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. ii ©TNS 2013 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. iii ©TNS 2013 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 iv ©TNS 2013 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. , v ©TNS 2013 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