Providing Safe Drinking Water in : The POUZN Aquatabs Program Results and Lessons Learned

PROGRAM CONTEXT water sources (Institut National de la Statistique et de l’Analyse Économique et al. Located on the west coast of Africa between 2007).1 The 2006 BDHS also indicated that Nigeria and Togo on the Gulf of Benin (Figure 94 percent of the population did nothing 1), Benin is one of the poorest and least to treat drinking water to prevent diarrhea. developed countries of the world, ranking Of those who did treat, 50 percent used 161/182 in the UN’s Human Development eau de javel (household bleach, which is not Index for 2009. Sixty-six percent of the manufactured to foodgrade standards and is population resides in not of a consistent concentration that allows rural areas. Overall health for proper dosing for water treatment) and indicators are poor, with a low 33 percent used other often inadequate life expectancy of 56 years treatments (such as straining through a and high infant (78/1000 live cloth). According to the Ministry of Health births) and child mortality (MOH) 2005 Annual Report and data from (123/1000 live births) the national health management information (UNICEF 2008). system (Système National d’Information et Lack of safe drinking water is de Gestion Sanitaires), the principal reasons a major problem confronting for health facility visits for children under Benin’s residents, particularly five were: malaria (41 percent), respiratory in rural areas, where, infections (20 percent), diarrhea and according to the 2006 Benin 1 A 2007 GTZ-funded survey of 300 deep wells in the Demographic and Health Ouéme and Plateau departments revealed that 97 Survey (BDHS), 43 percent do percent were contaminated with fecal coliform and other diarrhea-causing microbes. (Interview with GTZ not have access to improved advisor, June 2007, Ministry of Water, Directorate of Mines, Energy and Hydraulics.) CountryBrief gastrointestinal problems (15 percent), PROGRAM GOALS and anemia (7 percent). The World Health The goal of the Aquatabs program is to Organization estimates that 13 percent of reduce incidence of diarrhea among children deaths in children under five in Benin are under five by: caused by diarrhea.2 High diarrhea-related death rates can be attributed to poor  Creating a sustainable supply of and hygiene and sanitation practices and poor increasing access to a chlorine-based quality drinking water – both of which household water disinfection product (Aquatabs). contribute to the spread of water-related diseases.  Improving caregiver knowledge of the importance of treating and The Social Marketing Plus for Diarrheal appropriately storing household drinking Disease Control: Point-of-Use Water water. Disinfection and Zinc Treatment (POUZN)  Increasing use of Aquatabs to treat Project, implemented by Abt Associates household water. and Population Services International (PSI), was invited by the U.S. Agency for International Development (USAID) in TIMELINE Benin 2007 to implement an integrated diarrhea Aquatabs prevention and treatment program  The POUZN design team visited Benin in June 2007 to assess the need for and through private sector channels focusing 2 the feasibility of importing and social on water treatment at the household marketing a water disinfection product. level. The POUZN Project determined CountryBrief  that introducing the chlorine-based water  The POUZN workplan was approved by USAID in October 2007 and in March treatment tablet, Aquatabs, through the 2008 the POUZN team developed a private sector was the most appropriate detailed marketing plan. intervention for addressing the need for  The product was officially launched into household water treatment. Initial marketing the Benin market in September 2008. efforts centered around seven major urban and surrounding peri-urban areas located in  In 2009, the POUZN team expanded the following departments: Alibori, Atacora, marketing through a number of new community channels and in 2010 Atlantique, Bourgou, Collines, Donga, and launched a television advertisement that Zou, where PSI was already implementing considerably increased sales. a social marketing program that included  The program was evaluated using a child health products, and the capital city representative household survey in the of . In total the program reaches target departments in November 2009. 70 percent of the population or about 6.1 million people. Aquatabs are the only widely available product for disinfecting water, other than the household bleach mentioned above.

2 www.countdown2015mnch.org/ documents/2010report/Profile-Benin.pdf (2010. UNICEF) Program Components Price: After conducting formative research with potential consumers in a number of Product: Household Water Treatment areas of Benin, the decision was made to with Aquatabs. The POUZN team sell each strip of 10 tablets of Aquatabs for imported Sodium Dichloroisocyanurate a cost recovered retail price of FCFA 125 (NaDCC) tablets, manufactured by the Irish (US$0.25). Each tablet treats 20 liters of company Medentech under the brand name water; therefore, a strip of 10 is designed Aquatabs, for distribution in Benin. The to treat the drinking water for a family of June 2007 assessment examined the various five for approximately 10 days. Aquatabs product options and selected Aquatabs as are promoted as an effective and affordable the most appropriate product for Benin, household drinking water treatment product given that there was not an acceptable local to consumers in lower socioeconomic groups manufacturing option. Aquatabs, packaged where water treatment has not been the in strips of 10 tablets, have proven effective norm. in field trials in the developing world for treating water in the home (Clasen Due to the fact that the Aquatabs packaging et al. 2007). The 67 mg tablet imported contained no use information, the team specifically for this project was registered in developed a colorful box, with use Benin by PSI through an Autorisation de Mise instructions printed thereon, to educate the Benin en Marché. target population. Unfortunately, this doubled Aquatabs the base cost of the product. In order to 3 maintain an affordable yet sustainable price, the initial margins for both wholesaler and CountryBrief retailers were kept relatively low, as shown in Table 1. Medentech has since redesigned its packaging, both making it more colourful and printing use instructions in three languages on the reverse side. This will allow the POUZN team to eliminate the overpackaging and readjust trade margins as old stocks are depleted.

Table 1. Retail and Consumer Price Margins for Aquatabs

Prices Treatment Prices Margin % (US$) Base Price for Tablet 40 FCFA $0.08 — Packaging 40 FCFA $0.08 — Promotional poster enhances brand Total Cost (PSI) 80 FCFA $0.16 6% recognition at clinics Wholesaler/NGO 85 FCFA $0.17 17% and retail outlets. Retailer 100 FCFA $0.20 25% Consumer 125 FCFA $0.25 — Distribution: Ensuring the television advertising, which has already Access to and Availability improved demand, and reductions in base of Affordable Products costs through revised packaging, which will impact wholesaler and retailer margins, Building on its existing distribution system, should address these issues. PSI expanded the network for Aquatabs POUZN promotional efforts were (Figure 2) by working actively with two concentrated in the seven target private pharmacy wholesalers and one departments and the capital city of government pharmacy wholesaler, Centrale Cotonou. However, Aquatabs are d’Achat des Medicaments Essentials (CAMÉ), distributed nationwide and are available to distribute and sell Aquatabs through for sale in approximately 1,050 commercial private pharmacies and public sector outlets and 450 public health clinics clinics and pharmacies. In addition, the throughout the country. POUZN team worked with 10 commercial wholesalers to market the product through The government’s pharmaceutical the commercial distribution channels wholesaler, CAMÉ, operates in a fashion for fast-moving consumer goods such as similar to commercial wholesalers. shops and kiosks. Given that this is a low They purchase Aquatabs from PSI at the Benin cost product with relatively low profit wholesale price and sell to clients through Aquatabs margins for distributors and retailers, public sector clinics at the full cost price. 4 and still untested demand by consumers, Both CAMÉ and clinics benefit from this one additional pharmaceutical wholesaler, price structure with the margins funding CountryBrief covering half of the pharmacies in southern distribution costs and contributing to Benin refused to carry the product and only sustainability through this channel. While half of the commercial wholesalers agreed sales through the clinics were initially slow, to market the product. Both the advent of they have increased markedly with the advent of both the television advertising and a new supervisory linkage between the Figure 2: Distribution System clinics and the community sales personnel. A portion of institutional sales are also distributed through public health centers as part of emergency relief efforts.

Since inception, 47 percent of the product has been purchased by commercial wholesalers and sold through shops and kiosks, 14 percent was purchased by pharmaceutical wholesalers and marketed through private pharmacies, 4 percent was purchased by CAMÉ for sale through MOH health clinic pharmacies, 31 percent of sales were made to institutional entities (primarily the Red Cross) for humanitarian one promoting household water treatment response; and 4 percent sold to other more generally) were developed in 2008 distribution channels (Figure 3). and more than 32,500 radio spots were aired during the period March− Figure 3: Aquatabs Sales Channels December 2009. In 2009,

4% Commercial due to slow first-year sales Wholesalers outside of emergency channels, Pharmaceutical 31% Wholesalers it became apparent that the 47% Government Pharma team needed to expand its Wholesaler CAME Institutional (NGOs for efforts to advertise Aquatabs Humanitarian Needs) as a necessary household 4% Other 14% product and improve brand recognition. This included stepping up radio advertising, developing a Promotion: Improving television commercial, and placing billboards Caregivers Knowledge in strategic locations in each of the target and Practice departments. In late March 2010 the team launched a television advertisement With 94 percent of Beninese not treating on two national television stations, one Benin their water with any method at the start Aquatabs private and one public. This had additional of the program, POUZN had the dual positive impact on sales, supporting the challenge of introducing both the concept of 5 efforts of the community and retail sales water treatment and the product. Cholera agents, who found that both consumers and CountryBrief outbreaks in Cotonou and retailers were much more likely to buy an and a flood emergency in Ouéme and Plateau departments immediately prior to the launch (August and September 2008) allowed the POUZN program to respond quickly with supplies of Aquatabs, strengthening exposure to the product and the importance of household water treatment. As a result, international NGOs continue to be a major purchaser of Aquatabs as shown in Figure 3 (above).

POUZN utilized both mass media and interpersonal communication to increase demand for Aquatabs.

Mass Media: POUZN’s initial mass media Group sensitization sessions by efforts utilized national radio networks to community health workers improve reach households living in urban and peri- knowledge on urban areas. Two safe water radio spots the need to treat water, increase user (one promoting the Aquatabs brand and self-confidence, and encourage sales. initial supply of the product after they had As of May 2010, the POUZN project had seen the advertisement. This also sharply trained 1,842 individuals in both public and increased orders by wholesalers. NGO sectors to support promotion of Aquatabs. These included over 400 MOH The POUZN team also produced briefs health clinic staff, 211 hygiene and sanitation on safe water and diarrhea for use by 14 assistants from the Department of Hygiene community radio stations with reach deep and Sanitation, 90 individuals from partner into the rural areas. Using those briefs NGOs and radio stations, 179 community- the community radio stations prepared based health promotion/sales agents, and community radio messages, special 124 other promotion agents. More recently, interviews, and other media programs 64 community-based animators and 772 specific to household water disinfection. women leaders from approximately 100 These community radio activities women’s groups were trained and engaged supplemented national radio broadcasts. to both sensitize community members and Interpersonal Communication (IPC): to sell Aquatabs door-to-door. Sixty Peace To complement the mass media promotion Corps volunteers were also trained on the team engaged 13 NGOs with point-of-use water disinfection, allowing community agents trained in community them to promote the use of Aquatabs in Benin development and outreach skills. The NGOs their various community development Aquatabs were provided with training in diarrhea efforts. 6 prevention techniques and with the POUZN team set monthly targets for delivery of IPC CountryBrief through sensitization sessions. POUZN Program Evaluation Research Results In November 2009, the POUZN project conducted a survey of 2,914 households with children under five in the target departments to assess program progress. PSI also conducted a retail audit survey during the same month to assess coverage and penetration of all of its socially marketed products, including Aquatabs. In May 2010, the POUZN team conducted a mystery client survey to assess Aquatabs promotion through pharmacy outlets. The results of these research studies are highlighted below. Where appropriate, the data were compared with baseline data provided by the 2006 BDHS. Community-based sales assures community accesss to Aquatabs. Use of Aquatabs as Of that 12 percent, 18 percent had used a a Household Water chlorine product (usually household bleach), Treatment Product 52 percent were currently using Aquatabs, 10 percent had used a filter, 3 percent had Comparison of data from the 2006 BDHS boiled their water and 9 percent had used and the 2009 POUZN survey shows that another unspecified product or method. the proportion of households with children Of Aquatabs users, 5 percent reported using under five that had ever treated their water the tablets daily, 33 percent reported use in the past using any method increased from 1−3 times per week, while 44 percent were 4 percent to 12 percent.3 Factors found to intermittent users (during the wet or dry be strongly associated with treating water season, during a change from one water were exposure to mass media messaging, source to another, or when they were unable social norms (behaviors supported by to boil). Of those who had heard of Aquatabs, friends, family and/or other community but had not yet tried the tablets, 63 percent members), knowledge that one must treat did not feel the need to use them; 10 percent the drinking water to make it safe to drink, said they were “impossible to find.” and self-confidence in being able to use a water treatment product correctly. Benin Aquatabs Figure 4: Water Treatment Behaviors in Households with Benin Water Treatment Behaviors 7 Children Under Five CountryBrief 14.0% 12.1% 12.0%

10.0%

8.0% Baseline (2006 DHS) 6.3% 6.0% POUZN 2009 Survey 3.9% 4.0%

2.0% 0.1% 0.0% Ever Treated Water*** Currently Use Aquatabs*** ***p<.001

3 These results are based on comparable data: for both years, the data shown here are from a population- based survey of households with children under five in the POUZN program departments. Improving Access to During a mystery client survey of 10 Aquatabs private pharmacies in the Cotonou area in May 2010, 98 percent of personnel Aquatabs users obtained the product recommended Aquatabs when clients asked primarily from private pharmacies (28 for a product to disinfect water, which is percent) or public health clinic pharmacies not surprising given that the retail audit (26 percent) but also from markets (12 study showed that 95 percent of outlets percent), kiosks (11 percent), and other surveyed in Cotonou carried the product. outlets (9 percent). Community sales agents It is significant that commercial outlets are and NGO sales accounted for 8 percent both carrying the product and are referring of sales. Community sales channels opened clients to the product when asked. only in late 2009 and are expected to increase in importance in the future. Urban users tended to purchase Aquatabs from Effectiveness of Mass a pharmacy (36 percent) or public health Media and Interpersonal clinic (25 percent) while rural users tended to purchase Aquatabs from a public health Communication Efforts clinic (44 percent) or market vendor (36 The POUZN team implemented a two- Benin percent). pronged communication strategy in Benin. Aquatabs The team developed and aired both The POUZN team conducted two retail generic and branded mass media messages, 8 audit surveys in December 2008 and utilizing national radio networks to reach November 2009 in all 12 administrative households living in urban and peri-urban CountryBrief departments of Benin. These surveys areas. The team also implemented an IPC indicated that coverage (defined as at least campaign to increase demand in rural one point of sale in the enumeration area catchment areas, working through NGOs [town or segment of larger cities] surveyed) already trained in community development and outreach skills, to create awareness and of Aquatabs had improved from 7.5 percent promote product use. in December 2008 (soon after product launch) to 35.5 percent by November 2009, POUZN staff analyzed water treatment ranging from 20 percent in the department behaviors in relation to the respondent’s of Couffo to over 95 percent in exposure to at least one message about Aquatabs or water treatment4 either via (encompassing the capital city of Cotonou). one of the radio spots or via a women’s Penetration (defined as percentage of shops group meeting or community sensitization in each enumeration area which carried the session delivered by one of POUZN’s product) had improved from 1.6 percent to partner NGOs. The household survey 10.4 percent during this same period. The results indicated that 21 percent of POUZN team made significant efforts over respondents had heard of Aquatabs. Of the one-year period to increase coverage those who had ever used Aquatabs, 40 and penetration in departments with percent had heard an Aquatabs message; 22 previously low rates, resulting in significant percent had heard a message on the radio increases in northern departments, but (which ran from March to December 2009); particularly in the capital area of Littoral. 4 Generic (water treatment) and branded (Aquatabs- specific) messages ran at equal frequencies during the promotional period. 11 percent had seen a generic message obtained information about Aquatabs from on water treatment on the television an NGO community animator or MOH (branded TV advertisements were not aired community health worker or health clinic until March–April 2010); and 10 percent staff while urban respondents discussed had heard a message via an interpersonal Aquatabs more often with neighbors, contact (NGO animator or family member). friends, relatives and market traders. NGO partners have been active since October POUZN placed considerable emphasis 2008, reaching over 150,000 individuals in on promotion through IPC channels. group sensitization sessions or community Research results indicated that among promotional events. respondents who had a personal contact that involved discussing Aquatabs, 52 Figure 5, below, illustrates the association percent had discussed Aquatabs with between exposure to safe water or friends, neighbors, or relatives, 30 percent Aquatabs promotional messages and water with health personnel, 11 percent with treatmen behaviors. Individuals who had community animators, 10 percent with heard a message were twice as likely to market traders (commerçants), and 9 percent either treat their drinking water or to use with community health workers. Rural Aquatabs. An individual’s perceived access respondents, when compared to urban to/availability of water treatment products respondents, were more likely to have was also statistically significant. Benin Aquatabs

Figure 5: Water Treatment by Respondents with and without 9 Exposure to Messages on Safe Water/Aquatabs , 2006–09 (% of CountryBrief households) 25.0%

20.8% 20.0%

15.0% 13.0% Baseline (2006 DHS) Not Exposed 9.9% 10.0% Exposed

6.0% 4.7% 5.0%

0.1% 0.0% Ever Treated Water Currently Use Aquatabs Summary Program Lessons Learned Conclusions Community-based awareness-raising The percentage of targeted households alone is not sufficient to increase with children under five years ever treating sales. The project team found that sales their water increased from 4 percent to 12 in rural areas did not take off until the percent. Of those treating their water, more project added both television advertising than half had tried Aquatabs at least once. Pharmacies − both commercial and those and created a cadre of community- associated with MOH health centers − based sales personnel to complement were the primary sales points, followed by the communications program, providing commercial retail outlets (boutiques, market immediate, local access to the product. stalls, etc.). Few consumers purchased Mass media plays an important role from community sales agents, but this is expected to change over time, given the in creating awareness of and demand new emphasis on this sales channel. Many for previously unknown products. consumers continue to use the products in Radio advertising, via either local or national critical seasons of the year, upon changing stations, was important in encouraging sales their source of water supply or during but the advent of television advertising disease outbreaks. created sufficient product awareness for Benin Aquatabs Exposure to behavior change messages sales takeoff. Furthermore, in urban areas, (either through mass media or IPC) was television is particularly effective when 10 clearly an important driver of use. Research working to identify new retailers. New showed that radio was the primary retailers who have seen the product on CountryBrief source of information, followed by generic the television are more apt to be open to television programming. Respondents who stocking the product. had heard a message about Aquatabs were twice as likely to purchase and try the The community (family, friends, and product, compared to those who had never relatives) is an important source of heard a message. Research results indicated information and influence. Social norms a positive association between exposure are a significant feature of Aquatabs use to at least one POUZN program message and these individuals are frequently cited and ever treating, ever chlorinating, and reference points for advice. Information currently using Aquatabs. about Aquatabs was frequently obtained from family or friends, indicating the diffusion effects of the many sensitization sessions of partner NGOs and the need for effective community-based IPC, particularly in rural areas where television ownership is low or non-existent. The cost of packaging can be a Acknowledgments deterrent to marketing Aquatabs This report was authored by Vicki through commercial channels. If use MacDonald, Abt Associates Inc., along with instructions are clear on the product itself Justin Buszin and Njara Rakotonirina of and through campaign messages, eliminating Population Services International. overpackaging can reduce the cost of the product and allow for wholesaler and The authors would like to acknowledge retail margins that are more attractive to the PSI team in Benin led by Leget Foyet, the trade, thus making the product more Katharine McHugh, and Cyprien Zinsou for commercially viable. their contribution to implementation and evaluation. They would also like to thank Dr. Pascal Zinzindohoue and Ms. Michele Seibou of the United States Agency for International Development (USAID) Mission to Benin for their support throughout implementation of this program. This issue was designed and produced by Maria Claudia De Valdenebro, Abt Associates Inc. Benin Aquatabs

11 CountryBrief

Commercial outlets provide nearly half of all Aquatabs sales. References Recommended Citation

Clasen, T. et al. 2007. Household MacDonald, Vicki, Justin Buszin, and Njara Water Treatment Using Sodium Rakotonirina. September 2010. Providing Safe Dichloroisocyanurate (NaDCC) Tablets: Drinking Water in Benin: The POUZN Aquatabs Program. Country Brief. Bethesda, MD, USA: A Randomized Controlled Trial to Assess Social Marketing Plus for Diarrheal Disease Microbiological Effectiveness in Bangladesh. Control: Point-of-Use Water Disinfection Am.J Trop Med.Hyg. 76(1): 187–192. and Zinc Treatment (POUZN) Project, Abt Associates Inc. and Population Services Institut National de la Statistique et de l’Analyse International. Économique (INSAE), with the collaboration of Programme National de Lutte contre le Sida (PNLS), and Macro International Inc. November 2007. Benin, Standard Demographic and Health Survey, 2006. Cotonou, Bénin and Calverton, Maryland, USA: INSAE, PNLS, and Macro International Inc.

United Nations Children’s Fund (UNICEF). December 2008. State of the World’s Children.

About POUZN F or more information about POUZN DISCLAIMER or current publications (available for Social Marketing Plus for Diarrheal Disease Control: The author’s views expressed in this download) please contact: publication do not necessarily reflect the Point-of-Use Water Disinfection and Zinc Treatment POUZN (POUZN) Project Abt Associates Inc. views of the United States Agency for 4550 Montgomery Avenue, International Development (USAID) or Contract No. GPO-I-00-04-00007-05 Suite 800 North the United States Government. Bethesda, MD 20814 USA POUZN is led by Abt Associates Inc. Tel: 301.347.5000 in collaboration with Fax: 301.913.9061 Population Services International http://www.pouzn.com September 2010