The Safe Water System (SWS) is a simple, inexpensive water quality intervention, appropriate for the developing world and proven to reduce diarrhoeal disease incidence in users by 22 to 84 per cent. The objective is to make water safe through disinfection and safe storage. The intervention includes point-of-use household water treatment with sodium hypochlorite (chlorine-based) solution, safe water storage and behaviour change communication.
In particular, the initiative aims to reduce diarrhoeal diseases in children under five and other vulnerable populations.
Society for Family Health (SFH), an affiliate of Population Services International, partnered with the Centers for Disease Control and Prevention to launch SWS in Zambia in 1998. The solution is locally manufactured, then distributed and marketed as ‘Clorin’ to consumers, various non-governmental organisations and other partners involved in community mobilisation activity.
Since its commencement, SFH has sold or distributed more than 17 million bottles of Clorin, each of which protects a family of 6 for a month. Since national introduction in 1999, both reported incidence of diarrhoea among children under-five and child mortality has reduced.
An estimated 1.1 billion people worldwide lack access to an improved water source. In addition, hundreds of millions more continue to drink contaminated water despite having access to an improved water source, because of unsafe water treatment and distribution systems and unsafe water storage and handling practices.
The health consequences of inadequate water supply and sanitation services include an estimated 4 billion cases of diarrhoea and 1.9 million deaths each year, mostly among young children in developing countries. Indeed, diarrhoea is a leading cause of morbidity and mortality in children less than five-years-old in the developing world.
While larger scale projects such as the construction of deep wells or piped water systems remain an important objective of many development agencies, a shortage of time and resources leaves hundreds of millions of people without access to safe water.
To address immediate needs, in 1992 the Centers for Disease Control and Prevention (CDC) and the Pan-American Health Organization (PAHO) developed a simple, inexpensive technology to prevent waterborne diseases by improving the quality of drinking water at the household level. The Safe Water System (SWS) incorporates three elements:
55 per cent of the Zambian population overall — and up to 78 per cent in rural areas — draws their water from an unimproved source, putting them at significant risk of diarrhoeal diseases, including cholera. Cholera is endemic in Zambia during the rainy season. In 1997, the World Health Organization (WHO) estimated that Zambia had the second highest number of cholera cases in Africa.
Despite good immunisation coverage, Zambia continues to experience high infant and under-five mortality. The 1996 Zambian Demographic Health Survey (ZDHS) reported the infant mortality rate as 109 deaths per 1000 births and under-5 mortality as 197 deaths per 1000 births. In other words, 1 in every 10 children dies before experiencing their first birthday and 1 in every 5 before their fifth. Waterborne diseases contribute significantly to the country’s high infant and under-five mortality rates. In 1998, a total of 18,484 suspected cases of cholera were reported through routine Health Monitoring and Information Systems. Of this number, 7,564 were cases of those aged under 5 years.
People living with HIV and AIDS are also at high risk of diarrhoeal disease due to their compromised immune systems. Poor sanitary conditions, limited access to safe water and poor hygiene practices all contribute to diarrhoeal disease.
In 1994 to 1995, the CDC was working with a local NGO on a SWS project in Bolivia. Field trials of the intervention in peri-urban and rural populations demonstrated that households using the product had improved domestic water quality and reduced diarrhoeal disease incidence by 40 per cent or more.
Wanting to test and replicate these successful findings, USAID saw the need for a point-of-use water treatment in Zambia and provided funding for a small study to test feasibility of the intervention. Also keen to develop the evidence base and test the concept of the SWS, CDC approached the Zambian Ministry of Health (MoH), which was immediately supportive of the intervention and invited CDC to conduct an initial field trial in Kitwe, Zambia.
Small field trials in Kitwe were conducted to determine if household use of disinfectant and special water storage vessels could improve water quality and decrease diarrhoea.
Two peri-urban communities in Kitwe (Ipusukilo and Luangwa) were selected as project sites based on their lack of a piped water system and having drinking water as a major concern. Two zones in Ipusukilo (166 households) were designated as intervention communities and 1 zone in Luangwa (94 households) was designated a control community.
The first field trial took place in 1998 from March to June. The intervention had three elements:
The intervention group was provided free sodium hypochlorite solution, taught about safe water storage and offered the opportunity to purchase the special vessel. The control group continued to use traditional water treatment and storage practices.
Once the baseline surveys were conducted the intervention was distributed. Weekly active diarrhoea surveillance, biweekly water testing for chlorine presence and a follow-up survey were conducted after the intervention period.
Initial results were promising: over the 8 weeks following the launch of the intervention, only 22 episodes of diarrhoea were reported in the intervention group, compared to 28 among the control group.
By the end of the study:
During weekly home visits over a 3-month period, compliance was high in intervention households: 97 per cent reported using disinfection and 72 to 95 per cent had measurable chlorine in their water in biweekly testing. The proportion that engaged in safe water storage practices increased from 42 to 89 per cent and the risk of diarrhoea (when compared to the control group) was reduced by 48 per cent.
CDC reported the success of the field trials in Kitwe to the MoH and USAID and recommended a pilot project. In October 1998 the Society for Family Health (SFH), a Zambian non-governmental organisation (NGO) affiliated with Population Services International (PSI), was contracted to implement a social marketing programme to produce, market and distribute a new sodium hypochlorite product to treat water and prevent diarrhoea. PSI was successful in its bid for modest funding from USAID to run small pilot social marketing projects in discrete regions of the country.
The goals of these pilot projects were to:
In addition to the two peri-urban areas in Kitwe that were included in the initial field trials, three sites in Lusaka were selected for the pilots – Mandevu, Chaisa and Marapodi. These areas lacked a safe and adequate water supply and reported 257 cases of cholera in 1996 alone.
In August 1998, CDC visited Chaisa, a peri-urban neighbourhood where approximately 1,200 families obtained their water from 56 communal taps and 40 wells, to conduct qualitative research through focus groups and key informant interviews with the target audience.
A market visit in the neighbourhood also set the stage for the brand to be developed and provided important insight into water storage practices and consumer habits (what people buy and how much they pay for basic consumer goods).
Additionally, SFH conducted several group discussions which provided information on common attitudes toward water in the neighbourhood. This information was used to develop product material, which was tested in two more focus groups.
A knowledge, attitudes and practices (KAP) study was carried out by SFH regarding water in the pilot sites. This formative research was used as a baseline for project monitoring, but also informed the marketing and communication strategies. The research provided information on:
Clorin disinfectant solution:
The product was distributed through:
SFH developed an effective communication campaign in collaboration with the Central Board of Health (CBOH) and other partners, to educate the population about diarrhoea prevention and promote the use of Clorin as the most effective method of preventing diarrhoea. To create more awareness of the product, SFH implemented a generic as well as a branded promotional campaign at the national level.
The campaigns aimed to promote Clorin as:
Specific educational messages to educate and motivate the target audience to treat their domestic water regularly included:
SFH used various communication channels, including:
Two types of posters pretested well with focus groups:
Additionally a two-page leaflet titled ’How can you make your drinking water safe?’, with illustrations and measuring instructions, was developed for health workers and promoters for distribution.
SFH targeted two audiences in its promotional campaign:
In October 1998 the Clorin pilot project was launched with a public event in which local children performed SWS skits and local dignitaries made speeches. The event was covered in local print and broadcast media.
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.Trained community health workers educated their neighbours about the causes and prevention of diarrhoea and correct use of Clorin. Branded T-shirts were given away at public events. A video was produced and showed to different communities around the country in mobile video units. Clorin signs and billboards were painted on the walls outside health clinics and in other strategic locations.
There were some unforeseen problems during the pilot. For example, in Lusaka one water company felt threatened by the intervention, as it saw it as a challenge to the safety of the water they supplied. The water company asserted that it had already chlorinated the water (which CDC verified it did not) and also informed people that if they chlorinated the water from the taps they would get cancer. CDC worked hard to overcome this to ensure people received the correct information. They quoted WHO guidelines that clearly state that potentially contaminated water should be chlorinated and that disinfection byproducts are not a consideration. The rationale for this guideline is that millions of children die of diarrhoea before the age of five, but the very rare case of a cancer occurring from disinfection byproducts would not manifest until after age 60 or 70 years.
Sales were modest in the first few months of the pilot but nonetheless surpassed expectation, with about 3,000 bottles sold between October and December 1998. Then in January 1999, a number of small, localised cholera outbreaks coalesced into a nationwide epidemic. The demand for Clorin increased dramatically and the initiative was instrumental in helping the MoH control the outbreak by distributing more than 30,000 bottles of Clorin. Total sales of Clorin increased to 41,000 by December 1999.
In 2000, SFH, in collaboration with the District Health Management Teams (DHMTs), expanded the distribution of Clorin to increase the supply and availability. Clorin is now available nationally in urban and rural areas in clinics, pharmacies, drugstores, groceries, supermarkets, motels, hotels, bars, workplaces and private clinics. Clorin is distributed through a national network of production sites, field offices and retail outlets and is sold at a discounted price to distributors, wholesalers, NGOs, public clinics and schools.
In addition to utilising mass media, SFH has expanded many successful interpersonal communication programmes. A child-to-child school programme was developed to educate teachers and students on the importance of treating water with Clorin all year round and to take these messages home to their parents.
Furthermore, detailed programmes are used to educate health providers and retailers on correct product usage. Door-to-door volunteers, who earn a commission on every bottle they sell, educate the public about the consequences of drinking poor quality water and proper method of water treatment and storage. SFH also undertook substantial interpersonal communications efforts at grassroots level to educate vulnerable populations about the link between unsafe water and disease, the need for treating drinking water at the household level and the mechanics of product use.
Special promotional events, including Christmas fairs and National Sanitation Day, are staged at critical times of the year, for example at the beginning of the rainy seasons to educate the population about the importance of treating water with Clorin.
Key stakeholders include:
The project had a very high level of approval, as evidenced by positive reactions from authorities like the MoH, Central Board of Health, District Health Management Boards from Lusaka and Kitwe, members of the project communities, and mass media sources.
Data on diarrhoea visits to Ipusukilo and Luangwa Clinics suggested that the number of clinic visits for diarrhoea declined in 1998 compared to 1997. This reduction coincided with increasing sales of Clorin. In comparison, diarrhoea data from Mindolo, a peri-urban community in Kitwe that did not participate in the Clorin project, showed no decline in clinic visits for diarrhoea in 1998 when compared to 1997.
Clorin sales increased steadily from 3,000 in 1998 to nearly 3,000,000 in 2008 alone.
SFH conduct its own national household TRaC (Tracking Results Continuously) surveys every two years to measure Clorin use and safe water practices. 2006 TRaC survey results include:
Drivers of use
According to the 1996 ZDHS, the overall incidence of diarrhoea in the 2 weeks prior to the survey was 23 per cent, though 1 study in 1997 indicated it could be as high as 45 per cent in children under 5. However since the introduction of Clorin the 2007 ZDHS reported an incidence of only 16 per cent among under-fives.
Although child mortality remains at an unacceptably high level, it has decreased. The 2007 ZDHS reported a reduction in under-5 mortality as compared to 1996 (from 197 per 1000 births to 119 per 1000) and a reduction in infant mortality (from 109 per 1000 to 70 per 1000).
The cost of production, marketing and distribution per bottle of Clorin sold was US$1.88 in 1999, the first year of the project when SFH sold 187,000 bottles. By 2003, when SFH sold 1.7 million bottles, the cost per bottle had decreased to US$0.33. To make the product affordable to populations at greatest risk of diarrhoea, the price per bottle was set at US$0.09. The loss per bottle therefore dropped from US$1.79 in 1999 to $0.24 in 2003. Even at the calculated loss per bottle in 2003, the cost per person-month of protection was US$0.04. At that time, it was calculated that at maximum production capacity a price of US$0.18 per bottle would permit full cost recovery. In 2009, the retail price of Clorin was US$0.15 per bottle and SFH achieved full recovery of production costs. Marketing and distribution still required a subsidy to maintain a low product price.
One of the principal goals of the project, in addition to preventing diarrhoeal diseases, is to be self-sustaining through sales of the Clorin solution. In terms of production, this has been achieved.
In 2004, in which 1.8 million bottles of Clorin were sold, investigators from Johns Hopkins University evaluated the programme using cluster sampling methodology to survey a nationwide sample of 1,319 households. 65 per cent of respondents reported ever using Clorin and 42 per cent reported current use of the product. Through the detection of residual chlorine in water stored in households, the investigators confirmed that 13 per cent of all respondents, and 36 per cent of respondents who reported using Clorin for a year or more, were using the product on the day of the survey. However when compared with the findings of the 2001 ZDHS survey, Clorin was much more widely used, especially in areas with active social marketing. Community and neighbourhood influences are important in starting Clorin use.
Price was cited as a barrier by many former users, particularly those living in lower housing status. Other reasons for stopping were smell and taste, while one of the most important reasons for starting was use by a neighbour. As use was more common among educated water caretakers, the investigation recommended that those living in lower index housing should be a particular focus for marketing.
The use of Clorin did not affect the prevalence of diarrhoea among under-fives, although there was less diarrhoea in households that had received visits from the SFH. Also, diarrhoea was significantly less in households where there was visible soap at washing points.
The lower rates of Clorin use and residual chlorine in household water observed in this study compared to previous trials combined with the limitations of a cross-sectional study design explain why no effect against diarrhoea was found. It is also indicative of the challenges with taking a small efficacious activity to scale while retaining effectiveness.
From 1993 to 2003, CDC assisted PSI in eight countries to establish SWS projects. SWS implementation has varied according to partnership and social and economic conditions and the SWS has now been disseminated in 13 countries at national and sub-national levels through PSI.
Field trials have shown a reduction of risk of diarrhoea from 30 to 85 per cent following the implementation of a SWS project.
Apart from the 1999 cholera epidemic in Zambia, the SWS has been used as an emergency response tool for earthquakes and flooding in Bolivia in 1997 and 1998, cholera epidemics in Madagascar in 2000, flooding in Kenya in 2001 and Malawi in 2002, flooding in West Timor in 2004, the earthquake and tsunami in Indonesia in 2004, and the Haitian cholera epidemic of 2010 to 2011.
Although Clorin sales continue to increase each year, a number of barriers to use remain, which include lack of affordability, taste and smell, belief that source water is safe and not knowing enough about the product. In addition, Clorin use tends to be seasonal, with sales increasing during the rainy season when the population perceives a greater risk of cholera.
The main challenges that implementing organisations face include motivating people to use the product consistently, achieving higher levels of use in populations with little or no disposable income, and sustaining programmes without increasing product price, which would decrease access to the most vulnerable populations.
Social marketing has been particularly effective at creating product awareness, facilitating access through national distribution using the commercial sector and generating demand. In addition, access to a product means that interested NGOs can readily incorporate Clorin into their own programmes.
A major obstacle has been assuring consistent funding. Ideally programmes would become entirely self-sustaining. However this is not achievable in Zambia (which ranks 165 out of 177 countries on the Human Development Index) as this would make the price too high and unaffordable for the poorest families. Therefore educating partners that they need to subsidise products like the SWS or subsidise marketing and promotion campaigns so they remain accessible to everyone is important and must be maintained.
Early on during the 1999 cholera epidemic, SFH was asked by the MoH to give away Clorin for free in affected areas. SFH was reluctant to do this as it was afraid it would kill the commercial market. Yet despite this free distribution, SFH generated annual sales of 187,079 Clorin bottles that year. Sales then more than doubled in 2000 to 482,000 bottles and continued to increase beyond projections to 1,712,700 bottles in 2003.
Activating commercial networks to make an intervention accessible to people is important, but to increase the project’s impact a broad social marketing strategy is needed. Government endorsement, mass media, community-based agents, peer educators and street theatre are all equally important to the intervention mix.
The SWS has been integrated with HIV services to increase access to immune compromised populations, as well as into health facilities to permit health workers to wash their hands and administer medicines with safe water. It has also provided a platform for health workers to teach clinic clients about water treatment and handwashing.
With special thanks to Rob Quick (Waterborne Diseases Prevention Branch, CDC) and Cecilia Kwak (Child Survival Technical Advisor, PSI) who contributed to the content and development of this case study.