Microbiological effectiveness and cost of disinfecting water by boiling in semi-urban Indi

Clasen T, McLaughlin C, Nayaar N, Boisson S, Gupta R, Desai D, Shah N (2008) Microbiological effectiveness and cost of disinfecting water by boiling in semi-urban India. American Journal of Tropical Medicine and Hygiene;79(3):407–413.

This report authored for the World Health Organization (WHO) examined efforts to scale up other important household-based interventions (e.g., oral rehydration salts, treated mosquito nets) for lessons of potential value to scaling up HWTS.  A number of important recurring themes applicable to scaling up household water treatment and safe storage (HWTS) were found, including:

• focus on the user’s attitudes and aspirations;
• take advantage of simple technologies (minimize behavior change);
• promote nonhealth benefits, such as cost savings, convenience, and aesthetic appeal;
• use schools, clinics, and women’s groups to gain access to more vulnerable population segments;
• take advantage of existing manufacturers and supply channels to extend coverage;
• provide performance-based financial incentives to drive distribution;
• align international support and cooperation to encourage large-scale donor funding;
• use free distribution to achieve rapid scale-up and improve equity;
• use targeted subsidies, where possible, to leverage donor funding; and
• encourage internationally-accepted standards to ensure product quality.

In his workshop presentation, Clasen noted that all introductions of novel health interventions to low-income populations face similar challenges—creating awareness, securing acceptance, ensuring access and affordability, establishing political commitment, addressing sustainability—but several additional barriers exist that must be overcome to scale up HWTS. These include

• the widely held belief that diarrhea is not a disease;
• skepticism about the effectiveness of water quality interventions;
• technology shortcomings with the available interventions;
• need for correct, consistent, sustained use (as compared with one-time interventions, such as vaccines);
• the existence of several transmission pathways for waterborne disease;
• suspicion on the part of the public health sector regarding the commercial agenda and lack of standards governing HWTS products;
• the orphan status of HWTS within governmental ministries; and
• the lack of focused international commitment and funding for diarrheal diseases.

The goal of scaling up HWTS will not be achieved simply by putting more resources into existing programmes or transitioning current pilot projects to scale.  The gap between where we are and where we need to be is to great given the urgency of the need. What is needed is a breakthrough. The largely public health orientation that has brought HWTS to its present point now need to enlist the help of another group of experts: consumer researchers, product designers, educators, social entrepreneurs, micro-financiers, business strategists and policy advocates. The private sector is an obvious partner; they not only possess much of this expertise but also the incentive and resources to develop the products, campaigns and delivery models for creating and meeting demand on a large scale. At the same time, market-driven, cost-recovery models are not likely to reach vast populations at the bottom of the economic pyramid where the disease burden associated with unsafe drinking water is heaviest . . . mass coverage among the most vulnerable populations may be impossible without free or heavily subsidized distribution. For this population segment, the public sector, UN organizations and NGOs who have special access to these population segments must engage donors to provide the necessary funding and then demonstrate their capacity to achieve both scale and uptake. Governments and international organizations can also help encourage responsible action by the private sector by implementing performance and safety standards and certification for HWTS products; reducing barriers to importation, production and distribution of proven products; and providing incentives for reaching marginalized populations.