EXPANDING USE OF HOUSEHOLD WATER TREATMENT IN SOUTH KIVU, DEMOCRATIC REPUBLIC OF CONGO RESULTS AND LESSONS LEARNED PROGRAM CONTEXT in rural areas have access to improved water sources. Even then, water from an improved One of the largest countries in Africa in both water source may not be safe. Transport and size and population, the Democratic Republic storage of water can be major periods of re- of Congo (DRC) is one of the poorest contamination. The urban/rural divide carries in the world. According to the 2010 UN over into access to sanitation as well: only Development Index, it ranks 168th out of 4% of households in rural areas have access 169 countries, ahead of only Zimbabwe.1 For to improved sanitation compared to 36% in DRC’s 71 million people, life expectancy is a urban areas. relatively short 48 years, due to continuing civil conflict and high rates of poverty, disease The lack of safe water, adequate hygiene, and and famine.2 This high level of conflict has sanitation negatively impacts child health led to a humanitarian crisis in the country, and adds to the high mortality rate (148 per especially in the eastern regions. 1,000 live births). In 2007, 16% of children under age five had diarrhea during the two According to the 2010 Multiple Indicator weeks preceding the Demographic and Health Cluster (MICS) survey, only 47% of the Survey (DHS).4 According to the 2010 MICS population has access to improved water survey, this has grown to 18%.5 sources. 3There is also a significant urban/ rural disparity in water access. About 83% of In 2007, the United States Agency for people in urban areas versus 31% of people International Development (USAID)-funded Social Marketing Plus for Diarrheal Disease 1 UNDP 2010 2 From 1996 - 1997 and from 1998 - 2003, DRC suffered two civil wars (IDMC 2010). 4 Ministère du Plan et Macro International 2008. 3 Ministere du Plan, Institut National de la Statistique, UNICEF 5 Ministere du Plan, Institut National de la Statistique, UNICEF 2010 2010 CountryBrief Control: Point-of-Use Water Disinfection remained internally displaced across DRC, and Zinc Treatment (POUZN) project was of which over 1.5 million were in North and invited by the USAID Mission to DRC to South Kivu.8 expand the water disinfection program in POUZN collaborated with USAID’s bilateral DRC. The POUZN program, implemented health project AXxes, which provides basic by Abt Associates Inc. and Population health services, to increase access to PUR Services International (PSI), engages the by leveraging community networks and private and NGO sectors in marketing and integrating water treatment messages into promoting POU water treatment products. AXxes’ primary health care work. The The DRC program ran from late 2007 POUZN project covered 28 health zones through December 2009 with program of the AXxes project in South Kivu focusing evaluations occurring in early 2010. in particular on the four major cities of In DRC, building on an existing Uvira, Bukavu, Minova, and Fizi as well as program implemented by their associated health zones: Uvira, Kadutu, PSI’s affiliate, Association de Bagira, Ibanda, Fizi, Kalehe and Minova. Santé Familiale (ASF), POUZN Of the 4.7 million people in the region, Democratic focused on expanding the the POUZN project sought to meet the Republic of marketing and promotion of water treatment needs of households with the Congo the Procter and Gamble (P&G) children under the age of five who make up point-of-use (POU) water approximately 20% of the population. 2 treatment product, PUR Purifier of Water, in South Kivu. South Kivu was CountryBrief PROGRAM GOAL chosen due to its high levels of diarrheal disease, tendency for cholera epidemics, and AND OBJECTIVES USAID prioritization of this conflict zone. The goal of the POUZN program was to reduce morbidity and mortality of children South Kivu, along with North Kivu, under five by preventing childhood diarrhea. continous to be the center of the conflict resulting from the Second Congo War (1998 The program objectives were: to 2003). This tropical region possesses 1. To improve access to PUR water lush natural resources and borders Rwanda, treatment in both the public and private Burundi and Tanzania. However, in contrast sectors, to its beauty, South Kivu has become 2. To increase use of the PUR water known for conflict and human rights abuses treatment solution, and perpetrated by the Congolese military.6 The war uprooted communities, destabilized 3. To improve knowledge of POU water treatment effectiveness and use, including social structures, and negatively impacted knowledge of: the provision of basic social services. Millions lack access to safe drinking water, Diarrhea transmission and prevention, food, tools, clothes, or basic supplies in particular the risks posed to for farming.7 In 2009, 1.9 million people children under five; 6 Sergrow 2007 7 IDMC 2010 8 OCHA 2009 Proper hygiene techniques, including PROGRAM COMPONENTS hand washing; and PRODUCT: ENSURING EVERY SIP IS Proper water storage techniques SAFE WITH HOUSEHOLD WATER TREATMENT TIMELINE Developed by P&G, PUR PSI began working in DRC in 1987 through Purifier of Water treats water ASF, a locally registered non-governmental through a combined process organization that successfully delivers HIV/ of disinfection with cal cium AIDS, malaria, family planning, and maternal hypochlorite and flocculation and child health interventions across DRC with iron sulfate. PUR is in 10 out of 11 provinces. packaged in four-gram powder sachets, each of which treats In 2006, with funding from P&G, ASF 10 liters of water within launched a POU water treatment program 30 minutes. It is effective in by marketing and promoting the use of PUR removing 99% of bacteria, through commercial and non-traditional viruses, and parasitic cysts like giardia outlets in the 10 provinces, with a focus on and cryptosporidium, and also removes Democratic urban areas. Republic of arsenic and DDT. Thanks to the flocculent the Congo Building on this foundation, the POUZN component, the product is especially effective program in DRC developed and in areas or situations with turbid water. 3 implemented a set of interventions to Sachets of PUR are light and compact, easy increase PUR use in the South Kivu region CountryBrief to transport and store, and have a shelf life starting in October 2007. of three years. Because of the many logistical To evaluate the impact of the program complications and costs associated with the activities, POUZN executed a quantitative distribution of goods in DRC, including the household survey in January 2010, followed absence of roads and the high cost of air by a qualitative study on water treatment shipments, individually packaged sachets of and hygiene in Bukavu in May 2010. PUR are a cost effective water treatment intervention. In May 2009, with UNICEF funding, ASF launched Aquatabs nationally to offer PRICE: PRICING PUR APPROPRIATELY consumers another household water FOR MAXIMUM UPTAKE treatment option. This chlorine water PUR was priced in DRC to ensure treatment tablet, manufactured by the affordability, recovery of the cost of goods Ireland-based company Medentech, is sold (which includes the product, quality distributed through both commercial and testing, and shipping and handling), and emergency relief channels. Though the allowances for margins for those selling the Aquatabs program was not funded by the product. With the support of USAID, ASF POUZN project, it is referenced here to was able to import PUR tax-free into DRC. offer the broader context of the household This resulted in more funds being made water treatment market in DRC. available for educational activities on the benefits of safe water, storage, and hygiene. TABLE 1: PRICE STRUCTURE FOR ONE SACHET indicated confusion over the fact that OF PUR IN DRC PUR was provided free at some times and Wholesalers NGOs Retailers Consumers had to be purchased at others. Retailers USD 0.041 0.046 0.050 0.055 were particularly concerned since some CDF* 38 41 45 50 consumers assumed that the retailers * Exchange rate of US1$=CDF900 had received PUR at no cost and were then selling it at a much greater profit. As shown in the table above, a wholesaler Nonetheless, caregivers said that using PUR price of $.041 provides wholesalers a was less costly than collecting and burning small profit margin of $0.009 and retailers firewood to boil their drinking water. a profit margin of $.005 when sold to PLACEMENT: IMPROVING ACCESS TO consumers at $.055 per sachet. The margin PUR IN SOUTH KIVU motivates retailers to consistently stock and supply PUR, but it is unclear if such Nationwide, marketing and distribution a limited margin is enough to provide of PUR was predominantly focused on 1) adequate incentives to wholesalers and urban areas with more vibrant commercial retailers.9 There is some anecdotal evidence sectors, 2) areas of higher need, including Democratic that suggests that vendors are selling PUR those affected by cholera outbreaks or Republic of those with large numbers of displaced the Congo at much higher prices (up to 200 Franc Congolese Democratique or CDF) in rural people, and 3) areas where a significant 4 areas. portion of the population draws water from unprotected sources such as rivers or lakes. Building on the initial willingness to CountryBrief However, limited funding prior to POUZN’s pay study in 2006, PSI/ASF executed involvment hindered the program’s reach further qualitative research in 2010 to and ability to deepen its distribution and explore issues of pricing. The majority of educational efforts in rural areas. As a respondents agreed that 50CDF – 100CDF result, USAID, through POUZN, specifically was an affordable price range for PUR, thus targeted expansion of PUR distribution and there may be some flexibility to revise the FIGURE 2: DISTRIBUTION SYSTEM marketing into rural areas of South Kivu.