Lorelei Goodyear, MPH

PATH

Rob Quick, MD MPH

Centers for Disease Control and Prevention

Integration Achieves Results

Malawi ANC/Hygiene Kit Model

What do we know about adoption and sustained use of HWTS?

• Commercial success = 5-10% penetration

• Social marketing increases knowledge of need to treat, brand awareness, and product trial

• Safe Water System (chlorine + safe storage container) has global reach

• Challenging to exceed 10-15% adoption

Product Need Value/relevance

Awareness Action Maintenance

Trial/initial use Current Use

Purchase Sustained Use

Behavior Change Continuum

Blantyre and Salima Program

• Training of clinic staff

• 15,000 water hygiene kits

• 3 free refills of WaterGuard and soap at ANC, delivery, and postnatal visits as incentive for clinic attendance

• Health Surveillance Assistant home visits, education and monitoring

• PSI advertising and product distribution

Blantyre and Salima Program Timeline

Baseline Survey &

Program Implementation

2007 2008 2010

1 year Follow-up Evaluation

Survey

3 year Follow-up Evaluation

Survey

Sustained Usage

2007 Baseline (N=198)

2008 Follow-

up (N=198)

2010 Follow-

up (N=198)

Confirmed WG use (WG bottle + residual chlorine)

1% 62% 28%

Confirmed WG use and purchase (WG bottle + residual chlorine + purchase)

1% 33% 22%

Confirmed residual chlorine (stock chlorine or WG)

5% 73% 53%

Effective Incentive

Water Hygiene Kit

Trusted Sources

Health Surveillance Assistants

ANC Nurses

“Teachable Moment”

Can results be replicated?

Machinga Implementation-2009-2011

25,000 Water and Hygiene Kits distributed in 15 health facilities throughout Machinga District

Up to 4 free refills of WaterGuard and soap provided at ANC and postnatal visits to promote clinic attendance

Home visits by Health Surveillance Assistant (HSA) assured ongoing education and monitoring

Required presence of husband or partner of pregnant woman at ANC visit to receive Water Hygiene Kit to increase their participation

WaterGuard Results

Baseline (n=106)

Follow-up (n=97)

Confirmed WG use (WG bottle + positive chlorine test) *

0% 69%

Confirmed WG use AND purchase of WG *

0% 36%

* p < 0.0001

ANC Services and Outcome of Pregnancy

Malawi DHS( 2010)

Participants (n=97)

4 or more antenatal visits 21% 56%

Delivery at health facility 72% 90%

Baby returned for 6 week infant check-up

--- 90%

Partner Involvement HIV Testing and Prevention Services

Participants (n=97)

Partner came to ANC visit 100%

Partner VCT 99%

Participant VCT 99%

Couple disclosure of HIV status 98%

HIV-exposed infants on ARV prophylaxis

90%

2 Pilot Cost Comparison

Original ANC program

(Blantyre & Salima)

9 months

Relative per

person cost

% of Cost

CHAI program

(Machinga) Year 2

Relative per

person cost

% of Cost

Hygiene kit costs $70,407 4.69 55% $113,031 4.52 67%

Program management $21,481 1.43 17% $17,404 0.69 7%

MOH management

and supervision

$10,416 0.69 8% $32,425 1.30 19%

Promotion and

Advertising

$19,678 1.31 15% $5,517 0.22 3%

Training Costs $6,793 0.45 5% $1,371 0.06 1%

TOTAL $128,775 $169,748

Number of participants 15,000 25,000

Per participant costs $8.58 $6.79

Malawi- Wide Scale up Cost Comparison

Blantyre and Salima Machinga

Cost per pregnant woman for scale up across all three provinces of Malawi

$8. 22

$7.99

Total recurring operating costs $4.2 million

$4.1 million

•2008 Malawi Census: 516,629 live births in Malawi.

•87% of births in rural areas.

•1st year expansion start up costs $4.6 million

•includes inflation projections

•potential economies of scale

Evaluation Limitations

Women in survey population may have received more HSA visits than other program participants

Some survey participants were lost to follow-up (<20%)

Behavior change may have been influenced by additional unrelated events or other programs

Conclusions

Prenatal care is an effective platform for promoting HWTS and HIV prevention in Malawi

Conclusions

Social marketing is complemented by sustained interpersonal communication between new mothers and trusted providers at teachable moments

Integration efficiently enhances outcomes and achieves lasting results.

Future Directions for ANC/Hygiene Kit Model

• Scale up in Malawi

• Evaluation of consistent use and health outcomes

• Replicate in other countries

• Potential adaptations

– Offer HWTS product choice

– Emphasize immunization, nutrition, and post-partum family planning

• Build stronger health/WASH alliances

Partner Acknowledgments

Implementation Partners Ministry of Health Malawi Population Services International (PSI) Clinton Health Access Initiative (CHAI) UNICEF Evaluation Partners: Centers for Disease Control and Prevention (CDC) PATH Abt Associates Donors: USAID Bill and Melinda Gates Foundation

Observed WG bottle in home Positive test for chlorine in stored water

+

Confirmed WaterGuard Use

Estimated Cost to Scale Program Nationally

Estimated commodity cost per participant: $5.44

Estimated implementation cost per household per annum (range): $2.56 - $5.13

Estimated total cost per household per annum (range): $8.00 – $10.57

Total cost for nationwide scale-up (range): $4,134,054 - $5,459,610

Observed WG bottle in home

Positive test for chlorine in stored

water

+ +

Reports WG purchase after

free bottles

Confirmed WG Use and Purchase

ANC services utilization (Malawi DHS 2010) Antenatal care = 97%

Delivery at health facility = 72%

Advantages of integrating interventions into ANC High coverage

Teachable moment

Use of trusted providers

Potential drawbacks of integration Crowding in health facilities

Stressed providers

Rationale for Integrating Interventions

into ANC Services