Long Term Household Water Treatment Solutions in Somaliland August 2014

Acknowledgement The study was made it possible through support provided by UNICEF and Deparment for International Development (DFID). In addition, we thank the Somaliland Ministry of Health (MOH) for authorizing and supporting this study and the MOH’s staff that provided supervision to the data collection teams while they were in the field.

We are also very grateful to all data collectors and their supervisors for the tireless efforts made to collect the data from all sampled sites and to PSI/Somaliland research team who helped us in the overall coordination of the field work. We are also grateful to Christopher Montague Hermann, Social Marketing Technical Advisor, PSI/Somaliland, Donato Gulino, Country Representative, PSI/Somaliland and Megan Kays, PSI Regional Researcher for East Africa for all the support and arrangements made that ensured the successful conclusion of the survey and the constent feedback of the whole process.

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Executive Summary

Background:

Access to safe water in Somaliland is a major challenge; it has been estimated that somewhere between 83%1 and 90%2 of the rural populations do not have access to safe drinking water. Most people living in Somaliland obtain their water from open sources, including springs, berkads, and dams. Open water sources are prone to contamination and increase the opportunities for water borne diseases to spread.

In an effort to respond to this issue, UNICEF launched a pilot program to distribute free ceramic water filters in rural villages and selected towns throughout Somaliland. Recipients of ceramic filters embraced the new solution. In light of the success of this program, UNICEF approached PSI Somaliland, known for its established private sector social marketing programs, to explore the viability of introducing ceramic water filters through the private sector.

The scope of the research was broadened to include various water treatment options, including ceramic filters, to better understand the market needs. UNICEF and PSI Somaliland proposed a market research study to understand the landscape of long term water treatment options, specifically the supply and demand side factors that might contribute to facilitating sustainable access, by employing a Total Market Approach in urban, peri-urban, and rural Somaliland.

Overall purpose of the study:

The overall objective of this project was to inform the introduction of long term household water treatment solutions in Somaliland. Specific objectives for the study were: • To conduct preliminary research into key supply and demand side factors to better understand the market for long term household water treatment solutions; • To understand the supply chain from retailers to wholesalers to manufactures; • To explore issues such as awareness of current household water treatment options, other drivers of purchase decision, and willingness and ability to pay among potential consumers; and, • To develop a set of recommendations for UNICEF and partners to identify strategic entry-points for long term household water treatment solutions in Somaliland.

1 MICS (2011) Multi Indicator Cluster Survey.

2 SWALIM (2007). Rural Water Supply Assessment.

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Methods:

A mixed methods study design was used to inform data collection in 4 Somaliland regions – Maroodi-Jeex, Togdheer, Saaxil, and Awdal. The study focused on two aspects: • Supply side – comprising of 23 key informant interviews with stakeholders in the health products supply chain • Demand side – comprising of 853 household survey questionnnaire interviews and 13 FGDs (separate male and female) in urban, peri-urban and rural Somaliland.

Findings:

The findings are focused on three major areas that the study sought to explore: a) Insights on water treatment behaviors and perceptions among household members; b) Opportunities, challenges and barriers to the social marketing of water treatment solutions overall; and c) Opportunities, challenges, and barriers to the social marketing of ceramic water filters.

a) Findings on household level water treatment solutions in Somaliland

Findings in this subsection are clustered around four areas: demographics, water treatment knowledge, water treatment practices, and willingness to pay for water treatment products.

Demographics 49.1% of the household respondents were aged between 31-40 years, 38% were 16-30 years; and 12.5% were above 41 years. Most respondents lived in urban areas (63.2%) followed by rural (30.2%) and peri-urban areas (6.6%). Most respondents did not have formal education or employment. The FGD participants represented a subgroup of these respondents and had similar characteristics.

Water treatment knowledge and practices The main sources of drinking water at household level are hawkers (31.7%) and public wells/taps (27.1%). Respondents reported taking up to 1 hour searching for water and sourcing possible carriers/ containers.

The study revealed a clear hierarchy of water treatment preference, with water treatment tablets used most often (48.8%), followed by boiling (35.9%), ceramic water filters (5.3%), bleach/chlorine (4.6%), straining through a cloth (4.6%) and finally powders (0.8%). Quantitative results indicated that water treatment tablets were popular among all wealth quintiles across all 5 regions of Somaliland in rural and urban areas, with boiling used as the

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next preferred means to clean/treat water. However, the richest quintile used a wider range of water treatment methods compared with the poorest and poorer quintiles.

Qualitative results show that both water treatment tablets and ceramic water filters were acceptable to consumers, and they were familiar with these options as the Ministry of Health and NGOs have been promoting their use through awareness raising programs and distributing them through public health facilities. Overall, both were perceived as safe options. In terms of taste, ceramic filters were preferred as offering a neutral taste compared to the slightly “bitter” taste of Biyosifeeye. Ceramic filters were perceived as slow, as it could take two hours to filter a liter of water. Ceramic filters were also seen as fragile, and were sometimes misused to store household goods rather than to filter water.

A number of channels were proposed by the respondents on how to deliver knowledge around water treatment, including: using school children to pass health messages, interpersonal communication at household level, collaboration with local organizations in the WASH cluster, training shopkeepers in rural areas and their suppliers (wholesalers) on the use and benefits of health products, using relevant global events to create awareness, using mobile technology to deliver health messages, using televised infomercials, and, engaging traditional elders especially among pastoralist communities.

The main source of water treatment products throughout Somaliland are chemists/drug shops. Both water treatment tablets and ceramic water filters were being sold at chemists/drug shops; however, very few chemists/drug shops sell ceramic water filters. For instance, in Hargeisa, Madar pharmacy is one of the few chemists selling ceramic water filters. Overall, the demand and use for water treatment tablets was significantly higher than ceramic water filters.

Demand for ceramic water filters through the private sector was low, as many community based organizations were providing them for free. In some cases, respondents reported having sold their filter to a retailer for money instead of using it to treat their water. Of those who owned a filter, 57% of respondents purchased the filter through a chemist/drug shop, 14% obtained them from CBOs, and another 14% from retail shops.

Willingness to pay for water treatment solutions As the top two methods of water treatment were water treatment tablets and boiling, the study focused willingness to pay for water treatment tablets, specifically PSI’s BiyoSifeeye. Using the Price Sensitivity Meter (PSM), the results suggest an acceptable price of 1,800 Somaliland shillings for a strip of 10 tablets. However, these findings are driven by the wide variation of prices being paid for BiyoSifeeye, ranging from the recommended 500 SOS to about 10,000 SOS. Given the lower uptake of Biyosifeeye among the poorest quintile and the greater need in this population, a preferred strategy may be to promote adherence to the recommended price (500 SOS), and create awareness on the recommended price. ,

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Given the presence of free ceramic filters via CBOs, consumers expressed little willingness to pay for the filters. Those who had purchased constituted less than 3% of the sample, suggesting a low consumer uptake of the product despite availability. Retailers also reported having attempted to sell ceramic water filters at the price of 20 USD, but had discontinued due to lack of interest from consumers.

b) Findings on supply side issues related to the social marketing of water treatment solutions in Somaliland

Data on this subsection was drawn from reports on a supply chain analysis of commonly used water treatment products at household level. The data was acquired through interviews from key Ministry of Health Officials, importers and retailers of health products in the study sites.

The results show that there are two major actors or stakeholders in Somaliland’s health product supply chain. The first are development actors (SRCS, Health Poverty Action, etc.) who source, donate, and facilitate the introduction of drugs or products into Somaliland in realization of the need for quality drugs and services in Somaliland. The second major actor are wholesalers that import a variety of health products from other countries including the United Arab Emirates (Dubai), Kenya, China, Djibouti, Ethiopia, Iran, and India into Somaliland and distribute them through the existing supply chain to pharmacies/chemists. Key challenges in the product supply chain include the limited number of distribution points for the top products (chemists/drug shops only) and inadequate supply in rural areas.

With reference to health product distribution, there was clear evidence that leveraging existing mechanisms were feasible options to improve availability of products. These include using Coca-Cola’s distribution system or other traditional commercial networks to move products and engaging private transporters to distribute products.

The findings suggested that mass distribution of ceramic filters would not be feasible, given their fragile nature, difficulty transporting, high cost of purchase, and the poor knowledge of retailers and consumers on their maintenance.

c) Feasibility of socially marketing ceramic filters

Overall, opportunities, challenges and barriers to the scale up of ceramic water filters in Somaliland were reported as follows:

 Opportunities. UNICEF has been providing filters for free to Somaliland residents, and the product has been well received by most consumers. The Somaliland Ministry of Health has proposed to address the misuse and maintenance of filters though education campaign on proper ceramic water filter use. These programs have the potential to increase awareness and uptake of ceramic filters, potentially creating a vi

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future market for the product. Ceramic filters are perceived as safe and providing a better taste to water than other options.

 Challenges. Major challenges with using filters at the consumer level included the time to filter water and the fragility of the filter. Willingness to pay for filters is also low as they are often provided for free; only the higher wealth quintiles had purchased ceramic filters. From a supply side, retailers were less willing to stock them given the low demand and high cost.

 Barriers. The fragile and bulky nature of ceramic water filters makes it difficult to transport them to rural and remote areas. The mobile nature of some populations also makes ceramic filters a poor fit for those who must relocate temporarily for their livestock.

Overall recommendations

The findings of the study suggest that given the general acceptability, ease of transport, willingness to pay for, and uptake of water treatment tablets in all regions and groups surveyed, tablets are the best available solution for sustainable water treatment in urban, peri-urban, and rural communities throughout the country.

With this in mind, our recommendations are as follows:

- Scaling up distribution of water treatment tablets via the growing private sector is critical in ensuring equitable access in all 5 regions of Somaliland. To ensure this, UNICEF and PSI Somaliland should consider supporting the introduction of water treatment tablets into the ever present private sector outside of chemists/drug shops. Shopping behaviour suggests that beneficiaries are already stocking up during multiple day trips at small shops, dukkas, and kiosks on their daily bundle of basic necessities (such as rice, flour, oil, sugar, and treats). Including these distribution points would ensure greater sustainable penetration and access.

- Learning from the success of Coca Cola’s local bottling and distribution company SBI has shown potential for distribution partnerships or replication of their model to access rural areas. The findings make it clear that there is a lot of potential to increase the market penetration (number of outlets across all 5 regions) of those products in demand, and leveraging these outlets to drive forward awareness of the importance of treating water (trade marketing, point of sale materials, etc.). Identifying distributors already operating warehouses in Borao or Berbera (port city) are efficient solutions to ensure a regional hub for rural distribution and to ease transportation costs of goods for regional retailers. vii

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- Data shows that not all consumers are correctly and consistently treating their water, so more BCC work through outreach and education is needed to communicate the importance of water treatment.

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Table of contents Acknowledgement ...... ii Table of contents ...... ix List of Tables ...... xi List of Charts ...... xii List of Figures ...... xiii 1.1 Health and health products in Somaliland supported by PSI ...... 2 1.2 Barriers to providing health services and products in Somaliland ...... 3 1.3 Background on marketing of health products in Somaliland ...... 4 2.1 Study rationale ...... 6 2.2 Overall purpose of the TMA study: ...... 6 2.3 Specific objectives: ...... 6 2.4 Key outcome of this TMA study: ...... 6 3.1 The total market approach method ...... 9 3.2 Use of the TMA model ...... 10 4.1 Research design ...... 13 4.2 Team roles: PSI Somaliland Office & TNS RMS EA ...... 13 4.3 Geographical scope ...... 14 4.4 Mapping the consumer landscape: quantitative ...... 14 4.5 Demand side interviews...... 15 4.5.1 Study Population ...... 15 4.5.2 Household Survey ...... 15 4.5.3 Focus Group Discussions ...... 16 4.6 Supply side interviews ...... 17 4.6.1 Key Informant Interviews ...... 17 4.6.2 The Clusters Visited for the Household Survey...... 18 5.1 Overall outline of results section ...... 22 5.2 Respondent demographics ...... 23 5.2.1 Participant demographics ...... 24

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5.2.2 Respondents Cluster Description ...... 25 5.2.3 Population demographics ...... 25 5.3 Understanding the value chain ...... 28 5.3.1 Description of supply side findings ...... 29 5.3.2 Demand for products ...... 30 5.3.3 Product availability ...... 31 5.3.4 Water treatment products ...... 31 5.3.5 Characteristics of product supply chain ...... 39 5.3.6 Overview of the value chain ...... 42 5.3.7 Opportunities, challenges and barriers to the social marketing of ceramic water filters ...... 43 5.3.8 Ways of reaching consumers efficiently ...... 46 5.3.9 Potential partners ...... 48 6.1 Outline of demand side findings ...... 50 6.2 Segmentation analysis ...... 52 7.1 Summary of findings...... 78 7.2 Recommendations ...... 79

8.0 Annexes

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List of Tables Table 4.1: Distribution of FGDs across regions targeted Table 4.2: Distribution of the Key Informant Interviews Table 4.3: Clusters visited Table 4.4: Areas visited within the clusters Table 5.1: Age distribution of the respondents by age groups Table 5.2: Distribution of respondents by place of residence Table 5.3: Urban age summaries of the respondents Table 5.4: Urban education level summaries Table 5.5: Occupation Table 5.6: Product availability – water treatment products by clusters Table 5.7: Product availability by place of residence Table 5.8: Water treatment products by wealth quintiles Table 5.9: Water treatment methods by place of residence Table 5.10: Water treatment methods by cluster Table 5.11: Water treatment product source by wealth quintiles Table 5.12: Source of Aqua tablets by wealth quintiles Table 5.13: Source of bleach/chlorine by wealth quintiles Table 5.14: Source of water filter by wealth quintiles Table 5.15: Diarrhoea treatment products by wealth quintiles Table 5.16: Diarrhoea treatment products by cluster Table 5.17: Diarrhoea treatment by place of residence Table 6.1: Distance from drinking water source Table 6.2: Common/ preferred water purification methods by cluster Table 6.3: Total Household Income Table 6.4: Source of drinking water by wealth quintiles Table 6.5: Main source of water for households by cluster Table 6.6: Source of drinking water by region Table 6.7: Toilets used by adults Table 6.8: Toilets used by children Table 6.9: What do you usually do/ use to treat your children of diarrhoea? Table 8.1: Time spent to collect water Table 8.2: Costs: How much the households spend on water weekly Table 8.3: Measures to improve access to safe drinking water Table 8.4: Percentage of residents affected by poor access to water Table 8.5: Diarrhoea treatment by household income Table 8.6: Water quality Table 8.7: Water treatment Table 8.8: Water contamination awareness Table 8.9: Type/ kind of toilet facilities Table 8.10: Household expenditure on water by clusters

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Table 8.11: Common/ preferred household water purification methods by household income

List of Charts Chart 5.1: Distribution of respondents by age groups Chart 5.2: Distribution of respondents by place of residence Chart 5.3: Occupation by clusters Chart 6.1: Access to clean drinking water Chart 6.2: Type/ kind of toilet facilities Chart 6.3: Diarrhea treatment methods by cluster Chart 6.4: What do you usually do/use to treat your children of diarrhoea? Chart 6.5: Household expenditure on water by cluster Chart 6.6: Pricing for Biyosifeeye Chart 6.7: Pricing for Shuban-DaweeyeChart 8.1: Proportion satisfied with the cleanliness/safety of the source Chart 8.1: Proportion satisfied with the cleanliness/safety of the source of water Chart 8.2: Treatment of diarrhoea in young children

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List of Figures Fig 2.1: Shuban Daweeye Fig 2.2: BiyoSifeeye Fig 2.3: Key outcome of TMA Study Fig 3.1: The Total Market Approach Fig 3.2: The TNS Growth Map Fig 4.1: Supply side methodology Fig 4.2: Supply-side method: information and analytical areas to be explored in the supply-side study element Fig 5.1: Overview of health products supply chain Fig 5.2: Actors in the supply chain Fig 5.3: Description of the PSI distribution channel Fig 5.4: Challenges in the supply chain Fig 5.5: Overview of the Value Chain Fig 5.7: Strengths, weaknesses, drivers and barriers in the supply chain Fig 5.8: Mechanisms of reaching consumers efficiently (1) Fig 5.9: Mechanisms of reaching consumers efficiently Fig 6.1: The TNS Behaviour Web © TNS Fig 6.2: Poorest quintile Fig 6.3: Poorer quintile Fig 6.4: Middle quintile Fig 6.5: Richer quintile Fig 6.6: Richest quintile Fig 6.7: Knowledge and description of clean water Fig 6.8: Methods used to make sure water is safe for drinking Fig 6.9: Initiative to make water safe Fig 6.10: Perspectives on diarrhoea Fig 6.11: Acceptability of water treatment products (BiyoSifeeye) Fig 6.12: Acceptability of diarrhoea treatment products

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1.0 Background and introduction

1.1 Health and health products in Somaliland supported by PSI PSI Somaliland was founded in 2007 to socially market safe water tablets and long-lasting insecticide treated mosquito nets to local communities. Since then, PSI has expanded their program to cover maternal and child health (MCH) to improve the health status of Somali people especially women, children and the most vulnerable. PSI works in partnership with the private and public sectors and with other development partners, providing life-saving products, clinical services and behavioral change communication interventions that empower Somaliland’s most vulnerable populations to lead healthier lives.

PSI has introduced a number of products to improve the lives of Somaliland citizens. The first two products were introduced in 2007 to address malaria related illnesses. One was the Badbaado insecticide-treated mosquito nets through the private sector by using the existing wholesaler-retailer supply chain. The second was Gaashaanka Kaneecada mosquito nets that were distributed through the public sector to 31 public health facilities, mainly maternal and child health centers. These nets are highly subsidized to ensure that vulnerable persons such as pregnant women and children under 5 could access them.

Access to birth spacing products and counseling services is still low. The contraceptive rate is estimated at 4.6%, while the unmet need for contraception is 29% and the total fertility rate is 5.9 (UNICEF, 2006). PSI currently provides birth spacing products such as oral contraceptives in 2010 and injectables in 2011. Uptake of these products is supported by interpersonal communication sessions to women of reproductive age in order to create demand and increase utilization of modern methods.

In Somaliland, approximately 80% of births are delivered at home, one of the leading causes of maternal mortality in Somaliland (UNICEF, 2006). PSI introduced Misoprostol for prevention and treatment of post-partum hemorrhage (PPH), which also overcame the challenge of lack of proper cool chain facilities in the poorly resourced health facilities. The introduction of Misoprostol was preceded by a country-specific, branded communication strategy.

Diarrhoea is one of the leading causes of death among infants and young Somali children caused by lack of access to safe water and poor food and domestic hygiene. The prevalence of diarrhoea among children 0-23 months is estimated at 21.6% (National anthropometric and micronutrient survey, 2009). PSI provides two products to prevent or manage diarrhoea. The first product introduced in 2008 is BiyoSifeeye, a simple and cost-effective water purification tablet to ensure access to safe drinking water. Second is the diarrhoea treatment kit (DTK) comprising of oral rehydration salts (ORS) and zinc supplementation tablets. These again are supported by education of caregivers and health providers on prevention and treatment of diarrhoea. Micro-nutrient Powder (MNP) and Lipid-Based Nutrition Supplement (LNS) for malnourished children have also been introduced into the market.

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For the treatment of pneumonia and also to address cases of malnutrition among under-5 years old children, PSI plans to introduce a pre-packaged pneumonia treatment (PPT) for children under 5 and micronutrient powder (MNP) to improve iron status and reduce anemia among infants 6-23 months old by the end of 2013.

1.2 Barriers to providing health services and products in Somaliland PSI in Somaliland operates in a challenging health context. As indicated in the previous slide, Somaliland's health indicators are among the worst in the world, the main problems being poor under-5 mortality (117 to 225 per 1,000 live births), maternal mortality (between 1,044 and 1,400 per 1,000,000 live births) and newborn mortality (61 per 1,000 infants dying within the first month of life). A fragile post-conflict health system, inadequate investment in health and inadequate qualified health personnel are contributing to these poor health indicators. Source: The Tropical Health and Education Trust (THET; Somaliland health sector strategy (2013-2016)

Other challenges such as high malnutrition levels across Somalia from famine, insecurity, lack of government access and limited coverage of health care services across most of the regions of Somalia, coupled with the absence of essential health, nutrition and water, sanitation and hygiene (WASH) facilities, is reported to lead to high levels of ill-health and frequent disease outbreaks. Somaliland health sector strategy (2013-2016)

Current confidence in, and access to, the health system is very low. For example, there is a severe shortage of professional health workers of all disciplines - health worker to patient ratio is 1:30,000 and the equivalent ratio for nurses and midwives 1:27,000. Many doctors are also known to run private clinics and serve for a few hours in government medical work, so these ratios might be misleading. Coverage of public health services in rural areas, and for nomadic populations, is very limited with less than 15% of the rural population having any access to any health provider. Immunization rates are low where a skilled provider attends fewer than 20% of births. Somaliland health sector strategy (2013-2016)

Public health facilities in Somaliland lack staff, are dilapidated and ill equipped to meaningfully discharge their functions. However, increase of non-state medical actors has brought about significant progress on the policy and strategy front. The enactment of the 2013-2016 National Health Policy provides support for a more cohesive health system. This Policy identifies the following as major challenges to the Health System in Somaliland: •Health providers describe difficult and demoralizing working conditions; •Huge staffing gaps of frontline health facilities make reliable, quality services virtually unattainable. Some clinics are empty while others are overcrowded; •MoH and Agencies are having difficulty in managing the rapid decentralization of health services and donor-driven programs;

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•Shortages of medical equipment, consumable supplies and essential drugs undermine facility functioning, damage reputations, inflate out-of-pocket costs to patients and fuel a spiral of distrust and alienation; •‘Exit’ from the public sector into an unregulated private sector; •High cost for health services, formal and informal, that is disproportionately borne by the poor; and •Users routinely complain of abusive and humiliating treatment by health providers

1.3 Background on marketing of health products in Somaliland Encouraging healthy behaviors and empowering people to make informed health decisions is at the center of PSI’s Behavior Change Communication (BCC) work in Somaliland. This is done through commercial marketing techniques to position products and services with messages that promote knowledge and help reinforce healthy behaviors.

Branded and non-branded BCC campaigns are also utilized to encourage healthy behaviors and product use. PSI communicates through a variety of channels, such as mass media (national and private TV and radio channels), peer education, community-theatre, interpersonal communication, information, education and communication (IEC) materials and special events. Source: PSI

In Somaliland, according to the Center for Health Market Innovations, the private sector enjoys relative popularity. There are 859 private health practitioners (80 private clinics and 779 private pharmacies) in Somaliland. Considering that there are 225 public health facilities (7 hospitals, 68 maternal and child health centers and 150 health posts), it is clear that the private sector currently offers a more extensive health network than the public sector (UNICEF, 2008).

It is against this background that PSI designed a social franchise network that heavily relies on private sector participation through an elaborate pharmaceutical distribution chain, called BULSHO-KAAB (i.e., community helper). With this strategy, PSI has managed to harness the potential of 153 private pharmacies on the one hand and contribute to the provision of affordable high-quality life-saving health services and products on the other to target the low-income communities in five regions of Somaliland.

There is a high number of private pharmacies in urban areas and the few private rural pharmacies suffer low level of qualified personnel and sell a lower proportion of human drugs (30%) compared to 59% of veterinary medicine (UNICEF, 2008).

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2.0 Study objectives

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2.1 Study rationale PSI Somaliland used a Total Market Approach to improve the health of women and children in Somaliland by strengthening access to and use of health products and services.

Having achieved successes in urban markets, PSI Somaliland aims to have deeper penetration in rural Somaliland with diarrhoeal and safe household water treatment.

Fig 2.1: Shuban.Daweeye 2.2 Overall purpose of the TMA study: • To improve understanding of the local market landscape in Somaliland and establish potential opportunities for PSI to increase accessibility and availability of PSI’s products and services with regards to diarrhoeal treatment and safe water treatment in rural areas. • Develop a set of recommendations for PSI and partners to identify strategic entry-points for PSI products

As a result of the research PSI will make program decisions that, resource permitting 1) increase use and 2) improve ‘sector sourcing’.

Fig 2.2: BiyoSifeeye 2.3 Specific objectives: • Understand the entire urban and rural area value/supply chain (manufacturing/ importation, distribution and financing) and key players, including their incentives, drivers, barriers, challenges and chokepoints - diarrhoeal treatment and safe water treatment. • With respect to diarrhoea treatment and safe water treatment, develop a segmented understanding of customers’ contexts, needs, buying behaviour, and barriers to adoption of desired behaviour

2.4 Key outcome of this TMA study: • Identify potential market-based opportunities, either through key stakeholder partnerships or; • Assimilation of lessons learned from proven market based models, to better respond to the rural areas’ needs and generate more value for money

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High Level Project Objective:

“To improve the health of women and children in Somaliland by strengthening access to and use of health products and services in urban and rural areas.”

Business questions / issues that need to be addressed

Identify most effective way of Identify how to effectively motivate reaching consumers in rural areas use and purchase among consumers

Information areas

• Characterise the entire • Segment the market using the value/supply chains in private and TMA approach and understand public sectors – for existing knowledge, attitudes and products behavior in the treatment areas • Characterize any effective supply of interest to PSI chains in the market, even outside • Identify key barriers to overcome in the area of behavior change the PSI product areas • Including support markets and drivers, including product pricing.

manufacturers (in HWT) • Identify and characterise key players and steps in the process • Understand interrelationships • Mechanics of products movements • Explore successful models or ways of reaching consumers efficiently and identify key success factors • Incentives at each level (profit / other) so prices and costs • Cost components • Drivers and barriers • Pinpoint possible strategic partners

Fig 2.3: Key outcome of TMA Study

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3.0 The total market approach methodology

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3.1 The total market approach method

The TMA approach is used in our analysis to ensure a comprehensive coverage of the market

Fig 3.1: The Total Market Approach Model

The TMA model segments the vulnerable population in terms of consumption patterns (access and psycho-social determinants of consumption, including willingness to pay), equity-based measures, and source of supply preferences. The purpose is to increase overall health system performance to realize greater effectiveness, equity and efficiency within the target population. Looking at each Somaliland market in this way will help us to understand the best market access model for PSI for each health category area.

1. Vulnerability This defines the existing and likely future market in terms of a vulnerability to undesired health or quality of life outcomes. 9

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2. Consumption This defines relevance of health service/product to the target vulnerable population.

3. Access and Willingness to Pay This brings out differences between consumers and non-consumers, in other words, determinants of consumption.

4. Equity Based Measures The main issue here is consumer socio-economic status indicators used to segment markets in terms of ability to pay.

5. Source of Supply Preferences This basis identifies whether current offerings by source of supply compete in ways that undermine efficiency, and where there may be opportunities for new product and service offerings that will shift consumers from subsidized sources of supply to commercial ones.

3.2 Use of the TMA model The TMA model forms a framework that can be used to assist PSI Somaliland improve its product availability and accessibility in Somaliland through a segmented approach. The very poor will require heavily subsidized or free product provision – a majority of who can only access healthcare from understaffed and ill-equipped public hospitals. The slightly better off segment may be able to purchase some products from private clinics, pharmacies and drug providers. Higher commercial-rated products are possible for the minority of the affluent and more economically stable segments of the population. This latter group is anticipated to be extremely small in Somaliland.

The model will enable PSI Somaliland to assess the characteristics of existing and likely future markets, and to define their comparative organizational advantage in terms of competence and value for money in delivering a range of products or services to rural and urban market segments, including the poorest, in Somaliland.

As levels of income increases within vulnerable urban and rural populations, there is need to increase and intensify product consumption and sustainability efficiency respectively so as to achieve higher product equity in terms of the proportion of current product consumption/source of supply to the total vulnerable population.

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3.2.1 Application of the TMA model

New target groups and markets

New products & services

services

Current products & services

Fig 3.2: The TNS Growth Map

More frequent / consistent use among current users especially in urban areas

In order to achieve your goal, PSI Somaliland seeks growth in up-take of beneficial products and services and positive behaviour change.

The TNS growth map (opposite) will guide our approach and help us to crystalize for each individual product / service category, how our insights will directly lead to growth in uptake and behaviour change.

The ultimate goal is that each at-risk SES quintile will be using products and services at desired rates and that each SES quintile will be sourcing from the appropriate sector. At the consumer end, this will be achieved by:-  Increasing the overall penetration and regularity of use or the beneficial behaviour among vulnerable people, through getting new households to use products or change their behaviour, either using existing products or services or launching products or services. A number of factors will be explored relating to drivers of behaviour change and improved market presentation of the products / services.

From the supply side, this will be achieved by  Identifying the best operational model to increase access to products and services at an affordable price. The research will aim ultimately to improve health status of the vulnerable population through improved diarrhoea treatment, and safe water treatment.

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4.0 Methods

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4.1 Research design

Mapping of value and supply chains

Supply side Key informant interviews with players in existing private sector formal and informal organizations study distributing these or related products (models outside the category areas were explored). Interviews with producers through distribution, wholesale if any, transporters, and various types of retailers for the private sector, and front-line and referral level health providers in the public sector were done. Stakeholder and Value chain mapping was done to identify points of low incentive or problem areas limiting supply.

Consumer landscape - Drivers and barriers to purchase and use Demand side study Interviews with frontline health providers (to provide information on attributes of the population that they serve), informal focus groups with relevant target audiences and a small-scale survey among different socio-economic groups / wealth quintiles will provide the demand side information were done.

4.2 Team roles: PSI Somaliland Office & TNS RMS EA • PSI carried out interviews in Somaliland through locally hired research assistants, jointly managed by PSI Somaliland and TNS RMS EA • TNS EA provided technical guidance and overall supervision to research assistants, and was responsible for tool development, data analysis and reporting.

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4.3 Geographical scope

HARGEISA REGION WESTERN REGION EASTERN REGION

Hargeisa Borama Burao Approx. Approx. Approx. Pop 1.3M Pop 39,100 Pop 0.4M

Rural Centers

Team Team Team

determined determined determined rural area rural area rural area within within 50Km within 50Km 50Km radius of radius of radius of Borama Burao Hargeisa

• Three additional interview sites (Wajaale, Laasada’awo and Sheikh ) were visited to enhance the rural and peri-urban population within the sample. • Selection of interview regions was based on budgetary and security considerations and upon MOH recommendation.

4.4 Mapping the consumer landscape: quantitative

A broad random sample of households was drawn for quantitative survey to help identify the key segments present in the population by wealth. Selection of sampling points was done in close consultation with PSI Somaliland.

In order to ensure that everyone in the sampled urban and peri-urban towns and rural centres was given an equal chance to be selected for interview, specific area-based sampling methodologies were employed based on the following elements: • Area (primary sampling unit - PSU) • Houses/homes/abodes within the area (secondary sampling unit)

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• Person to be interviewed within the home (ultimate sampling unit) will be a mother with a child under the age of 5

Because of the lack of statistics on specific areas within Somaliland, we used the following approaches: • Prior to commencement of interviews in each region, the town / region was sketched out and divided into cells or areas. Local boundaries such as Local Councils where present were used. A note of the apparent density of households was taken. • Sampling points comprised of 10 interviews at 10 households. • Higher density areas received more sampling points than low density areas • Households were randomly selected using the random route method from a randomly selected starting point in the selected vicinity.

On completion of a successful interview, households were skipped based on the nature of the environment where the interviews were taking place. For instance, enumerators sought to interview a mother with a child under the age of 5. Where not available at the time of the interview, the enumerator undertook to call-back to that household to interview her. If not be available on the day of interviewing, then that mother was substituted with another woman from the same sampling point. It was envisaged that 100% of areas drawn out will be used in the sample. TNS conducted spot checks accompanied by the field coordinator and supervisor. Telephone back-checks were conducted from Nairobi to follow up on anomalies or interesting issues arising from the interview data.

4.5 Demand side interviews

4.5.1 Study Population In order to cover rural, urban, and nomadic population profiles, qualitative and quantitative data was collected from five key cities/towns and the areas around them. The urban population in Hargeisa was sampled followed by Borama, Laasada’awo, Sheikh, and Burao. At each site, both qualitative and quantitative data was collected. 4.5.2 Household Survey The survey focused on having a better understanding of diarrhoea treatment and safe household water treatment at household level. Key informants within the household for these sectors was the mother, on the demand side study. The quantitative survey comprised a sample survey of 655 interviews, an interview length of 45 minutes using mCAPI data collection platform. An additional 198 rural booster interviews were conducted. The sample is representative of the Somaliland population of over 3.5 million people, within a margin of error of 3.4 and a confidence level of 95%.

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4.5.3 Focus Group Discussions Focus group discussions (FGD) were held with members of the community who would be the potential buyers of the oral rehydration salts (Shuban-Daweyee) and the water filtration tablets (BiyoSifeeye). To comply with local customs and ensure participant comfort all FGDs were gender specific and carried out in Somali.

Two facilitators were present and all FGDs were digitally recorded. Oral consent was obtained from all participants before the FGD commenced. An informal interview was held in Wajaale (a rural area with rivers and other water sources) with community health workers (CHW) trained by the WASH program.

Table 4.1: Distribution of FGDs across regions targeted: Town/Location Male Female (18-35 Female (36+ (18+ years) years) years)

Hargeisa 1 2 1 Borama 1 1 Wajaale 1 (CHW) Laasada’awo 1 1 Sheikh 1 1 Burao 1 1

Fig 4.1: Supply side methodology

Identify and interview Expert other key interview informants

Refine Map Map

Identify other stakeholders

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Key informant interviews were used to help map the public and private sector value chains in an iterative process Mapping of the value chain began with an “expert view” or a key informant in the chain. Then, drawing on the information provided, work through the chain interviewing relevant actors.

In rural areas, private sector interviews with producers / suppliers, dealers and retailers in water treatment, diarrhoeal treatment, childhood nutrition, non-severe paediatric pneumonia treatments, safe household water treatment, and safe motherhood (birth spacing) were done.

In urban areas, private sector interviews with actors as above in the water treatment chain were conducted. Key respondents included producers (especially in water treatment), importers, transporters, wholesalers / wholesale markets, Distributors, Supermarkets, small shops and informal kiosks, hawkers and market stalls, pharmacies , dispensers and drug stores.

Public sector health actors were interviewed at the local / frontline level in rural areas and in referral hospitals. Their knowledge on private sector supply was meant to enable an understanding of the positive and negative issues in the public sector. The key informant interview will focus on pharmacists, doctors, clinicians, nurses, nutritionists, public health personnel, environmentalists, community health workers, medical suppliers and retailers.

4.6 Supply side interviews

4.6.1 Key Informant Interviews Key informant interviews were held with various stakeholders at each location.

These included pharmacists, manufacturers, wholesalers, retailers, shopkeepers, and public health students.

Interviews were carried out in English or Somali and were digitally recorded unless the interviewee declined. Oral consent was obtained from all interviewees before the interview commenced.

Table 4.2: Distribution of the Key Informant Interviews 17

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Town/ Health Retailers Whole Total Location experts sellers Hargeisa 3 2 2 8

Borama 1 2 3

Laasada’awo 1 2 3

Sheikh 2 2 4

Burao 2 3 5

4.6.2 The Clusters Visited for the Household Survey The quantitative household survey was held in five key clusters and specific areas within the clusters as shown below: Table 4.3 Clusters visited

Interview Cluster Frequency Percent

Hargeisa 442 52

Borama 160 19

Laasada’awo 60 7

Burao 135 16

Sheikh 56 6

Total 853 100

Table 4.4 Areas visited within the clusters Cluster Areas Hargeisa Ahmed Dhagax; Koodbuur; Gacan Libax; Mohmoud Haibe Borama Sh. Cismaan; Sh. Ali Jawhar; Sh. Makaawi; Sh. Abdisamad Laasada’awo Laasada’wo North; Laasada’wo West Burao Mohamed Ali; Faarax Omar; Aden Sulieman; Koosaar; Sh. Bashiir Sheikh Lixle; Koosaar; Sh. Bashiir

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Fig 4.2: Supply-side method: information and analytical areas to be explored in the supply-side study element

Private Sector Public Sector

Information area Understand the entire urban and Understand the processes and rural area value/supply chain – challenges in public health sector key players, relationships, steps in driven supply of products and process, barriers and incentives, services in the PSI product category choke-points. areas Focus will be on (1) distribution of health products (in PSI categories or similar categories) (2) other successful private sector supply chains

Information area For HWT include manufacturing opportunities , challenges and barriers

Analytical area Identify the best model for Identify intervention and partnership reaching rural vulnerable opportunities audiences in each quintile Best product, price, communication approach Partners to work with / through Identify financing opportunities

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Qualitative Quantitative research research

Analysis Analysis

Integration with supply-side study to make Recommendations

Integration of the data began at analysis stage where qualitative data was analyzed following themes (issues of interest) explored through the quantitative aspect of the study. In this sense, qualitative data not only explored similar issues to the quantitative aspect, but also supplemented this data by adding perspectives that quantitative data cannot show.

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5.0 Results

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5.1 Overall outline of results section a) Findings on household level water treatment solutions in Somaliland

Respondent demographics: • Household demographics • Overview of wealth quintiles (segmentations)

Demand side findings: • Water treatment knowledge and practices • Diarrhoea treatment knowledge and practices

b) Findings on supply side issues related to the social marketing of water treatment solutions in Somaliland

Understanding the value chain: • Product availability • Perceptions of product availability • Product supply chain for health products in Somaliland

Discussion: • Key learnings and recommendations

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5.2 Respondent demographics

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5.2.1 Participant demographics

Table 5.1: Age distribution of the respondents by age groups Age of respondent n=853

Frequency Percent Valid Percent Cumulative Percent Age Groups 16 - 30 years 324 38.0 38.0 38.0 31- 40 years 419 49.1 49.1 87.1 41+ years 107 12.5 12.5 99.6 Don't know 3 0.4 0.4 100.0 Total 853 100.0 100.0

Chart 5.1: Distribution of respondents by age groups

Respondent age groups

Don't know 0.4

41+ years 12.5 percent 31- 40 years 49.1

16 - 30 years 38.0

0.0 10.0 20.0 30.0 40.0 50.0 60.0

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5.2.2 Respondents Cluster Description Table 5.2: Distribution of respondents by place of residence

Frequency Percent Valid Percent Urban 539 63.2 63.2 Rural 258 30.2 30.2 Peri urban 56 6.6 6.6 Total 853 100.0 100.0

Chart 5.2 Distribution of respondents by place of residence Percent Cluster Description

Total 100

Peri urban 6.6

Percent Rural 30.2

Urban 63.2

0 20 40 60 80 100 120

5.2.3 Population demographics

Table 5.3: Urban Age summaries of the respondents

Age summaries by clusters Age Std. (n=853) Observation Mean Mean Deviation Minimum Age Max Age Urban 539 33.3154 8.023013 16 99 Rural 258 34.31008 8.401221 16 99 Peri urban 56 31.64286 6.465091 21 49

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Table 5.4: Urban Education level summaries What is the highest level of education?

Cluster description never (n = 853) attended primary secondary tertiary university refused Total Urban 354 142 31 4 3 5 539 Rural 216 17 2 23 0 0 258 Peri Urban 41 8 6 0 0 1 56

Table 5.5: Occupation What is your occupation, if any?

Employee Laborer on Retired Retired Cluster Farming Civil in private Runs own farm (not own Laborer off-with without description (own farm) servant enterprise business farm) farm pension pension Refused* Total rural 51 27 4 19 2 4 1 5 145 258 urban 4 98 27 83 7 0 0 1 319 539 peri urban 0 9 3 4 0 0 0 0 40 56

*We should note here that this reponse is from household members (female) 80% of whom reported that they did not have jobs. A small proportion that could have jobs would not inform us for fear of being castigated by their male partners.

Chart 5.3: Occupation by clusters 600 539 Farming (own farm)

500 Civil servant

400 Employee in private 319 enterprise 300 258 Runs own business

200 Laborer on farm (not own 145 farm) 98 100 Laborer off-farm 51 56 27 27 40 7 9 4 2 4 0 3 0 Retired with pension 0 rural urban peri urban

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• The chart above shows an overview of occupation of the sample that participated in this study by area covered. • Results indicate that majority of the sample were reluctant to state their employment status or occupation. This is attributed to female household members many of whom were not employed and the few who had casual jobs did not want to state this for fear of the reaction of their male partners. • However, those that replied to this survey question stated that they were formally employed – in public and private sectors (i.e. in urban settings), were involved in farming (i.e. in rural Somaliland) and in some cases, some stated they were personal business owners (i.e. in both urban and rural settings).

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5.3 Understanding the value chain

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5.3.1 Description of supply side findings

 Demand for products

 Characteristics of product supply chain Describe current supply chains in the market Describe support markets and manufacturers

 Strengths, weaknesses, drivers and barriers in the supply chain

 Key players and steps in the supply chain  Interrelationships between actors in the supply chain

 Models of reaching consumers

 Product pricing

 Drivers and barriers in the supply chain

 Potential strategic partners

 Key learning points

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5.3.2 Demand for products

Table 5.6: Product availability - Water treatment products by clusters Treatment products used to make water safer to drink Hargeisa Borama Laasada’wo Burao Sheikh p Values BiyoSifeeye 17 44 (n=299) 162 (36.65%) 55 (34.38%) (28.33%) (32.59%) 21(37.5%) Pr = 0.694 10 27 Boiling (n=220) 122 (27.6%) 45 (28.13%) (16.67%) (20%) 16(28.57%) Pr = 0.170 Bleach/chlorine/ta blet (n=28) 8 (1.81%) 4 (2.5%) 5(8.33%) 10(7.41%) 1(1.79%) Pr = 0.003 Strain through a cloth (n=28) 20 (4.52%) 12 (7.5%) 0(0%) 12(8.89%) 10(17.86%) Pr = 0.000 water filter (n=33) 23(5.2%) 5 (3.13%) 3(5%) 1(0.74%) 1(1.79%) Pr = 0.149

Powder (n=5) 5(1.13%) 0(0%) 0(0%) 0(0%) 0(0%) Pr = 0.322

Table 5.7: Product availability by place of residence

Urban Rural Peri-Urban p Values 191 BiyoSifeeye (n=299) (35.44%) 87 (33.72%) 21 (37.5%) Pr = 0.826 127 16 Boiling (n=220) (23.56%) 77 (29.84%) (28.57%) Pr = 0.147 Bleach/chlorine/tablet (n=28) 19 (3.53%) 8(3.1%) 1 (1.79%) Pr = 0.770 Strain through a cloth (n=54) 37 (6.86%) 7(2.71%) 1 (17.86%) Pr = 0.000

Water filter (n=33) 10 (1.86%) 22(8.53%) 1 (1.79%) Pr = 0.000

Powder (n=5) 1 (0.19%) 4(1.55%) 0 (0%) Pr = 0.000

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5.3.3 Product availability

Quantitative perspectives Quantitative data from consumers showed that there existed a number of products in the market that could be used to make water safe. In order of use, BiyoSifeeye was reported to be highly used across all 5 regions visited (48.8%), followed by boiling (35.9%), water filter (5.3%), bleach/chlorine (4.6%), straining through a cloth (4.6%) and powders (0.8%).

Variations in use were also reported across the study regions for example with powder being reported to be used only in Hargeisa. BiyoSifeeye and Boiling methods were important water treatment methods being highly used in all regions when compared with other methods. Similar results were seen when their use was compared across urban, rural and peri-urban areas.

Qualitative perspectives Qualitative data complemented quantitative findings for both water and diarrhoea treatment products.

5.3.4 Water treatment products Key informants reported that water treatment products available in the market were Ceramic filters and tablets such as Falgen, Shuban-Daweeye, BiyoSifeeye, Zinc oxide, pharsorobin, Aqua and Watermaker tablets.

Specifically, Key informants stated that ceramic filters and Aqua tabs were thought to be safe by consumers as the Ministry of Health together with PSI and other NGO partners have been promoting their use through awareness raising programs and distributing them to MCHs. This is supported by reported widespread trust of products endorsed by international NGOs in Somaliland. The following quote highlights this: "There are BiyoSifeeye and other things and people are fully aware of it and use it without our advice because they know it. People have enough information on it and Ministry of Health, Water etc have all give awareness on getting clean water. And there are other NGO’s who provide such products." KII, Director of Water Agency, Burao

Diarrhoea treatment products Products available in the market for the treatment of diarrhoea include ORS, antibiotics, zinc supplements, and Getsai (sodium chloride stones). However, Key informants reported that Shuban-Daweeye was reported to be frequently used in the prevention and treatment of diarrhoea. Awareness raising campaigns have been undertaken to increase knowledge and use of these products especially during the rainy seasons when there are many disease outbreaks. Drugs were mainly sourced from pharmacists because they provided information 31

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on how to use the drugs and gave information on other health matters that are important to consumers. This is shown by the following quote: "During the raining time and change of the seasons always comes out diarrhoea and we use BiyoSifeye to prevent and Shuban-Daweeye to treat." KII Retailer, Laasada’wo

Table 5.8: Water treatment products by wealth quintiles Water Treatment by 5 Wealth Quintiles

poorest poorer middle richer richest p Values 0.008 Using BiyoSifeeye (n=299) 46 (27.06%) 61 (35.67%) 62 (36.47%) 53 (30.99%) 77 (45.03%) 0.000 Boiling (n=284) 72 (42.35%) 43 (25.15%) 46 (27.06%) 50 (29.24%) 73 (42.69%) Bleach/chlorine/tablet 0.000 (n=47) 2 (1.18%) 3 (1.75%) 6 (3.53%) 6 (3.51%) 30 (17.54%) Strain through a cloth 0.002 (n=54) 6 (3.53%) 5 (2.92%) 8 (4.71%) 14 (8.19%) 21 (12.28%) 0.296 Water filter (n=33) 8 (4.71%) 9 (5.26%) 6 (3.53%) 2 (1.17%) 8 (4.68%)

• We used quantitative data on wealth to create five wealth quintiles. • Quantitative results indicated that BiyoSifeeye (water treatment tablet method) was fairly popular among all wealth quintiles, with boiling used as the next preferred means to clean/ treat water. • Results suggest that alternative methods for treating water, such as use of chlorine tablets, straining through cloths and water filters were less used across the wealth quintiles. • Variation in choice of method used was seen with the richest quintile adopting a wide range of methods to treat water compared with the poorer and poorest wealth quintiles. This perhaps is attributed to more knowledge on the various methods to clean water despite being among the wealthier quintile

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Table 5.9: Water treatment method by place of residence Urban Rural Peri-Urban p Values BiyoSifeeye (n=299) 191 (35.44%) 87 (33.72%) 21 (37.5%) Pr = 0.826 Boiling (n=220) 127 (23.56%) 77 (29.84%) 16 (28.57%) Pr = 0.147 Bleach/chlorine/tablet (n=28) 19 (3.53%) 8(3.1%) 1 (1.79%) Pr = 0.770 Strain through a cloth (n=54) 37 (6.86%) 7(2.71%) 1 (17.86%) Pr = 0.000 Water filter (n=33) 10 (1.86%) 22(8.53%) 1 (1.79%) Pr = 0.000 Powder (n=5) 1 (0.19%) 4(1.55%) 0 (0%) Pr = 0.000

Table 5.10: Water treatment method by cluster Treatment products used to make water safer to drink Hargeisa Borama Laasada’wo Burao Sheikh p Values 162 17 44 21 BiyoSifeeye (n=299) (36.65%) 55 (34.38%) (28.33%) (32.59%) (37.5%) Pr = 0.694 10 16 Boiling (n=220) 122 (27.6%) 45 (28.13%) (16.67%) 27(20%) (28.57%) Pr = 0.170 Bleach/chlorine/tablet (n=28) 8 (1.81%) 4 (2.5%) 5(8.33%) 10(7.41%) 1(1.79%) Pr = 0.003 Strain through a cloth 10 (n=28) 20 (4.52%) 12 (7.5%) 0(0%) 12(8.89%) (17.86%) Pr = 0.000 Water filter (n=33) 23(5.2%) 5 (3.13%) 3(5%) 1(0.74%) 1(1.79%) Pr = 0.149

Powder (n=5) 5(1.13%) 0(0%) 0(0%) 0(0%) 0(0%) Pr = 0.322

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Table 5.11: Water treatment products source by wealth quintiles BiyoSifeeye (n =349) poorest poorer middle richer richest p Value

Kiosk 3 (4.84%) 1 (1.35%) 3 (4.55%) 1 (1.79%) 0 (0%) Pr = 0.216 Pr = 0.335 Retail shop 2 (3.23 %) 0 (0%) 2 (3.03%) 0 (0%) 1 (1.1%) Pr = 0.631 Supermarket 0 (0%) 0 (0%) 1 (1.52%) 0 (05) 1 (1.1%) Pr= 0.645 Open air market 0 (0%) 1 (1.35%) 2 (3.03%) 2 (3.57%) 2 (2.2%) Pr = 0.002 Chemist/drug shop 48 (77.42%) 56 (75.68%) 57 (86.36%) 50 (89.29%) 87 (65.6%) Pr = 0.104 NGO 4 (6.45%) 5 (6.76%) 2 (3.03%) 0 (0%) 1 (1.1%) Pr = 0.369 CBO 1 (1.61%) 4 (5.41%) 5 (7.58%) 2 (3.57%) 2 (2.2%)

Table 5.12: Source of Aqua Tablets by wealth quintiles Purchase Aqua Tablets poorest poorer middle richer richest p Value Kiosk (n=1) 0 0 0 1 0 Pr = 0.339 % 0% 0% 0% 33.33% 0% Chemist/drug shop (n=22) 2 2 6 2 10 Pr = 0.184 % 100% 66.67% 100% 66.67% 100%

• The main source of water treatment products across all wealth quintiles was chemist or drug shops. • This suggests that chemists are an important consideration in the distribution of health products in Somaliland.

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Table 5.13: Source of bleach/chlorine by wealth quintiles

Bleach/chlorine n=30 poorest poorer middle richer richest p-value Kiosk 0 0 1 1 0 Pr = 0.192 % 0 0 16.67 16.67 0 Supermarket 0 0 0 0 1 Pr = 0.965 % 0 0 0 0 3.33 Open air market 0 0 0 0 1 0.965 % 0 0 0 0 3.33 Chemist/drug shop 2 3 6 4 29 Pr = 0.075 % 100 100 100 66.67 96.67 NGO 0 0 0 0 1 Pr = 0.965 % 0 0 0 0 3.33 CBO 0 0 0 0 1 % 0 0 0 0 3.33

Table 5.14: Source of water filter by wealth quintiles Water filter (ceramic/sand/composite/etc.) n=46 Kiosk 0 0 0 1 0 Pr = 0.003 % 0 0 0 12.5 0 Retail shop 1 0 0 0 0 % 14.29 0 0 0 0 Pr = 0.757 Supermarket 0 0 0 0 4 % 0 0 0 0 40 Pr = 0.451 Chemist/drug shop 4 6 6 4 5 % 57.14 46.15 75 50 50 Pr = 0.451 CBO 1 1 2 3 0 % 14.29 7.69 25 37.5 0 Pr = 0.196 Total 7 13 8 8 10 • Similar to the previous tables on sources of BiyoSifeeye and Aqua tablets, chemists or drug shops were reported to be the main source of bleach/chlorine for treating water. • However, slight variations were seen regarding sources of water filters where though chemists/drug shops were the main source (57%), other sources were visited (CBO – 14.3%; retail stores – 14.3%)

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Table 5.15: Diarrhoea treatment products by wealth quintiles

Diarrhoea treatment by wealth quintiles n=853 poorest poorer middle richer richest P Value Oralite or ORS 71 66 72 71 92 Pr = 0.047 41.76 38.6 42.35 41.52 53.8 Zinc 14 20 23 32 56 Pr = 0.000 8.24 11.7 13.53 18.71 32.75 Shuban-Daweeye 47 69 81 75 108 Pr = 0.000 27.65 40.35 47.65 43.86 63.16 home-made sugar-salt solution 5 5 6 16 23 Pr = 0.000 2.94 2.92 3.53 9.36 13.45

Another home-made liquid such as porridge, soup, yoghurt, coconut water, fresh fruit juice, tea, milk, or rice water 11 1 3 4 5 Pr = 0.016 6.47 0.58 1.76 2.34 2.92 Pill or syrup 10 8 17 17 20 Pr = 0.093 5.88 4.68 10 9.94 11.7

Home therapy/herbal medicine 2 3 7 8 10 Pr = 0.095 1.18 1.75 4.12 4.68 5.85 Vitamin A Supplements 2 6 4 10 5 Pr = 0.154 1.18 3.51 2.35 5.85 2.92

• ORS was reported to be mainly used to treat diarrhoea across the wealth quintiles followed by Shuban-Daweeye and zinc. • Home remedies such as home-made sugar-salt solutions, or use of herbal medicine were reported but by much lower number of respondents.

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Table 5.16: Diarrhoea Treatment products by cluster Diarrhoea treatment by Clusters n=853 hargeisa borama Laasada’wo burao sheikh P Value Oralite or ORS 194 68 24 58 28 % 43.89 42.5 40 42.96 50 Pr = 0.850 Zinc 64 24 15 30 12 % 14.48 15 25 22.22 21.43 Pr = 0.073 Shuban-Daweeye 167 84 24 74 31 % 37.78 52.5 40 54.81 55.36 Pr = 0.000 home-made sugar-salt solution 5 5 6 16 23 % 2.94 2.92 3.53 9.36 13.45 Pr = 0.000 Another home-made liquid such as porridge, soup etc. 19 2 1 2 0 % 4.3 1.25 1.67 1.48 0 Pr = 0.100 Pill or syrup 33 17 2 9 11 % 7.47 10.63 3.33 6.67 19.64 Pr = 0.010 Injection 7 3 1 0 1 % 1.58 1.88 1.67 0 1.79 Pr = 0.669 Home therapy/herbal medicine 18 7 3 2 0 % 4.07 4.38 5 1.48 0 Pr = 0.305 Vitamin A Supplements 15 7 2 0 3 % 3.39 4.38 3.33 0 5.36 Pr = 0.189

• Across the sites surveyed, ORS was highly used followed by Shuban-Daweeye, zinc and pills or syrups for diarrhoea treatment. • Homemade and herbal remedies were not highly used.

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Table 5.17: Diarrhoea treatment by place of residence urban rural Peri-urban Oralite or ORS 233 111 28 Pr = 0.607 % 43.23 43.02 50 Zinc 83 50 12 Pr = 0.247 % 15.4 19.38 21.43 Shuban-Daweeye 274 75 31 Pr = 0.000 % 50.83 29.07 55.36 home-made sugar-salt solution 32 15 8 Pr = 0.047 % 5.94 5.81 14.29 Another home-made liquid such as porridge, soup etc. 9 15 0 Pr = 0.002 % 1.67 5.81 0 Pill or syrup 45 16 11 Pr = 0.005 % 8.35 6.2 19.64 Injection 6 5 1 Pr = 0.632 % 1.11 1.94 1.79 Home therapy/herbal medicine 19 11 0 Pr = 0.292 % 3.53 4.26 0 Vitamin A Supplements 18 6 3 Pr = 0.467 % 3.34 2.33 5.36

• ORS and Shuban-Daweeye were mainly used to treat diarrhoea across urban, rural and peri-urban sites. • However, some variations were seen where there was less use of Shuban-Daweeye in rural sites.

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5.3.5 Characteristics of product supply chain

Fig 5.1: Overview of health products supply chain

•NGOs – products sourced through donations at mother country •Businesses – import products from manufacturers in the region (especially Kenya) •PSI Somaliland – major source of health products Procurement

•NGOs donate health products to MOH that in turn distributes these to its maternal and child health centres or directly to communities on awareness creation days •PSI Somaliland has warehouse in Hargeisa and distributes products through PSI representatives to pharmacies. These representatives also check for stock outs and train pharmacists on product use. Distribution •Pharmacies also distribute products through public transport mechanisms, with associated problems of assuring product quality at delivery point

•Maternal and child health centres that receive donations through MOH •BulshoKaab affiliated pharmacies and other private pharmacies all over Somaliland •Retailers who stock health products for sale to community members Delivery

• The diagram above presents an overview of the overall health product supply chain in Somaliland including roles of stakeholders at the three major supply chain points. • There are no manufacturing plants for health products in Somaliland. Therefore most health products are imported. Main actors in the importation of health products are international NGOs (donations or purchase from their country), pharmacies or chemists (import mainly from Kenya) and PSI Somaliland. • While the NGOs mainly work with MOH or directly with consumers during awareness creation programs, PSI Somaliland (also directly provides products to consumers during awareness creation activities) is perceived to be a major supplier to the dominant private sector pharmacies. • “The drugs at the MCHs are donated. The UNICEF, WHO and other governments and INGOs that help us. The INGOs bring them from their country. But there are also the private sectors for medication imports. But as a government it is donated.” KII MOH Government Official, Shabeel 39

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Fig 5.2: Actors in the supply chain Actor Wholesalers NGO’s PSI Somaliland

Involvement Wholesalers are an NGO’s such as UNICEF, PSI socially market health important player in the Health Poverty Action, products through awareness health product supply chain WHO, etc) import health creation programs to create as they directly import and products and a) supply demand for their products and retail health products to them to MOH for ensure their availability in pharmacies/chemists as distribution to MCHs; b) pharmacies by distributing well as drug shops support awareness creation them to pharmacies/chemists throughout Somaliland. and through community that have agreed to partner They distribute the outreaches, provide such with them. This is done though products by using products such as ceramic PSI Somaliland appointed commercial transport water filters and Aqua tabs. representatives who distribute networks to reach rural health products to pharmacies regions of Somaliland. and chemists. They are however not known to reach the rural areas that wholesaler’s target.

• There are three major actors or stakeholders in Somaliland’s health product supply chain. The first that supports the MOH are international NGOs (UNICEF, Health Poverty Action etc.) who source and donate drugs to the MOH in realization of the need for quality drugs in Somaliland. The MOH in turn distributes the donated drugs to its own health facilities in Somaliland. • PSI Somaliland is the second major actor in the supply chain and deserves special mention as she sources quality health products and goes further to engage consumers to create demand for products and pharmacists to ensure that they provide a good service for product uptake. • The third major actors are wholesalers who fill the gap between PSI Somaliland and the International NGOs. They import generic health products from the United Arab Emirates (Dubai) and Kenya into Somaliland and distribute them to pharmacies/chemists.

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Fig 5.3: Description of the PSI distribution channel Distribution channels Activities

Community health meetings (and These types of forums provide a PSI with to gauge community readiness to awareness creation campaigns and forums receive information on PSI health products and how to use them. These such as Child Health Days) activities are often times done in collaboration with the MOH and other NGOs. Direct supply to patients (health facility PSI distributes water and diarrhoea treatment kits to patients that include as point of entry) Shuban-Daweeye and BiyoSifeeye. Pharmacies and shop outlets PSI also distributes their products through pharmacies and shops for sale to the public. Some of the pharmacies are affiliated to such as the BulshoKaab pharmacy network comprising of private pharmacies in many regions of Somaliland. Households (face 2 face visits) PSI also distributes the BiyoSifeeye product directly to households for use in purifying water and making it safe for drinking

Fig 5.4: Challenges in the supply chain Challenge Poor coverage Shortage of Inadequate supply Product source distribution outlets Description Products such as Ceramic In areas where some Disease outbreaks In some instances, filters and aqua tabs are products such as especially during rainy where there are highly demanded but BiyoSifeeye are on high seasons rapidly deplete competing products, their distribution does demand, shortages occur not cover some parts of the stock of diarrhoea those from European due to few distribution the country. This is outlets or that they are far treatment kits resulting countries were felt to confirmed by a study that in stock outs. have a better edge to be explored barriers to away and hence ceramic filter use in inaccessible. People thus BiyoSifeeye was also purchased when Gabiley (Somaliland) have to cover long reported not available at compared to products after free distribution by distances to purchase some pharmacies (e.g., from Africa e.g. Kenya Concern Worldwide (an these products. Nomadic Laasada’wo) which was international NGO). people are particularly attributed to being only Respondents reported affected as they do not that there was poor have a fixed residence. accessible from PSI. market availability of the filters hindering potential use (Adam 2014). Other challenges: • Lack of information on how to use water treatment products: A retailer in Sheikh reported that they had never seen or used water filters. The retailer also reported that the community at Sheikh did not know how to use BiyoSifeeye appropriately (i.e. many lacked knowledge of the right quantities needed to mix with water). In addition, the retailer mentioned that there were frequent complaints about the taste and smell of BiyoSifeeye treated water.

©TNS 2013

• This suggests an opportunity for PSI to promote awareness of appropriate use of the product, with Sheikh being a possible market for PSI’s products. Source: Adam, HM (2014): Barrier Analysis on Ceramic Filters (Gabiley). Concern Worldwide Somaliland.

Fig 5.5 Overview of the Value Chain

Wholesalers PSI – iNGOs – distribution – import import products & marketing donations

MOH

Campaigns

Retailers MCH services (chemist, drug in Health

shops) Facilities

CONSUMERS

5.3.6 Overview of the value chain

• Three product supply chains can be identified for diarrhoea and water treatment products: • The 1st chain focuses on international NGOs who get drug donations and distribute these to consumers mainly through the MOH. Through awareness campaigns, some donations go directly reach to consumers

©TNS 2013

• The 2nd chain is a relatively large supply chain managed by PSI Somaliland who import drugs and directly distribute them to pharmacists through appointed representatives. Health products also directly reach consumers when PSI raises public awareness through use of campaigns. • The 3rd chain is more commercial and focusses on wholesalers who purchase health products from Dubai (UAE) or Kenya and sell them to retailers including drug shops and pharmacists. Qualitative data shows that wholesalers, for example from Burao, distribute to Laasada’wo and Sheikh retailers while those in Berbera sell to retailers in Sheikh. These wholesalers distribute commodities through trucks used to transport animals, products and humans.

5.3.7 Opportunities, challenges and barriers to the social marketing of ceramic water filters

Issue Opportunities Challenges Barriers Description • UNICEF has been • It takes long to filter water The fragile nature of ceramic providing them for using the ceramic filter, 2 water filters makes it difficult free to Somaliland hours to filter a litre of to transport them to rural and residents which can water was reported. remote areas considering lack increase uptake of the • These filters are fragile of good roads. water filters. thus can easily break from • The Somaliland constant use, which made ministry of health has people misuse them to proposed to address store household goods. the misuse though • As the filters have been education campaign provided for free, it might on proper ceramic be difficult to sell them water filter use. through social franchising • Ceramic filters are to be difficult. also thought to have a • The filters also have a high neutral effect on taste cost of purchase of water unlike compared with water BiyoSifeeye which treatment tablets thus was reported to make retailers might also not be water have a 'bitter' willing to stock them. taste.

©TNS 2013

Fig 5.7: Strengths, weaknesses, drivers and barriers in the supply chain

Strengths Weakness

©TNS 2013

Barriers Opportunities

©TNS 2013

5.3.8 Ways of reaching consumers efficiently

Fig 5.8: Mechanisms of reaching consumers efficiently (1) Mechanism Explanation Focusing on school children Current awareness creation mechanisms need to also focus on schools to pass messages to pass health messages especially on toilet use as a means to reduce diarrhea. This is in light of the finding that a minimum of 25% of children use the bush/field as their toilet. Interpersonal communication Use of media such as radio and posters to create awareness is reported to be a key factor to at household level providing the much needed health product information to the consumer. Considering that many people have not gone to school, there is a need to go the last mile to potential users’ households. There might be need to request communities to suggest a male and female volunteer who can be trained by PSI Somaliland to pass on health messages to individual households. Collaboration with The WASH cluster comprises of Somaliland organizations that have an interest in addressing organizations in the WASH water and sanitation related challenges in the country. It would be useful if PSI Somaliland, if cluster not already a member, could join and begin engaging members with relation to partnering with them to create awareness in their areas of operation to improve uptake of water and diarrhea treatment products. Train shopkeepers in rural Shopkeepers are the point of contact with potential consumers of PSI Somaliland’s health areas and their suppliers products in rural areas. Considering the need to deepen uptake of health products in these (wholesalers) on the use of areas, it would be useful to develop a training program that focuses on improving shopkeepers’ health products knowledge of using water and diarrhoea products. It might also be useful to include wholesalers who are potentially a useful channel for distributing PSI Somaliland's health products to rural and remote Somaliland regions. Using relevant global events Global events related to water (world water day in March) or sanitation (world toilet day in to create awareness November), if celebrated in Somaliland could be another avenue for awareness creation related to water, sanitation and hygiene issues.

©TNS 2013

Fig 5.9: Mechanisms of reaching consumers efficiently Mechanism Explanation Engaging Coca Cola Coca Cola Somaliland has a strong distribution network for their products across the country. The Somaliland’s distributors, both company owned and private, are supplied with Coca cola products that they in distribution network turn distribute through their networks to rural villages. This network can be used to help distribute PSI’s products across Somaliland. Discussions with Coca Cola bottling company in Somaliland suggest that they are willing to partner with PSI Somaliland to undertake this task.

Using existing Using the example of Bihar, a pastoralist area, large wholesalers/stockists can be approached to traditional commercial help distribute PSI Somaliland's health products after being shown their importance. These networks stockists or wholesalers have been in existence for long and have built up a network of retailers in remote regions based on barter trade or borrowing and repayment basis – which has worked. It is suggested that to work, the basis of engagement be commercial where PSI Somaliland products would have to be priced lower than the current prices for the traders to have some margin, however small. Thus, while PSI Somaliland can concentrate on urban areas, the wholesalers/stockists can be engaged to supply health products in rural areas. Engaging private Wholesalers are a point of contact on transporters they use to distribute their products to rural transporters on areas. PSI Somaliland can engage these transporters as a way of ensuring that their products are distributing health carried safely to retailers and that they also understand the importance of using the health products products themselves. They also are a communication mechanism among their fellow transporters and retailers along the routes they use. Using mobile telephony PSI Somaliland can consider doing a health competition where winners can be given PSI to pass health messages Somaliland health products to use in their households. This can also help spread messages on health in the country. This however, would only be useful for urban areas where mobile access is good. Using televised This aims to pass health messages paying attention to Somaliland people’s love for televised news infomercials that they pass orally to others. PSI Somaliland could draw on Coca cola’s experience of introducing ‘Coke Zero’ to develop a dramatized infomercial that will not only educate but also be a point of discussion on the health of Somaliland people.

Engage traditional We suggest that traditional elders in rural and remote villages in Somaliland be approached and if elders possible, informed on the value of using health products such as those marketed by PSI Somaliland. They would be an important avenue for awareness creation in communities still holding on to traditional values such as the pastoralist ones. For others, the elders are also a means to engage men on the need to use health products that reduce the potential for preventable illnesses

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5.3.9 Potential partners

• Potential partnership opportunities for PSI include:

• Partnering with Amoud University Medical School whose students perform a variety of community health tasks as part of students’ practicum in Borama.

• Khat retailers who were reported to transport the product to very remote regions of Somaliland. Ethical issues arising from potential association of health products with Khat have to be considered.

• Partner with Coca Cola as they have a well-established distributorship system that assures the delivery of soft drinks to many parts of Somaliland. This draws on similar partnerships in Tanzania and Ghana.

• Utilization of local transportation that serves rural Somaliland - buses or trucks that wholesalers use when aiming to supply goods to rural areas such as Laasada’wo.

• Deliberate targeting of wholesalers travelling to rural areas to help distribute their products in remote Somaliland regions.

• MOH especially through the WASH cluster so that PSI Somaliland informs stakeholders of planned activities which can reduce duplication of efforts and create synergies between actors as well as enable MOH to have a coordinating role.

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6.0 Consumer perspectives on health products

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6.1 Outline of demand side findings

•Consumer perspectives on water • Sources of water • Water quality and treatment • Challenges related to water access and treatment • Pricing related to water

•Consumer perspectives on diarrhoea prevention, treatment and management • Perceptions of hygiene issues • Diarrhoea treatment • Sources of diarrhoea treatment products • Challenges of diarrhoea treatment methods • Pricing of diarrhoea products

•Credible sources of information on health issues

©TNS 2013

Consumer study: The TNS Behaviour Web

Morality

Costs and Habit Benefits

Efficacy Behaviour Heuristics

Context / Legitimacy Setting

Social and Cultural Norms

Fig 6.1: The TNS Behaviour Web © TNS

We used the TNS behaviour Web to develop the questionnaire and to probe all the potential barriers and drivers of change in each of the PSI categories of interest. Thus in each of the TMA segments, the framework helps us understand what prevents uptake and what might encourage uptake of PSI products for water and diarrhoea treatment.

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6.2 Segmentation analysis

Fig 6.2: Poorest quintile

Residence by age av. Respondent’s age av.

12.50 34 yrs % 41+ average age of respondents 38.00 % 31-40 49.10

% 16-30

34.5% 37.7% 51.2%

Urban of adults use of children use bush/field 1.8% bush/field 61.8% (35.9% use own (22.9% use own pit latrine) Rural Peri-urban pit latrine)

work for a 15.7% salary/wag civil e from: 12.4%service 82.9% 29.9 min never attended school own Is average time taken business (8.8% completed primary 6% level education) to get water own farm

32% 27% 41.8%

use access BiyoSifeeye use ORS to water from to treat treat pond/lake diarrhoea

©TNS 2013

Fig 6.3: Poorer quintile

Residence by age av. Age

12.50 33.6% % 41+ 38.00 average age of respondents % 31-40 49.10 % 16-30

52.6% 42.7% 36.3%

Urban of adults use own of children traditional pit use bush/field 2.9% latrine (19.9% use (31.6% use 44.4% bush/field) own pit toilet) Rural Peri-urban

15.7% work for a salary/wag civil service e from:

80.7% 29.4min 12.4%

never attended school own business is average time taken to (14% completed primary 6% level education) get water own farm

28.1% 35.7% 40.4%

use use Shuban- access BiyoSifeeye to Daweeye to treat water water from treat hawkers diarrhoea

©TNS 2013

Fig 6.4: Middle quintile

Residence by age av. Respondent’s age av.

12.50 % 33.4% 41+ 38.00 % 31-40 average age of respondents 49.10 % 16-30

66.5% 70.6% 41.2%

Urban of adults use Of children use own 6.5% own traditional traditional pit 27.1% pit latrine (8.2% latrine (35.3% use Peri-urban use bush/field) Rural bush/field

work for a 15.7% salary/wag civil e from: 77.7% 27.9min 12.4%service

never attended school own Is average time taken business (17.7% completed 6% primary level education) to get water own farm

40% 36.5% 47.7% use use Shuban- access BiyoSifeeye Daweeye to treat water from to treat water diarrhoea hawkers

©TNS 2013

Fig 6.5: Richer quintile

Residence by age av. Respondent’s age av.

12.50 33.3% % 41+ 38.00 % 31-40 average age of respondents 49.10 % 16-30

40.9% 77.2% 74.3%

Urban of adults use own of children use traditional pit 10.5% own traditional pit 12.3% latrine (1.2% use latrine (29% use Peri-urban bush/field) Rural bush/field)

work for a 15.7% salary/wage from: civil service

69% 20mi 12.4%

n never attended school own business is average time taken to (24.6% completed primary 6% level education) get water own farm

45 30.1 43.9% % % use use Shuban-

access BiyoSifeeye to Daweeye to treat water from treat water diarrhoea hawkers

©TNS 2013

Fig 6.6: Richest quintile

Residence by age av. Respondent’s age av.

12.50 % 33.2% 41+ 38.00 % 31-40 average age of respondents 49.10 16-30 %

83% 49.7% 29%

Urban Of children use of adults use own 11.1% traditional pit shared traditional pit 5.9% latrine (7.6% have latrine (25.2% use Rural Peri-urban flush toilet) bush/field)

work for a 15.7% salary/wag e from: civil service

48% 10.2min 12.4%

never attended school own business Is average time taken to (32.6% completed primary 6% level education) get water own farm

48% 45% 63.2% use Shuban- use Daweeye to treat diarrhoea access BiyoSifeeye to treat water water from taps

©TNS 2013

Water-related issues

Chart 6.1: Access to clean drinking water

What is the main source of drinking water for

members of your household? (n=853)

7.4

0.8

9.0

1.4

4.6

1.1 Percent

1.8

3.3

31.7

12.0

27.1

0.0 10.0 20.0 30.0 40.0

• The main sources of drinking water at household level are hawkers (31.&%) and taps (27.1%). • Reasons for choice of getting water from a particular source include: if water from a particular source has not caused health problems in the past; it looks clean; has no smell; and if it is affordable. • However, respondents are not always aware of the source of their water and did report that their suppliers at times got water from unclean wells or mixed the water (water from clean and unclean sources). • Respondents also stated that failure to repair tanks and poor maintenance of wells caused water contamination.

©TNS 2013

• This means that most water-borne diseases will persist as long as the supply of contaminated water persists and if respondents do not actively take steps to adopt efficacious methods to treat their water.

Table 6.1: Distance from drinking water source

Distance/ How long does it take to go there, get water and come back in minutes?

Cluster Observations (n) Mean Std. Dev. Min Max

Urban 201 55.83085 58.62466 1 240

Rural 205 27.98537 30.38632 2 180

Peri urban 32 95.6875 43.11832 24 180 • Results presented above show that much time is spent searching for water with some respondents taking up to 1 hour searching water and sourcing possible carriers/ containers. • As a result, some individuals look to fetch water once every three days. • This means that if a respondent comes across a water of dubious quality, they are likely to purchase it for lack of uncertainty on when they would be able to find an alternative source of water.

Table 6.2: Common/ preferred water purification methods by cluster

What do you usually do

to make the water safer

to drink?

Using Boiling Adding filter Use water Solar Let it stand and

Biyosifeeye bleach/chlorine/ tablet tablet Adding a through Strain cloth (ceramic/sand/c omposite/etc.) disinfection settle Powder Total Household Urban 191 127 19 (5%) 12 (3%) 12 (3%) 10 (3%) 1 (<1%) 10 1 (50%) (33%) (3%) (<1%) clustering 383 Description Rural 87 (40%) 77 (35%) 8 (4%) 6 (6%) 6 (3%) 22 (10%) 2 (1%) 8 (4%) 4 (<1%) 220 Peri urban 21 (47%) 16 (36%) 1 (2%) 1 (2%) 1 (2%) 1 (2%) 2 (3%) 2 (4%) 1 (<1%) 45 299 220 28 19 19 33 5 20 5

©TNS 2013

• In light of challenges related to water quality, households have adopted several methods to make water safe to drink. • Accross all clusters (urban, peri-urban and rural), BiyoSifeeye followed by boiling methods were reported to be the main methods used to make water safe to drink. • Though water filters were less used in the three clusters, it appears that there was higher reported use in rural areas (10%) compared with urban (3%) and peri-urban (1%).

Table 6.3: Total Household Income Total monthly household income (binned) (Somaliland shillings) Interview cluster 250001 - 500001 - 750001 - 1000001- 1250001- 1500001- 1750001- description =<250000 500000 750000 1000000 12500000 1500000 1750000 2000000 2000001+ Total urban 184 58 100 75 30 20 5 19 48 539 % 34.14 10.76 18.55 13.91 5.57 3.71 0.93 3.53 8.91 100 rural 107 73 42 19 2 2 2 3 8 258 % 41.47 28.29 16.28 7.36 0.78 0.78 0.78 1.16 3.1 100 peri urban 8 5 9 10 2 9 2 3 8 56 % 14.29 8.93 16.07 17.86 3.57 16.07 3.57 5.36 14.29 100 Total 299 136 151 104 34 31 9 25 64 853 % 35.05 15.94 17.7 12.19 3.99 3.63 1.06 2.93 7.5 100

Pr = 0.000

While varying between rural and urban regions, the analysis of household income shows that here are a few households with weatlh above 1000001 Somaliland shillings per month. Most households range from 250,000 Sh.So to 750,000 Sh.So. This suggests that financial issues could be a major consideraiton in the purchase and use of health products, toilet construction and water sources in the country, especially for the lower income households.

©TNS 2013

Table 6.4: Source of drinking water by wealth quintiles Wealth Quintles/ Consumer segment main source of drinking water for members of the household poorest poorer middle richer richest Total taps 32 40 33 44 82 231 % 18.82 23.39 19.41 25.73 47.95 27.08 tanks 13 19 26 32 12 102 % 7.65 11.11 15.29 18.71 7.02 11.96 Hawkers 21 48 68 77 56 270 % 12.35 28.07 40 45.03 32.75 31.65 Piped into residence/compound/ plot 1 1 3 7 16 28 % 0.59 0.58 1.76 4.09 9.36 3.28 Public tap 1 2 6 4 2 15 % 0.59 1.17 3.53 2.34 1.17 1.76 Well on residence/plot 3 4 2 0 0 9 % 1.76 2.34 1.18 0 0 1.06 Public well 12 15 10 2 0 39 % 7.06 8.77 5.88 1.17 0 4.57 River/stream 3 4 5 0 0 12 % 1.76 2.34 2.94 0 0 1.41 pond/lake 54 20 2 1 0 77 % 31.76 11.7 1.18 0.58 0 9.03 Rainwater 4 2 1 0 0 7 % 2.35 1.17 0.59 0 0 0.82 Other specify 26 16 14 4 3 63 % 15.29 9.36 8.24 2.34 1.75 7.39 Total 170 171 170 171 171 853 % 100 100 100 100 100 100

Pr = 0.000 • Sources of water varied greatly by wealth quintiles. The richest and richer quintiles appeared to source water from taps (they were able to pay for the service) and hawkers (perhaps they could pay a higher premium for water). • The poorest sourced their water from ponds/lake (31.8%) suggesting a great need to create awareness on water treatment processes in this quintile. • Other sources of water for the poorest and poorer quintiles were taps (18.8% and 23.4% respectively) and hawkers (12.4% and 28.1% respectively). • Residents concurred that the cost per barrel is Sh.So 8000. Tap water has a higher initial cost related to the cost of installing pipes at about 600 dollars or more. Some households therefore agree to share the cost in order to afford clean piped water. Households unable to meet the installation cost sometimes bought water from households with tap water

©TNS 2013

Table 6.5: Main source of water for households by cluster

Main source of water for the household

Piped into residence/co Well on Cluster mpound/plo Public residence/ Public River/ pond/ Rainw Other description taps tanks hawkers t tap plot well stream lake ater specify Total urban 191 92 216 28 5 0 1 0 0 0 6 539 35.4 % 4 17.07 40.07 5.19 0.93 0 0.19 0 0 0 1.11 100 Rural 40 2 6 0 10 9 38 12 77 7 57 258 % 15.5 0.78 2.33 0 3.88 3.49 14.73 4.65 29.84 2.71 22.09 100 peri urban 0 8 48 0 0 0 0 0 0 0 0 56 % 0 14.29 85.71 0 0 0 0 0 0 0 0 100 Total 231 102 270 28 15 9 39 12 77 7 63 853 27.0 % 8 11.96 31.65 3.28 1.76 1.06 4.57 1.41 9.03 0.82 7.39 100 Pr = 0.000

• Some variations were seen in water sources that households accessed by cluster. For the urban and peri-urban clusters, water tanks were reported to be a major source of water that was not the case for the rural cluster. • Perhaps attributed to activities of NGOs was the presence of public wells (14.7%) and public taps (3.9%) in rural areas that were less reported in urban and peri-urban areas. Respondents from rural areas reported to source their water from ponds or lakes (29.9%).

©TNS 2013

Table 6.6: Source of drinking water by region

%Clustering Main source of drinking water for members of the household Hargeisa Borama Laasada’wo Burao Sheikh Total Taps 37 126 40 28 0 231 % 8.37 78.75 66.67 20.74 0 27.08 Tanks 42 6 2 44 8 102 % 9.5 3.75 3.33 32.59 14.29 11.96 Hawkers 166 1 1 54 48 270 % 37.56 0.63 1.67 40 85.71 31.65

Piped into residence/compound/ plot 0 25 0 3 0 28 % 0 15.63 0 2.22 0 3.28 Public tap 3 0 7 5 0 15 % 0.68 0 11.67 3.7 0 1.76

Well on residence/plot 9 0 0 0 0 9 % 2.04 0 0 0 0 1.06 Public well 33 0 5 1 0 39 % 7.47 0 8.33 0.74 0 4.57 River/stream 7 0 5 0 0 12 % 1.58 0 8.33 0 0 1.41 pond/lake 77 0 0 0 0 77 % 17.42 0 0 0 0 9.03 Rainwater 7 0 0 0 0 7 % 1.58 0 0 0 0 0.82 Other specify 61 2 0 0 0 63 % 13.8 1.25 0 0 0 7.39 Total 442 160 60 135 56 853 % 100 100 100 100 100 100 Pr = 0.000

• Variations were also seen by the specific regions that the study visited. Hargeisa had the most variety of sources of drinking water which suggests some attention is needed to address water treatment. • Sheikh had 2 sources of drinking water (tanks and hawkers) suggesting the need for increase in variety of water sources. • Burao residents reported sourcing water from hawkers (40%), tanks (32.6%) and taps (20%). Similar to Sheikh, there is a need to focus on improving awareness of the

©TNS 2013

need for water cleanliness among water providers such as hawkers and tanks in Burao, Hargeisa. • Borama and Laasada’wo residents reported getting water mainly from taps (78.8% & 66.7% respectively). This also means that there is need for development of other sources of drinking water.

Fig 6.7: Water quality and water treatment Knowledge and description of clean water

Key Issue Knowledge and Whether clear water is Sickness from water Cleanliness around description of clean safe water source water Findings Unclean water is described Respondents felt that not Water from wells with Water trucks and as having a reddish color all clear water is safe. rigs was perceived to livestock are while clean water from They perceived that only be safe to drink as responsible for the the one from wells that respondents thought hygiene and sanitation pipes is perceived to be have rigs or taps was that it had been at the wells where pure and clear. safe. purified and goes they fetch water but While some trust clear However, some through clean pipes. others believe that as water to be safe, others do respondents felt that it Vendors that fetch long as the water not and treat it with was not necessary to put water from dams containers are clean BiyoSifeeye. Those who water treatment tablets supply water that is there are no issues to trust clear water from the to the water that was not clean. Some worry about. clear. believe that it is God’s pipes to be safe only treat will for one to become water sourced from the sick, highlighting how wells, trucks, water tanks socio-cultural beliefs or if the water has colour. influences behavior.

©TNS 2013

Fig 6.8: Water quality and water treatment Methods used to make sure water is safe for drinking

Method BiyoSifeeye Traditional Information Comparison of Water storage methods sources on water traditional water safety methods filtering with Aqua tab Findings Most people know Boiling drinking Main reported Varied responses Water is stored in BiyoSifeeye but water for people sources are mass were reported with tanks, jerricans report lacking suffering from media (TV & some respondents and barrels. The adequate kidney problems radio) and MOH claiming that the different knowledge on the and children. Use of during campaigns tablet (Shuban- containers are doses required. plants called ASAL or when they visit Daweeye) is more used for different Other and DAMEER health facilities efficient than other purposes with the respondents (donkey grass) to and private methods. Other water in barrels admit to having clean water. The pharmacies. respondents used specifically the tablet but do ASAL leaf from Information on believed that boiling for drinking while not use it as they GALOL tree is dried traditional water would kill all tank water is for trust that water is and placed in water purification insects and germs washing and other clean. making it turn red methods is orally while another group general uses. Majority of the killing bacteria, transmitted from of respondents felt Water in jerricans respondents germs and other one generation to that water that had and barrels is rarely use organisms in the the next. been treated with usually treated BiyoSifeeye and water. ASAL is more chlorine does not and used for only use it when trusted by the need to be treated drinking. they think it is community which again. These varied necessary but claims that it clears responses suggest a prefer it to other cholera. This lack of knowledge modern and tradition has been on water treatment traditional passed on from methods that needs methods. ancestors. to be addressed. Another decantation method called XAREEDIN is also used to clean water.

©TNS 2013

Fig 6.9: Water quality and water treatment

Initiatives to make water safe

Key Issue Water cleaning Roles of partners in safe Government The private sector programs water provision Findings Many respondents PSI is reported to have The Ministry of Water is Members of the reported to be unaware of awareness program on tasked with ensuring private sector who initiatives on improving water safety that focuses that there is a steady own wells sometimes on BiyoSifeeye and Aqua supply of clean and safe use that water for water safety awareness tab awareness in the water for the irrigation purposes and requested for communities. In Hargeisa, community. only. At times, they information on how to a water agency supplies However, it should aim sell these water to clean water storage water while private to partner with water water trucks who in containers and training companies supply water retailers and NGOs to turn supply to children on how to use in other regions and ensure a steady supply consumers. water and keep the water districts. Private of safe drinking water The water in the farms companies own water to Somaliland residents. is not potable and clean. wells and install water needs to be treated Some respondents pipes in towns for before use, an action however reported that businesses. that respondents they received information In Hargeisa persons who getting such water did from Deqa (a CBO) and own wells do not install not take. others from PSI on pipes to households but BiyoSifeeye and Aqua tab. instead use trucks to deliver water to the community.

©TNS 2013

Perceptions of diarrhoeal prevalence

Chart 6.2: Type/ kind of toilet facilities Type of toilet facilities available

Perc…

0 10 20 30 40 50 60

• The chart above indicates that the majority of homesteads in Somaliland own a pit latrine, with very few homes having toilet that feeds into the main sewer system. • Pit latrines, which in essence are a means of keeping human faecal matter away from seeping into main water sources, improving sanitation and thus reducing likelihood of diarrhoeal morbidity and mortality. • However, it is difficult to say from these results if ground water is unaffected by the existence of pit latrines in Somaliland. Literature suggests that surface run off from open latrines increase likelihood of water contamination

©TNS 2013

Table 6.7: Toilets used by adults

Kind of toilet facility your adult household members usually use Own Shared Shared Flush Toilet without Own flush Shared traditional traditional pit Own (VIP) (VIP) trench pit/working Cluster toilet flush toilet pit toilet toilet latrine latrine toilet flush No facility/bush/field 16 5 (0.93 334 170 5 7 3 (0.56 3 7 Urban (2.97%) %) (61.97%) (31.54%) (0.93%) (1.30%) ) (0.56%) (1.30%) 1 6 95 47 0 0 0 3 107 Rural (0.39%) (2.33%) (36.82%) (18.22%) (0%) (0%) (0%) (1.16%) (41.47%)

Peri 1 (1.79 37 17 1 3 0 0 0 urban %) 0 (0%) (66.07%) (30.36 %) (1.79 %) (5.36%) (0%) (0%) (0%)

Table 6.8: Toilets used by children

Kind of toilet facility your children aged 5 years and below use Shared Own Shared Shared Flush Toilet without Own flush flush traditional traditional pit Own (VIP) (VIP) trench pit/working Cluster toilet toilet pit toilet toilet latrine latrine toilet flush No facility/bush/field 9 3 195 146 6 7 2 3 139 Urban (1.67%) (0.56%) (36.18%) (27.09%) (1.11%) (1.30%) (0.37%) ( 0.56%) (25.79%) 1 1 65 40 0 0 0 5 140 Rural (0.39%) ( 0.39%) (25.19%) (15.50%) (0%) (0%) (0%) (1.94%) (54.26%) Peri 0 0 16 12 1 3 0 0 23 urban (0%) (0%) (28.57%) (21.43%) (1.79%) ( 5.36 %) (0%) (0%) (41.07%)

©TNS 2013

Chart 6.3: Diarrhea treatment methods by cluster Vitamin A Supplements

Home therapy/herbal

medicine Peri urban Peri Injection

Pill or syrup Rural Another home-made liquid such as porridge, soup, yoghurt, coconut water etc home-made sugar-

salt solution interview Cluster Description Cluster interview

Urban Shuban-Daweeye

0 50 100 150 200 250 300 Zinc

Number of households

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Table 6.9: What do you usually do/ use to treat your children of diarrhoea?

Interview Cluster Description

Urban Rural Peri urban  A fluid made from a special packet called Ora-lite or ORS? 233 (32%) 111 (37%) 28 (30%)  Zinc 83 (12%) 50 (16%) 12 (13%)  Shuban-Daweeye 274 (38%) 75 (25%) 33%)

 home-made sugar-salt solution 32 (4%) 15 (5%) 8(9%)  Another home-made liquid such as porridge, soup, yoghurt, coconut water etc. 9 (1%) 15(5%) 0(0%)

Action taken Action  Pill or syrup 45 (6%) 16 (5%) 11(12%)  Injection 6 (1%) 5 (2%) 1(1%)  Home therapy/herbal medicine 19 (3%) 11 (4%) 0 (0%)  Vitamin A Supplements 18 (3%) 6 (2%) 3 (3%) Totals 719 304 94

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Fig 6.10: Perspectives on diarrhoea Knowledge on diarrhoea causes and treatment

Who suffers from Deaths from Causes of diarrhoea diarrhoea treatment Treatment sites diarrhoea? diarrhoea

Variations in Respondents Respondents were Modern and Respondents sought knowledge of persons reported knowing knowledgeable on the traditional treatments treatment from suffering from individuals who causes of diarrhoea are used. Most hospitals, MCHs and diarrhoea were seen. had died from and reported these to respondents take pharmacies. Some respondents had diarrhoea related include: their children to the Many respondents no knowledge of such illnesses, with food poisoning, poor pharmacy. Drugs used reported that they incidences while others children being hygiene, dirty or include syrup, Zinc trusted doctors’ claimed that their own particularly at risk. contaminated food, pills twice a week, and prescriptions. Some and neighbors children amoeba, not trimming ORS for energy. reported that where had suffered from it. the child’s nails, Others used the doctors are Respondents felt that improper hand Shuban- Daweeye inaccessible, they will any person could get washing practices, tablet. use traditional and diarrhoea but children lack of clean water and Traditional treatment home treatment were more vulnerable. using unclean water includes the use of methods such as the vessels. GAYDHE, ASAL, use of syrup, and herbs. RUMAAN, Lemon and GANSHAR (herbal medicines from plants for diarrhoea treatment).

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Fig 6.11: Acceptability of water treatment products (BiyoSifeeye) Ease of use Willingness to use Preferred product Willingness to pay Product packaging product/ how purchase points and instructions often

Biyosifeeye was felt to Willingness to use the Respondents reported Prices respondents Respondents stated be easy to use and was product is dependent that products should were willing to pay for that clear information perceived to act on knowledge. Those be available in the BiyoSifeeye varied was needed on the quickly that know little about pharmacies and shops ranging from 2500 appropriate dosage it would prefer to get so that they can easily SOS, 3000 SOS, 3500 for treating water, it free for testing prior access them. This will SOS, 5000 SOS and feeling that an to purchasing it from allow them to test the others 10000 SOS. overdose could be pharmacies. products and use Some respondents harmful while a lower Current users report them if found to be insisted on getting dose would be that BiyoSifeeye is working well. information on the ineffective. Urban available in the product prior to using respondents believed pharmacies, are it while others desired that they understood satisfied with the to prove that it is BiyoSifeeye usage, product’s current better than what they arguing for more price and would buy it are used to before awareness creation from the nearest shop. using it continuously. for rural residents.

Fig 6.12: Acceptability of diarrhoea treatment products

Ease of use Willingness to Where would you Willingness to pay Product use the product want to get the packaging and product instructions

Respondents Respondents already Respondents Respondents were willing There is a belief that generally agreed accessing the product preferred to get it at to pay to get this product sourcing the product that it is easy to were ready to the MCHs when they and offered prices ranging from a physician is use continue using it. go there to seek from 3000 SOS, 3500 SOS, better as they give Others with little treatment. Others felt 2000 SOS, 5000 SOS, 4000 instructions on how to access reported that that for increased SOS and even 10000 SOS. use it. Respondents they would use it if it access, the product This perhaps shows an who had learnt about became accessible should be distributed awareness of the the product from other to shops, health importance of preventing users felt that it is centers and and treating diarrhoea good and important in pharmacies. among the respondents. treating diarrhoea.

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Influence of income on diarrhoea and water treatment practices

Chart 6.4: What do you usually do/use to treat your children of diarrhoea?

Vitamin A 2000001+ Supplements

1750001 - 2000000

1500001 - 1750000 Home therapy/herbal 1250001 - 1500000 medicine

1000001 - 1250000

Injection 750001 - 1000000

500001 - 750000

Total household income (Binned) income household Total 250001 - 500000 Pill or syrup

<= 250000

0 50 100 150 200 Number of households

• Shuban-Daweeye was a well-known diarrhoea treatment method across the household income segments

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Chart 6.5: Household expenditure on water by cluster Average Weekly expenses on water by cluster

Above 300,000 200,001-300,000 Peri urban 150,000-200,000 Rural 100,001-150,000 Urban

50,001-100,000 Shillings

10,001- 50,000 Weekly average Weekly

on WATER in SomaliWATER onin 0 - 10,000 householdexpenditure

0 50 100 150 200 250 300 350 Households

• Low income households appeared to spend more money per week on water compared to higher income households. This suggests a need to either lower the cost of water or to increase water sources which would in turn lower water prices.

Chart 6.6: Pricing for Biyosifeeye

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• Using the Price Sensitivity Meter (PSM), the recommended price for BiyoSifeeye is 2,000 Somaliland shillings. This is the ideal price as per the PSM intercept.

•For the minimum selling price, BiyoSifeeye should be sold at 1000 Somaliland shillings, while the maximum price should be 3000 Somaliland shillings. The respondents, who reported having ever bought BiyoSifeeye, bought it on average for between 500 – 2000 Somaliland shillings. For this amount, they find the product to be affordable as reported in the qualitative results

•The PSM model recommends a much higher price than is currently the norm. This is driven by the wide variation of prices being paid for BiyoSifeeye, ranging from the recommended 500 SOS to about 10,000 SOS.

•This suggests a need to control the price range to the recommended 500 SOS through better distribution systems and more creation awareness on recommended prices. This issue is the same for Shuban-Daweeye reported in the next slide.

Chart 6.7: Pricing for Shuban-Daweeye

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• Using the Price Sensitivity Meter (PSM), the recommended price for Shuban-Daweeye is 1,800 Somaliland shillings. This is the ideal price as per the PSM intercept.

• For a minimum selling price, Shuban-Daweeye should be sold at 1000 Somaliland shillings, while the maximum price should be 2500 Somaliland shillings.

• Respondents, who reported having ever bought Shuban-Daweeye, bought it on average for between 500 – 2000 Somaliland shillings. For this amount, they find the product to be affordable as reported in the qualitative results.

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7.0 Key learnings and recommendations

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7.1 Summary of findings Generally, qualitative results from this study suggest that imported products (by INGOs or endorsed by them) are well-regarded and preferred over locally made solutions.

• Ceramic filters, that are endorsed by UNICEF are liked as they are free and come ready to use. The Ministry of Health was reported to be introducing a training program on how to maintain ceramic filters which might influence uptake. However, the length of time it takes to purify water using these filter was noted to be a point of contention among potential users. There is thus need to engage ceramic water filter manufacturers on how to reduce the length of time taken to clean water and perhaps lower the prices of the filters are to be marketed through retailers.

• Results showed that BiyoSifeeye was a well-known brand and popular product. The marketing efforts by PSI to increase the reach of this product are commendable. Although BiyoSifeeye has been reported to work well, more efforts to increase consumer knowledge of product use (mixing ratios) and product make up (chlorine base) might help increase uptake of it, reducing complaints of the apparent bitter taste it has.

• Where water treatment tablets or ceramic filters were not readily available, consumers have adopted boiling as a method to clean water. Consumers also appear to be knowledgeable about how to store boiled/ clean water separate from other untreated water thus keeping it safe for consumption. Awareness campaigns should continue to promote clean water mangement in areas where water treatment tablets and filters are not available.

• In terms of sanitation practice, data suggests that handwashing after using a toilet and especially before eating is a practice that is well promoted by the MOH. Data from the study showed that among those sampled, many were knowledgeable of good hygiene practice, which may be a result of the MOH awareness campaign. However, in terms of actual practice, it is worth noting that across the poorer quintiles, children who use bush/ pit latrines (25%) are less likely to wash their hands as water is scarce.

• The widespread presence of chemists/ pharmacies in Somaliland make these the first point of entry for most distributors to target in urban areas. Pharmacists are also the preferred source of medical treatment and supplies, as most people feel safe seeking consultation as they provided health information in addition to guidance on how to use water and diarrhea treatment products.

• Rural areas present an additonal challenge as there are few pharmacies or chemists and poor roads make some areas difficult to access. However, shopkeepers from these areas were reproted to source and stock a variety of products that consumers in those regions

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used. These shopkeepers form an important entry point for the distribution of PSI Somaliland products.

• It is important to note the role of health facilities in distribution of health products which are mainly sourced from the Ministry of Health. These facilties can also be approached through the Ministry of Health to help distribute PSI Somaliland’s health products.

7.2 Recommendations

• There is need for social marketing approaches to focus on the need to treat water especially in rural areas. Such approaches could focus on the need to reduce household costs through less diarrhoeal episodes in the households which for example, could allow household members to have more time to generate income and allow children to go to school without getting sick.

• There is need to increase knowledge of diarrhoea treatment in rural areas. This might mean, in addition to using the current approach of passing message through billboards, to use more interpersonal communication (IPC) for example through door to door approaches or interfacing with communities during public events. We also suggest that PSI not use peers to cascade messaging, but utilize community leaders such as Imams or women leaders in cascading health messages. Other potentially important mechanisms include using televised infomercials which targets Somaliland people’s interest in getting new information and orally transmitting it to others.

• There is need for concerted action to increase the use of ceramic water filters. We note here that though liked by respondents who had received them from free distribution campaigns; their fragile nature, high cost of purchase, and poor knowledge on their maintenance prohibits widespread use in Somaliland. We suggest that support be given to the Ministry of Health Somaliland to undertake awareness campaigns on proper use and maintenance of the ceramic water filters. Further, negotiations with ceramic water filter manufacturers should be done to lower the price of the filters so that they are accessible to Somaliland residents.

• Another approach is targeting men who - as the main bread winners for families and in the culturally patriarchal society - ultimately decide how money is used in the homestead:

• First, messages highlighting their important role as ‘protectors’ of the households from illnesses or being model household heads should be emphasized.

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• Second, there is need to work with local opinion leaders such as Imams who can then arrange for PSI to meet with male household heads and discuss with them ways of improving household health. • Third, there is need to address the concern around the taste or smell of water after being treated using BiyoSifeeye. One suggestion could be to check the formulation of the tablet and make it neutral so that people do not perceive change in taste after treating their water with it. The other way is an awareness campaign on this issue to inform people to expect the slightly bitter taste from treating water using BiyoSifeeye.

• The study has shown that there are existing challenges in reaching rural populations with PSI’s acknowledged life-saving products. This calls for the exploration of potential partnerships that include working with: • Amoud University medical school whose students perform a variety of community health work as part of students’ practicum in Borama. Being medical staff in training, they can help spread information on BiyoSifeeye and Shuban-Daweeye to communities where they serve. • Khat retailers who were reported to transport the product to very remote regions of Somaliland. Ethical issues arising from potential association with Khat will have to be considered. • Coca cola distributors who have a major distribution network in Somaliland. PSI should draw on lessons learnt from using the Coca cola distribution network in Tanzania and Ghana prior to engaging Coca Cola in Somaliland. • Buses or trucks that wholesalers use when looking to increase reach in rural areas such as Laasada’wo. PSI representatives can work with or target wholesalers travelling to rural areas to help distribute their product. • PSI should consider setting up warehouse in Borao or Berbera (port city) as a hub for rural distribution of PSI products. This will allow quicker movement of health products to areas of need. It could also serve as a backup storage to help assist in situations when there is a diarrhoeal outbreak.

• We also recommend that PSI Somaliland targets members of micro credit schemes (where available) who can pool their resources to purchase health products and form natural groups that can be informed on the need to treat water.

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8.0 Annexes

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Water delivery Table 8.1: Time spent to collect water

Minimum Maximum Mean Time N time spent time spent spent Std. Deviation Q3.2 How long does it 853 0 240 23.47 42.563 take to go there, get water and come back (in minutes)

Valid N (listwise) 853

Table 8.2: Costs: How much the households spend on WATER weekly

Minimum Maximum Mean costs of all N cost cost the respondents Std. Deviation Q5.3a How much in 853 0 800000 31318.01 74293.783 total did your household spend on WATER for the last 7 days in Somali Shillings?

Table 8.3: Measures to improve access to safe drinking water

Q6.3.1: What do you usually do to make the water safer to drink Frequency (n) Percent % 1. Using BiyoSifeeye 299 35.1 2. Boiling 220 25.8 3. Adding bleach/chlorine/tablet 28 3.3 4. Adding tablet 19 2.2 5. Strain through a cloth 54 6.3 6. Use water filter 3.9 3.9 (ceramic/sand/composite/etc.) 7. Solar disinfection 5 0.6 8. Let it stand and settle 20 2.3 9. Powder 5 0.6 853 100.0 Total 82

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Key informant opinions on access to safe drinking water

Table 8.4: Percentage of residents affected by poor access to water

Satisfied with the cleanliness/safety of the source of water that household members often use for drinking

Frequency Percent Valid Percent Yes 480 56.3 56.3 No 373 43.7 43.7 Total 853 100.0 100.0

Chart 8.1: Proportion satisfied with the cleanliness/safety of the source of water

Total 100

No 43.7 Percent

Yes 56.3

0 20 40 60 80 100 120

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Table 8.5: Diarrhoea treatment by household income Total household income (In Somaliland Shillings) 250,001 500,001 750,001 1,000,001 1,250,001 1,500,001 1,750,001 <= – – – – – – –

250,000 500,000 750,000 1,000,000 1,250,000 1,500,000 1,750,000 2,000,000 2,000,001+ Total A fluid made from a special packet called Oralite or ORS? 160 52 58 30 18 11 5 7 31 341 Zinc 73 15 17 11 8 6 3 1 11 134 Shuban- Daweeye 135 51 64 52 20 17 2 7 32 348 home-made sugar-salt solution 12 9 7 7 4 4 3 4 5 50 Another home- made liquid such as porridge, soup, yoghurt, coconut water, fresh fruit juice, tea, milk, or rice water 13 4 1 1 2 1 0 1 1 23 Pill or syrup 19 7 19 8 2 3 0 5 9 63 Injection 3 1 2 3 1 0 0 1 1 11 Home What do you usually do/ use to treat your children of diarrhoea?Whattreat children usually use do/ to do your you therapy/herbal medicine 16 2 5 1 0 1 1 1 3 27 Vitamin A Supplements 6 5 7 5 2 1 0 0 1 26

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Water quality and water treatment

Table 8.6: Water Quality The source of the water that I and my household members There are times when I or my The source of The source of There are household the water the water times when I often use for members that I and my that I and my or my often use for drinking is collect water household household I am satisfied with household drinking is surrounded using members members the cleanliness/safety members surrounded by run-off unwashed often use for often use for of the source of water store drinking by leaking water hands and/or drinking is drinking has that I and my water in dirty septic tanks entering into dirty also shared objects falling household members water Cluster and latrines the source containers by animals into it. often use for drinking containers. 56 36 70 Urban (10.39%) 48 (8.91%) 44 (8.16 %) (6.68%) 35 (6.49%) 243 (45.08%) (12.99%) 50 58 71 68 67 84 Rural (19.38%) (22.48%) (27.52%) (26.36%) (25.97%) 99 (38.37%) (32.56%) Peri urban 2 ( 3.57%) 0 0% 0 0% 1 1.79% 1 1.79 % 12 21.43% 0 0%

Table 8.7: Water Treatment There are In my In my times when I In my household the In my In my In my household or my household container In my household the household the household people wash household there is a specifically household the container container the cup used hands before members separate for storing container specifically specifically for drawing fetching store drinking container drinking specifically for storing for storing water from water from water at home specifically water is a for storing drinking drinking the the container in open for storing narrow drinking water is water is kept container used to store and/or dirty drinking necked water is kept always out of reach of storing water drinking water water container clean covered children has a handle water. containers. 238 245 (45.45 345 359 348 (64.56 323 281 113 (44.16%) %) (64.01%) (66.60%) %) (59.93%) (52.13%) (20.96%) 114 130 122 ( 115 110 (42.64 107 ( 41.47 107 (41.47 (44.19%) (50.39%) 47.29%) (44.57%) %) %) %) 90 (34.88%)

19 33.93% 16 28.57% 22 39.29% 23 41.07% 23 41.07% 17 30.36% 16 28.57% 3 5.36%

Water quality and water treatment 85

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Table 8.8: Water Contamination awareness Water contamination awareness; water can be contaminated through contaminated objects falling transportation storing water surface water collecting water through into the well. from the source at home in leaking run-off entering with unwashed animals using Water to the house in open and/or septic tanks wells and hands and/or the same Handling and dirty water dirty water Cluster and latrines springs dirty containers source Storage container containers 216 195 229 202 188 Urban (40.07%) (36.18%) 205 (38.03%) (42.49%) (37.48%) 193 (35.81%) (34.88%) 66 Rural (25.58%) 59 (22.87%) 40 (15.50%) 53 (20.54%) 49 (18.99%) 38 (14.73%) 46 (17.83%) Peri 44 urban (78.57%) 30 (53.57%) 29 (51.79 %) 35 (62.50 %) 25 (44.64%) 23 (41.07%) 28 (50.00%)

Table 8.9: Type/ kind of toilet facilities

Kind of toilet facility adult household members usually use N %

Own flush toilet 18 2.1

Shared flush toilet 11 1.3

Own traditional pit toilet 466 54.6

Shared traditional pit toilet 234 27.4

Own (VIP) latrine 6 0.7

Shared (VIP) latrine 10 1.2

Flush trench toilet 3 0.4

Toilet without pit/working flush 6 0.7

No facility/bush/field 114 13.4

Total 868 100.0

Chart 8.2: Treatment of diarrhoea in young children 86

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Modes of treating children of diarrhoea

3.2

3.5

1.4

8.4

2.8 Percent % 6.4

44.5

17.0

43.6

.0 10.0 20.0 30.0 40.0 50.0

Table 8.10: Household expenditure on water by clusters Clusters

Urban Rural Peri-urban Total 0 - 10,000 153 220 14 387 10,001- 50,000 302 33 29 364 50,001-100,000 54 3 10 67 100,001-150,000 13 1 2 16

150,000-200,000 4 0 0 4 200,001-300,000 3 1 0 4 Above 300,000 10 0 1 11

Weekly average average Weekly on expenditure household Somaliland in WATER Shillings Total 539 258 56 853

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Table 8.11: Common / preferred household Water purification methods by household income What do you Use water usually do to Adding filter Let it bleach/ Strain (ceramic/ stand make the water Using chlorine/ Adding through sand/ Solar and safer to drink Biyosifeeye Boiling tablet tablet a cloth composite) disinfection settle Powder Total <= 250,000 123 (42%) 94 20 14 (5%) 21 (7%) 15 2 7 (2%) 4 (32%) (7%) (5%) (1%) 296 250,001 - 43 (47%) 30 2 (2%) 1 (1%) 5 (5%) 6 (4%) 0 (0%) 4 (4%) 0 (0%) 500,000 (33%) 91 500,001 - 45 (47%) 34 2 (2%) 1 (1%) 6 (6%) 4 (4%) 3 (3%) 0 (0%) 0 (0%) 750,000 (36%) 95 750,001 - 32 (46%) 26 (38%) 1 (1%) 0 (0%) 5 (7%) 1 (1%) 0 (0%) 4 (6%) 0 (0%) 1,000,000 69 1,000,001 - 15 (58%) 8 (31%) 1(4%) 1 (4%) 1 (4%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 1,250,000 26 1,250,001 - 12 (50%) 8 (31%) 0 (0%) 0 (0%) 2 (8%) 1 (4%) 0 (0%) 1 (4%) 0 (0%) 1,500,000 24 1,500,001 - 2 (29%) 0 (0%) 0 (0%) 0 (0%) 3 (43%) 0 (0%) 0 (0%) 2 0 (0%) 1,750,000 (29%) 7

household income 1,750,001 (Somaliland - 6 (38%) 2 (13%) 1 (6%) 0 (0%) 4 (25%) 1 (6%) 0 (0%) 2 0 (0%) 2,000,000 (13%) 16 2,000,001+ 21 (39%) 18 1 (2%) 2 (4%) 7 (13%) 5 (9%) 0 (0%) 0 (0%) 1 (2%) (33%) 54 Total Shillings) Total 299 220 28 19 54 33 5 20 5

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Table 8.12: Common/ preferred household Water purification methods by cluster

What do you usually do to make the water

safer to drink?

water filter filter water

Using Biyosifeeye Boiling Adding Use disinfection Solar Let it stand

bleach/chlorine/ tablet tablet Adding through Strain a cloth (ceramic/sand/compos ite/etc.) and settle Powder Total Household Urban 191 (50%) 127 19 12 12 10 1 (<1%) 10 (3%) 1 (<1%) clustering (33%) (5%) (3%) (3%) (3%) 383 Description Rural 87 (40%) 77 (35%) 8 6 (6%) 6 22 2 (1%) 8 (4%) 4 (<1%) (4%) (3%) (10%) 220 Peri 21 (47%) 16 (36%) 1 1 (2%) 1 1 2 (3%) 2 (4%) 1 (<1%) urban (2%) (2%) (2%) 45 299 220 28 19 19 33 5 20 5

• BiyoSifeeye and boiling water were commonly used water treatment methods across the three clusters.