs to prevent malaria

2. Early childhood (under 5s) Vaccinations – BCG, measles, polio, HBV, etc.

Nutrition – exclusive breastfeeding for 6 months

Prevention of infections – use of ITNs

3. Late childhood: School-based health Personal hygiene: promote and support hand

washing and general cleanliness

Sanitation – use of toilets, provision of sanitary

towels

Diet/food practices – nutritional services,

school feeding program, milk, fruits, etc

Prophylactic treatment – periodic deworming,

Physical activity – increased PE classes and

extracurricular physical activities

Psychological support - counseling to reduce

delinquent behaviour, tobacco, alcohol and

drug use

Health education and hygiene – part of the

curriculum

Road safety education – part of the school

curriculum

Health care services – early diagnosis and

treatment

Some evidence on the positive

relationship between school-based

health programs and academic

performance

Some evidence

--- from Literature

A. Diet and Nutrition

undernourished children have

decreased school attendance, less

attention, and lower academic

performance, and also experience more

health problems compared to well-

nourished children

Taras H. 2005; Galal & Hulett, 2003; Kretchmer et al.,

1996; Meyers et al., 1991

B. Sexual behaviours:

students who do not engage in sexual risk behaviors receive higher grades than their classmates who do engage in sexual risk behaviors.

students with higher grades are less likely to engage in sexual risk behaviors than their classmates with lower grades,

CDC (2010). Sexual Risk Behaviors and Academic

Achievement.

C. Physical activity:

In addition to the known positive health

impacts, there is evidence that physical

activity in schools may help improve


CDC (2010). The association between school based

physical activity, including physical education, and

academic performance.

D. Water and Sanitation• In schools with access to water and sanitation

facilities, teachers engage pupils frequently on discussions about health; this promotes teaching and learning thus increasing student’s chances of excelling in their academics.

• Pupils who study in schools that provide water and soap are more likely to wash hands than those in schools that do not have the facilities.

• Healthy schools improve national academic performance.

African Population and Health Research Center, 2011

Conclusions

• Health and education are intricately linked.

• Health risks can affect academic success.

• Public health interventions can improve

health, learning and academic performance.

• Comprehensive and coordinated school

health programs that address policy issues,

curriculum content and implementation, and

health services are needed to improve

educational outcomes.

Some Questions

• What are the limitations in the

current knowledge and research on

the association between public

health measures and academic

performance?

• How can academicians be involved

in translating the research findings

on school health into policy?

Thanks

Worms at Work: Long-run Impacts

of Child Health Gains

July 14, 2011

Kisumu Hotel, Maseno University

Presented by:

Prof. Edward Miguel, Ph.D.

University of California, Berkeley

• Advocates argue that child public health investments generate

high returns through improved adult living standards.

• Optimal subsidies for public health depend on both the direct

and externality, or spillover, impacts.

• But it is challenging to estimate causal impacts:

– Some studies show that adult health affects productivity, but

child health could also affect education, occupational choice.

– Panel datasets that track children into adulthood are rare.

– Isolating the impact of child health is difficult (confounding).

– Few studies are set up to measure treatment externalities.

Kisumu-7/2011 Worms at Work 23

The Impact of Public Health Investments

Worms at Work 24

The Case of Deworming

• 1 in 4 people worldwide are infected by intestinal worms –

hookworm, whipworm, roundworm, schistosomiasis – with

high rates in Africa, especially among school-age children.

• Worms cause anemia, stunting, lethargy.

• Broader Impacts on immune system, malaria?

– Kirwan et al (2010) on deworming in Nigeria.

• Inexpensive, infrequent and safe treatment, but costly

diagnosis WHO support for mass school-based treatment

in high prevalence regions, like most of Kenya.

Kisumu-7/2011

Worms at Work 25

ICS Primary School Deworming Project

• 75 rural primary schools in Busia, Kenya (30,000 children

aged 6-18), with deworming treatment phased in over three

years (25 schools at a time).

• Over 90 percent worm infection rates at baseline (S.

Brooker, A. Luoba, et al. 2000, East African Medical Journal).

• List randomization of phase-in: Group 1 (starting in 1998),

Group 2 (1999), Group 3 (2001).

– Due to the design, on average the groups are similar in all

ways but one: the intervention.

• In 2001, cost-sharing in half of Group 1 and 2 schools. Take

up 75% with free treatment free; 18% with cost-sharing.

• The program ended in 2003.

Kisumu-7/2011

Worms at Work 26Kisumu-7/2011

Worms at Work 27

Short-Run Impacts of School Deworming

• After one year of deworming, rates of serious worm infections

were 25% in the treated schools versus 52% in untreated.

• Significant gains in height, self-reported health.

• School absence fell by one quarter (7 percentage points).

• Reduced re-infection and school absence among other

community members, including:

– Untreated children in treatment schools; children in other

schools within 6 km.

• Accounting for spillovers, the cost per year of increased

school participation was only US$3.50.

Kisumu-7/2011

Worms at Work 28

Long-Run Impacts: Data and Measurement

• Kenya Life Panel Survey, KLPS (1998-2009): a representative

sample of 7,530 people from the deworming sample.

• By the 2007-2009 survey round, most were 20-26 years old.

• 85% effective tracking rate among those still alive.

• Differences in deworming treatment: 2.5 years of additional

child deworming in Groups 1 and 2, versus Group 3.

Kisumu-7/2011

Worms at Work 29

Long-Run Impacts: Health and Education

• Self-reported health status is significantly better (p<0.05); no

significant change in height or body mass index (BMI).

• On average, the total time enrolled in school between 1998

and 2008 rose by 0.3 years in the deworming treatment group

(p<0.05), and test scores also improved by 0.1 s.d. (p<0.10).

• More grade repetition, but not grade completion.

Kisumu-7/2011

Long-run Economic Impacts

• As adults, individuals in the treatment group ate 0.1 more

meals / day (p<0.01), and there are externalities: their

neighbors also ate 0.08 more meals/day (p<0.01).

• Deworming beneficiaries work longer hours: hours rose 12%

(1.76 hours, p<0.10) in the full sample, and among both wage

earners and the self-employed (p<0.05).

-- In a decomposition, the effects are concentrated among

those with positive hours (2.4 hours per week, p<0.05).


Disaggregating the Economic Impacts

• Examine effects among wage earners, self-employed, and

farmers. There are no large shifts between these groups.

• Strongest effects among wage earners:

– Work hours rise 12%, or 5.2 more hours per week (p<0.10)

– 0.5 fewer work days missed per month due to poor health

(p<0.05).

– Total earnings in the past month rose 29% (p<0.01).

– Men triple employment in manufacturing (9 p.p., p<0.01).

– Women: less casual labor, domestic work (17 p.p., p=0.11)




Long-run Impacts among Self-Employed

• Some positive effects among the self-employed:

– Suggestive positive point estimates on self-reported and

constructed profits, and total employees hired

– Combining these variables, the mean effect size is 0.175

standard deviation units (p<0.05)

• Few estimated impacts in agricultural production.

• Challenging to measure productivity in this sector:

• Measurement error?

• Individual versus family production?

• Differential impact across sectors?


Evidence of Externalities

• Positive, large and statistically significant local spillovers in

terms of both meals eaten (0.080, p<0.01) and labor supply

for those with positive hours (2.75 hours/week, p<0.05).

• Deworming creates an estimated 20% increase in labor

earnings for wage earners within 6 km of treatment schools

(p=0.2).


The Economic Returns to Deworming

• Benefits:

– Higher earnings in the treatment group, plus spillovers.

– Gains for those not earning wages; other health benefits

• Costs:

– (i) deworming pills and delivery (plus deadweight loss of

raising government revenue);

– (ii) opportunity cost of time spent in school and not working

• Depends on assumptions, but estimated social financial

internal rate of return is 74.1% per year, treating the

increased hours worked as a gain in endowment.

• Externality benefits alone justify full subsidies for school-

based deworming. E.g., 2009 Kenyan national program.



Kenya’s National School-Based Deworming Programme

Karen LevyRegional Director,

Deworm the World Initiative

Dr. Charles MwandawiroAssistant Director,

KEMRI

Background: The National School Health Policy and Guidelines

• Signed and launched in May 2009

• Policy developed by Ministry of Education, Ministry of Public Health and Sanitation, various partners and stakeholders.

• The policy provides:

– A legal framework

– Clear cut leadership for ownership and sustainability

– A guide to program implementation

National School Health Policy

School-based mass deworming adopted as an effective preventative and treatment measure; policy instructs that:

“Treatment shall be administered to all school-age children, including those out of school, based on the prevalence and intensity of worms and bilharzias in the area.”

- GoK Nat’l School Health Policy, p. 32

Roles under the National School Health Policy

Ministry of Education: main coordinating body; chairs National Inter-Agency Committee

“Will coordinate all aspects of the implementation of all health related activities within schools”

Ministry of Public Health: technical support; chairs National Technical Committee

“Will provide integrated curative, preventive and promotive health services”

Geographic Targeting

• Scientific basis for targeting mass treatment• Increases efficiency and effectiveness of program

• Helps to explain resource allocation choices to local and national leaders and politicians

43

Worm Prevalence vs. Population Density(information from Dr. Simon Brooker, KEMRI-Wellcome Trust)

Three areas of high prevalence: Coast; Western/Nyanza; parts of Eastern/Central

Map of Phase I Coverage

IPA’s Deworm the World Initiative

• Policy development

• Operational support

• Catalytic funding

• PR and advocacy

• Technical assistance (direct and indirect)

Implementing School-Based Deworming in Kenya

Using existing infrastructure and personnel

46

47

Training Roll-Out

Training Materials

48

Engaging Stakeholders

Engaging Stakeholders• Programme Launched at KEMRI

• Press Conference attended by Ministers, Assistant Ministers, Permanent Secretaries of both ministries

50

• Covered by print media, television, and numerous radio stations

Engaging Stakeholders: Deworming day press coverage

51

Technical Support: M&E

52

Partnership and Collaboration

Deworming Programme

MoE

MoPHS

KEMRI-ESACIPAC

KEMRI-Wellcome

Trust

JICA, World Bank, other

donors

DtW, PCD, other

partners

Others

Achievements• Roll-out of Phase I successfully reached all 45

targeted districts

• Over 1,000 district and division personnel trained (MoE, MoPHS, KEMRI)

• Over 16,000 teachers trained

Over 3.6 million children in over 8,200 schools were

dewormed!54

55

The National School-Based Deworming Programme:Improving the Health and Education of Kenya’s Children

Prof. JR Aluoch

Professor of Medicine &

Dean, School of Medicine

Maseno University

Around the World in 80 Days by Jules Verne

According to the Guinness Book of Records,

the longest time a human has survived

without water is 18 days.

In 1981 a series of prisoners in Northern

Ireland went on hunger strike. They joined

the protest in stages. Ten of them died. The

numbers of days the ten who died lasted

were ..... 46 59 60 61 61 61 62 66 71 73

Less than 1% of the world’s water is accessible to

direct human use (WHO)

More than half the of the poor in the developing

world are ill from causes related to hygiene,

sanitation and water supply (Water Supply and

Sanitation Collaborative Council [WSSCC], 2008)

37% of people in Sub-Saharan Africa do not use

improved sources of drinking water (WHO and

UNICEF 2010 Joint Monitoring Programme [JMP])

3.575 million people die each year from water

related diseases (WHO)

Unsafe sanitation and drinking water account

for at least 7% of the total global disease

burden

43% of water related deaths are due to

diarrhea (WHO 2008)

88% of cases of diarrhea worldwide are

attributable to unsafe water, poor sanitation

and insufficient hygiene (WSSCC, 2008)

98% of water-related deaths occur in the

developing world (WHO, 2008)

At any given time half of the world’s hospital beds

are occupied by patients suffering from water-

related preventable diseases (2006 UNHDR)

Children in poor environments often carry 1,000

parasitic worms in their bodies at any time

(water.org)

About 4,500 children die each day from unsafe

water and lack of basic sanitation facilities,

countless others suffer from poor health,

diminished productivity and missed opportunities

for education (water.org)

In 2006, only 57% of Kenyans had access to

improved drinking water, and only 42% had

access to improved sanitation facilities

(USAID)

Under age 5 mortality rate due to diarrheal

disease (2000) was 16.5% (USAID)

Over 50% of hospital visits in Kenya are for

illnesses related to water, sanitation and

hygiene (USAID)

Ensuring access to clean water for human

consumption and use is mandatory.

Chlorine Dispensers:Using Randomized Evaluations

to Innovate

Researchers:

Michael Kremer

Edward Miguel

Clair Null

Alix Peterson Zwane

Motivation

• 2 million children die of diarrhea annually; unsafe water is a major cause

• Infrastructure approaches often infeasible in rural and informal settlements

• Recontamination during transport and in the home is a major problem even if water is clean at the source

• Point-of-use treatment with dilute chlorine could drastically reduce diarrhea, yet relatively few households use chlorine even in areas exposed to several years of vigorous social marketing: – 70-90% of study households familiar with WaterGuard– About as many volunteered that “dirty” water is a cause of diarrhea– Only 5-10% of households regularly used chlorine to treat their water

• So how to increase take-up?

Innovation through Randomized Eval.

• Use series of randomized evaluations to understand factors affecting take-up of point-of-use chlorination:– Price – Persuasion– Peer effects– Product’s delivery system

• Iterative research process – Use results earlier research to design strategies that

increase take-up– Then test alternative strategies– Next phase currently underway focuses on how to make

most effective strategies sustainable and scalable

Why a Randomized Evaluation?• Some people already use WaterGuard – can we infer

from them why they do so?

– NO : They could be different from those who do not use WaterGuard in many ways o Maybe they are wealthier so it’s easier for them to afford

– At least this we can observe

o Maybe they are more concerned about health

– We can’t measure people’s motivations

– No way to separate out these differences and all the other characteristics & behaviors they could be correlated with

• Randomized evaluations let us change just one element at a time to identify the influence of that particular factor in people’s decisions

– Randomization makes groups comparable

First RE: Give WaterGuard for Free

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Price=0(Household visit)

Price=10(Coupons)

Price=20(Social marketing)

Self-reported Positive test Coupon redemption

First RE: Give WaterGuard for Free

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Price=20(Social marketing)

Self-reported Positive test Coupon redemption

Seemed that price and convenience both mattered

Some indications that peers’ decisions were also important

Dispenser Hardware Bulk Chlorine RefillsLocal Promoter

Chlorine Dispenser System

Reduces cost, leverages community member to provide on-going persuasion, makes chlorination convenient, harnesses peer effects

Isolating the Important Factors

Group 0 – Pure comparison

Group 1 – Persuasive scripts:

Group 1A – Household script only

Group 1B – Community script only

Group 1C – Household + community scripts

Group 2 – Promoters + coupon for 1 free bottle / household:

Group 2A – Flat-fee promoter

Group 2B – Incentivized promoter (paid per positive test)

Group 3 – Promoters + dispenser (unlimited supply):

Group 3A – Incentivized promoter (paid per positive test)

Group 3B (added later) – Volunteer promoter

Study Design

• 88 springs randomized into community-level interventions

• Household-level script randomization at comparison & community script springs

• Baseline surveys, interventions

– ~20 sampled household’s per spring

• Short-run follow-up (~3 weeks)

– increase sample by ~5 household’s per spring

• Medium-run follow-up (3-6 months)

• Long-term follow-up I (18 months)

• Long-term follow-up II (30 months)

Take-up by Treatment Arm









Promoter or Dispenser?

Conclusions

• Very high take-up rates of chlorine for point-of-use water treatment when it is provided for free– But demand is very sensitive to price

• Persuasive messages don’t seem to make much difference beyond short-run (awareness already high)

• Local chlorine promoters were influential while paid (even when price discounts ran out), but did not create self-sustaining social norm of use without on-going subsidies– Combine potential of persuasive messages and peer effects

– Incentivized payments did not increase take-up

Conclusions

• Changing the way the product is delivered could be the solution

• Point-of-collection chlorine dispensers hold the most promise for a sustainable strategy for increasing take-up at scale

– Drastically reduces cost (mainly through packaging)

– Harnesses peer effects by making use decision public

– Helps to build habits of consistent use (more convenient)

Innovation for Poverty Action (IPA)Conference:

“Real World Impact of Applied Research:A Focus on New Approaches in Health Policy”

Kisumu, July the 14th 2011

PROMOTER MONITORING AND INCENTIVES RESEARCH

Celine Gratadour

Team:Principal Investigators in the US: Amrita Ahuja, Vivian Hoffman, Michael Kremer

Field Officers in Bungoma: Miriam Wekesa, Nettah Isavwa, Esther Avedi, Martha Mukwana, Valentine Bwire, James Mamadi, Ben Wekesa, Titian Korir, Benjamin Watako, Maureen Akinyi, Kevin Kayando, Norman Isavwa, Michael Omollo, Godwin Munialo, Stephen Okubo, Beryl Achando, Sheila Libese, John Kudoyi.

Dispenser Hardware Bulk Chlorine Refills Local Promoter


Dispenser Hardware Bulk Chlorine RefillsLocal Promoter


Previous work on chlorine dispensers

Adoption of Chlorination: Communities with Dispenser versus Control

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• Chlorine dispenser: a significant impact on chlorine adoption (8% in control villages versus 61% in villages with a dispenser);

• This figure persists across time within communities;

• But, there are significant variation across communities; the chlorine take-up rate varies from 30% to 90%;

• Promoter and promoter-community relationship seems to be important;

Assumption: The way the promoter is selected, incentivized and monitored matters.

3 weeks 6 mths 30 mths

PMI Research Questions

• If we focus on the Promoter, many questions need to be addressed as regards:

– 1/Promoter`s selection:

• Does the method of selection matter?

• In particular, if hand vote or secret ballot is used for the selection, does it affect the type of promoter elected?

– 2/Promoter`s Incentives:

• How should Promoters be incentivized?

• Monetary versus Non-Monetary payments?

• Flat-fee versus Performance-based payment?

PMI Research Questions

– 3/Announcement of Incentives before or after the selection:

• If we announce the incentive before the selection, does it affect the number and type of candidates?

– 4/Promoter`s Monitoring:

• Does monitoring matter?

• Who is the best person for monitoring the Promoter`s work? (Community members? Village elder?)

PMI Study Methodology

• Randomized Control Trial:

– 220 water sources randomly selected in Bungoma South and Bungoma East District;

– 220 chlorine dispensers installed with some variations on Promoter`s selection, Incentives and Monitoring

• Key outcomes:

– Share of Households with chlorine in their water at surprise visit;

– Share of Dispenser spot checks on which dispenser contains chlorine;

– Household Knowledge as regards the chlorine dispenser;

– Household Opinion as regards the work of the Promoter

PMI Timeline• July-August 2010

– Meeting with DC, DO, Chief, Assistant Chief

– Identification of all villages in Bungoma East (445) and Bungoma South (272)

• October-November 2010

– Random Selection of 40% of villages-Bungoma East (174) and Bungoma South (100);

– Meeting with village elders and selection of the main water source used for collecting drinking water in each village;

• December 2010

– Pilot of PMI survey instruments and interventions

PMI Timeline• January 2011:

– Notification of assistant chiefs and village elders;

• Mid February –Mid April 2011:

– Organization of 220 community meetings (community members education, selection and training of the promoter)

• Mid May –End June 2011:

– 3 Months follow-up survey-20 Households surveyed + Promoter

– Objective: to collect information on how many Households are using chlorine to treat their water? How many Households know the promoter? Is there chlorine in the dispenser?...

• Mid July – End July 2011:

– Promoter Appreciation Gift payment and Promoter Survey

• Next August 2011: Monitoring by Phone

• Next Fall 2011: 7 months Follow-up survey

• Next February 2012: 12 Months Follow-up survey

PMI Preliminary Results• Promoter`s selection (hand vote versus secret ballot)

– More often only one candidate when election by hand vote versus secret ballot;

– More often, this “unique” candidate had, by the past, some people sick in his/her family (cholera, typhoid, …);

• When the announcement of incentives is made before the selection:

– … candidates who stand are older;

– … more women stand and win the selection;

– … more candidates who stand used chlorine by the past;

– … candidates who win and become the promoter have a higher level of education;

• When the incentives is based on performance:

– … more women stand and win the election

PMI Challenges• 1/Difficult to get the right information on the water source

Is it the main water source in the village? How many households are using it?

• 2/Difficult to mobilize community members for the meeting

Need to involve more people in the village as Community Health Workers, Teachers, …

• 3/Introduction of Lifestraws by VF

2 new technologies whose objectives is for community members to get safe water

Confusion for community members … need to give more information

• 4/Difficult to change behaviors

“I don`t like the taste of chlorine”, “My husband does not like the taste”, “My water is safe to drink, why should I use chlorine?” …

Need to give more messages / information? Target also the husband in the household?

Community-Financed Dispensers project (CFD)

Vivian Hoffmann, Clair Null, Olga Rostapshova, Renaud Lapeyre

Bumula district, WesternRachuonyo South district, Nyanza

“Lipia Dawa kwa Maisha!”

Context• New paradigms emerge so as to promote participation,

bottom-up and community-based approaches, incl. in thehealth and water sector

• Over the past two decades, the GoK has pursued a policyof cost-sharing in the health sector

• Some critics arose as the policy could have become abarrier to utilization and adoption by the poor and mostvulnerable.

Where do we stand now in terms of research evidence in order to advise policy makers

whether to promote or not cost-sharing in the provision of local public goods, e.g. health and

water services?

Research questions

1) Is cost-sharing resulting in ownership effect?

2) Is cost-sharing resulting in sunk-cost effect?

3) Is cost-sharing resulting in selection effect?

4) What are the factors that determinecommunity capacity/willingness to raisemoney collectively?

5) How can one foster community collection ofmoney?

The project

• The CFD project is installing chlorinedispensers at drinking water sources for useby the surrounding community (excl.privately used water points)

• The community of users pays for the up-front payment of the dispenser device andin addition pays for the on-going cost ofchlorine refills (both at subsidized prices)

The project pilot • 26 dispensers were to be installed in May-June 2010 (Bumula

district): 4 for free, 12 proposed at a subsidized price• Upfront payment: 7 dispensers at 500Ksh and 5 dispensers at

30Ksh per each household• Payment for refills: Half sources were to organize an

harambee every 3 months while half were to go and buyregularly at the nearby duka

• Threat mechanism: 8 portable dispensers (rental agreement)versus 18 permanent dispensers (owned by the community)

• Compliance mechanism: 5 dispensers were equipped withboards where were written names of contributors and noncontributors

• All communities elected a fund-raising community and wereprovided with a receipt book and a contributor signatures’ logbook

Pilot preliminary resultsUP-FRONT PAYMENT OF THE DISPENSER

• All free dispensers were installed while 11 out 12subsidized dispensers were paid for by communities(92% success)

• Average community contribution for subsidizeddispensers was 1,180Ksh (1600Ksh with equalcontribution)

• Average number of contributors was 54 people persource

Pilot preliminary results (Cont.)ON-GOING PAYMENT FOR THE CHLORINE REFILLS• No harambee was ever organized, though chlorine was still

bought

• Names’ lists were rapidly abandoned

• After 12 months:

- 41% of permanent dispensers (11 out of 17) has nochlorine in the tank at spot check whereas only 12,5% ofportable dispensers have no chlorine in the tank (1/8).

- 21,4% of free dispensers have empty tanks while 45% ofsubsidized dispensers have no chlorine in the tank.

• Overall, community contribution to chlorine refills hasdecreased since January: 88% had chlorine in the tank End ofJanuary, 84% End March and 60% End of May

Challenges• Accountability/transparency of money collection

and use by fundraising members• Incentives for members in charge of money

collection and of the smooth running of the project(fundraising committee + promoter)

• Clear understanding by village members of theproject and its rules (payment, threat)

• High variation in the number of users between rainyand dry season (rain water catchment vs free-ridersfrom neighbouring villages)

• Complementarity/substitution issues with thedistribution of LifeStraw Family filters in Western

The way forward• Main study in Rachuonyo South: 100

dispensers to be installed.• Test further the ownership effect (free vs

subsidy) and the threat effect (portabledispenser)

• Test the factors that determine willingness tocontribute at the household level

• Baseline and installation before End of theyear, follow-up End 2012

THANK YOU!

104

Eric Kouskalis14 July 2011

Taking Chlorine Dispensers to Scale

• Diarrhoeal disease is the #1 cause of child deaths in Kenya, and the share of child deaths caused by diarrhoea increased from 2000 to 2008

105

Diarrhoeal Disease in Western Kenya

0

5

10

15

20

25

30

Coast Western Nyanza North Eastern

Rift Valley Eastern Central Nairobi

2-w

ee

k p

reva

len

ceDiarrhoeal Disease by Province

• Half of the child deaths in Kenya occur in Western and Nyanza Provinces

However, less than 10% of rural households use chlorine treatment

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Combating Diarrhoeal Disease

Chlorinating drinking water reduces diarrhoea 41%

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Potential for Impact

In Western and Nyanza, 7 million people could

benefit

Over 10 years:

32m diarrhoea cases averted

31,000 lives saved

Four types of partners have deployed ~790 chlorine dispensers to reach ~150,000 people

MoE MoPHS Local Governments Water Services Board

Partners DEOs of Busia, Nambale, Butula, Mumias

DHMTs of Busia,Namable, Kakamega Central, East, South, and Vihiga

Busia County Council, BusiaMunicipal Council, Mumias Municipal Council

LVNWSB

Operational model 33 schools with dispensers overseeing and supplying satellite dispensers at nearby community water points

16 health facilities each managing and supplying 10 dispensers through community health workers

Circuit rider chlorine delivery to water points

Promoters pick-upchlorine from local chemists

# of dispensers 227 160* 57 15

Est. people served 60,000 24,000 9,500 2,000

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Scaling Up with Partners

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Ministry of Education

• Student “Safe Water Champions” help local promoters ensure that dispensers are functioning

• Schools support community outreach and education efforts through students, SMC

• Chlorine is delivered in bulk to schools, where it is kept until needed in communities

• Ensures students are drinking safe water at home and at school

Thirty three schools have a school-based dispenser and dispensers at each communal water point in their catchment areas

110

Lake Victoria North Water Services Board

• Dispensers become integrated into source improvement projects

• Community Water Users Associations manage, refill, and maintain dispensers

• A chlorine supply is made available via a local retail chemist

Communities in the Busia, Butula and Funyula areas are served by LVNWSB dispensers

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Local Authorities

• Busia Municipality, Mumias Municipality, Busia County

• Installation and ongoing chlorine delivery are contracted out by the local authorities

• Chlorine delivered directly to sites by “circuit riders” on motorcycles

Three local authorities offer chlorine dispenser services to their constituents

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International Pilots

Pilots have begun in other countries to test the viability of chlorine dispensers in new contexts

• Ethiopia - Relief Society of the Tigray (ReST)

• Swaziland - Nazarene Compassionate Ministries (NCM)

• Bangladesh - International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B)

• India - International Development Enterprises (IDE)

• Haiti - Deep Springs International (DSI)

Chlorine Dispensers

Ambrose Fwamba

District Public Health Officer

Ministry of Public Health and Sanitation

14July 2011

Linking Rural Water Safety to

Health Facilities in Busia District

.

Introduction

• Partnership between MoPHS-Busia

District and Innovations for Poverty Action

(IPA) to provide community level drinking

water treatment through CHW managed

chlorine dispensers

Goal: Reduce Waterborne Illness

• Waterborne illness is a major problem in Busia

district

• Diarrhea was the leading cause of sickness for

children under five in Busia district in 2009, with

9,427 cases of diarrhea seen by health facilities

• Busia is vulnerable to cholera outbreaks, with the

most recent outbreak occurring in 2008

New Water Safety Plan:

CHW Managed Chlorine Dispensers

Integrate dispensers

into community health

system

Launched in

September 2010

Five Facilities:Matayos Health Centre

Busibwabo Dispensary

Lupida Health Centre

Madende Dispensary

Khayo Dispensary

50 water sources25% of dispenser

appropriate communal

water sources

10,000+ people

Dispenser Program Overview

Five dispenser clusters (facilities are yellow)

Implementation through CHWs

CHW Dispenser Duties (1 hour/week):

• Educate the community about child health,

waterborne illnesses, and dispenser usage

• Top up the chlorine tank monthly with bulk refills

from health facility

• Provide updates to CHEWs on household adoption,

refill frequency, dispenser promotion activities, and

hardware condition

Chlorine Distribution Through

Health Facilities

• Chlorine refills are

delivered to the health

facility in bulk

• The CHEW distributes

refills to the CHWs:

– 1 Dispenser per CHW

– 10 CHWs per facility

• CHWs top up the dispenser

tank at their home water

source each month

Preliminary Evaluation Results

Promotion

Chlorine Adoption

• 481 respondents were randomly surveyed from 48 different water points with dispensers

• ~45% of respondents’ stored drinking water tested positive for residual chlorine

CHWs and Promoters

• In general the CHWs have been more active in encouraging dispenser usage than the Promoters

– ~70% of respondents report that the CHW spoke with them about the dispenser compared to ~25% for the Promoter

– Although 40% said they speak with the CHW 1-2 time per month there is room for more outreach since ~30% of respondents said they have never spoken with the CHW

• Although the community education meetings were well attended several community members were not sensitized about the dispenser

– ~35% of respondents attended the first meeting

– ~30% of respondents did not attend the first meeting and no-one had spoken with them about the dispenser

Chlorine dispensers have

improved health in nearby

communities, so my village is

very excited to get a dispenser

at our water source. The

dispenser makes treating

water convenient and helps

everyone remember to use

chlorine.

-Karoli Samuel Ekesa,

Community Health Worker

Khayo Dispensary

Child diarrhea is one of the most

common illnesses this health

facility handles. Preventing

diarrhea through chlorination at

water sources will give my staff

more time to focus on patients

with other illnesses such as HIV

and malaria. It will also save

money for the facility and the

patients, since prevention is much

cheaper than treatment.

-Syphrine Waswa

Divisional Public Health Officer

Matayos Health Centre

Thank youJames Simiyu, Busia District Ag. DPHO

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