POUZN-Abt Associates: Where We Work

Point-of-Use (POU) Household Water Disinfection Programs:

Angola has the third highest under-five mortality rate in the world (260/1000 live births), with diarrhea a major contributor. In addition to high diarrheal prevalence (23% of children under five years of age), cholera poses a significant threat to Angola, and recent outbreaks have been crippling. To respond to this pressing need, POUZN supported the launch of Certeza, a dilute sodium hypochlorite solution, promoted by CDC as part of its safe water system (SWS) program, in Angola’s capital, Luanda, in collaboration with the Ministry of Health (MoH) and with major funding from the Esso Oil Company. The program increased access to safe drinking water by making Certeza readily available at the household level at a price affordable for low-income families, and increases awareness of and commitment to water treatment and hygiene improvement for all income strata. Access to Certeza not only served as a preventive measure to combat diarrhea incidence, but aided in the prevention of cholera as the program targeted cholera-prone areas.

Bangladesh has a population of nearly 159 million and is one of the most densely populated countries in the world. Rapid urbanization and high population density have led to unsanitary conditions and a lack of access to clean water, making slum dwellers vulnerable to disease. In Bangladesh, POUZN is working with the Social Marketing Company (SMC), one of the largest social marketing organizations in the world, to introduce and market a chlorine-based water treatment tablet, Aquatabs, to vulnerable urban populations. POUZN funding supports market research to determine Aquatab’s acceptability and market potential as well as pre-launch activities such as the development of brand positioning and demand creation activities through mass media and interpersonal communication channels.

Benin is one of the poorest countries in Africa ranking 163/177 in the UN’s Human Development Index. Only 65% of the population has access to improved sources of drinking water and the prevalence of diarrheal disease is high. POUZN is introducing a chlorine water treatment tablet (Aquatabs) into the private sector market. Aquatabs is marketed through PSI’s network of both public and private sector distributors, concentrating on catchment areas surrounding seven major urban centers located throughout the country. POUZN is partnering with USAID’s Integrated Support for HIV/AIDS Prevention and Family Health (IMPACT) Project and Projet Intégré de Santé Familiale (PISAF). These projects and their partner non-governmental organizations (NGOs) are integral partners in the training of both MOH and NGO personnel and in the delivery of community outreach through information, education and communication (IEC) programs. POUZN’s major focus during this final year is to implement a mass media campaign, primarily through television advertising, which will improve brand recognition, create demand for Aquatabs, and facilitate nationwide penetration of the product in the market.

The Democratic Republic of Congo (DRC) is the third largest country in Africa and one of the least developed countries in the world. The under-five mortality rate in the DRC is 205 per 1,000 live births. POUZN partner, PSI, commenced its safe water and diarrheal disease control program in the DRC in October 2006 with the point-of-use product, PUR Purifier of Water, with funding from Procter & Gamble (P&G). POUZN supported this program by funding expansion in the eastern province of Sud Kivu, an area impacted by 10 years of civil insecurity, and providing channels of distribution to rural communities and hard-to-reach populations. POUZN collaborated with USAID’s Project AXxes and its partner NGOs, leveraging community networks and integrating POU messages into AXxes efforts to improve primary health care. In addition, POUZN expanded commercial sector activities to ensure access to a POU water treatment product at multiple distribution points within communities throughout Sud Kivu.

Haiti is the poorest country in the western hemisphere ranking among the worst in terms of both political stability and health indicators. Haiti’s diarrhea prevalence rates are among the highest in the world. In 2006, USAID, through the Private Sector Partnerships for Better Health (PSP-One) project, provided funding to PSI to introduce a safe water treatment product, Dlo Lavi, initially in Port-au-Prince and peripheral zones. POUZN expanded the Dlo Lavi program to additional areas, including 34 target communes supported by USAID’s bilateral Pwoje Djam Project covering about 40 percent of the population. The Dlo Lavi program had a two-pronged distribution strategy: a) commercial sector distribution through shops, pharmacies, kiosks, etc. in the communes serviced by Pwoje Djam clinics and in urban areas of Haiti, and b) community-based distribution thru local and international NGOs. Behavior change messages were delivered via interpersonal communication channels principally through Pwoje Djam health centers and community outreach workers, enabling POUZN to focus on urban and rural areas with populations that were particularly vulnerable to acute diarrheal disease and faced the greatest challenges with regard to water quality.

With less than 14% of rural Malawians receiving piped water in their homes, over 70% storing their drinking water, and recontamination during storage a significant problem, POUZN is supporting the marketing of two highly effective water disinfection products in Malawi: WaterGuard, an easy to use liquid product and WaterGuard wa Ufa, a flocculent-disinfectant product manufactured by Procter & Gamble and distributed elsewhere under the brand name ‘PUR’ which both disinfects and clears turbid water of all solid materials. POUZN is expanding distribution of these key water treatment products to rural areas where incidence of diarrhea is 28% higher than in urban areas, socio-economic and educational indicators are lower, and where 85% of the population resides. POUZN has established new channels of distribution via collaborations with organizations currently working on water, sanitation, and hygiene as part of their community development activities, targeting primary caregivers, community-based health agents, and healthcare providers to motivate the purchase and consistent year-round use of POU water treatment and good hygiene practices.

In Kenya, mortality among children under five is high, with one in every nine children dying before his or her fifth birthday. Through POUZN, PSI/Kenya is expanding the WaterGuard program, increasing accessibility to and demand for POU products, building upon the current POU program by leveraging partnerships with both US-based and local non-governmental, community-based and faith-based organizations to reach deeper into poor and vulnerable communities with new channels of distribution, promotion and IEC messages. The POUZN-funded program focuses on Kenya’s Coast province, which has among the highest diarrhea prevalence rates in the country.

In a country plagued by poverty, 60% of the population lives below the poverty line, 42% of children are malnourished, and diarrheal disease is the second most common cause of death for children under five. Recognizing that contaminated drinking water is a significant contributor to the spread of diarrheal disease, POUZN is implementing a three-pronged program:

• re-launching PSI/Rwanda’s chlorine-based liquid water treatment product, Sûr’Eau, with renewed targeting of vulnerable populations, particularly families with young children, and an expanded distribution system that encompasses pharmacies and private sector providers; public channels, including health clinics and the 21,000-strong national health animator network; and schools
• piloting a program to test the viability of targeted promotion and distribution of Sûr’Eau to families participating in community-based health insurance schemes (mutuelles) in two districts. POUZN, in partnership with the USAID Health Systems 20/20 project, has evaluated this pilot intervention concluding that this is an effective method for reaching poor households and encouraging purchase and use of the product. Click here to view the Baseline Research Report

• initiating a program targeting persons living with HIV/AIDS (PLWHA) in each of Rwanda’s 22 PEPFAR districts, including training public sector, staff counseling and testing personnel, and palliative care partners from several PLWHA associations, strengthening their capacity to promote Sûr’Eau and raise awareness of the role and benefits of household water treatment in the prevention of diarrhea.

POUZN Zinc Treatment Programs

WHO and UNICEF now recommend that children under five years of age with acute diarrhea be treated with a 10-14 day course of zinc along with either oral rehydration salts (ORS) or a similar home-made (sugar/salt) solution. ORS prevents the child from dying of dehydration (the most common killer of children with diarrhea) and zinc reduces both the severity and duration of the diarrhea and has a protective effect as well. POUZN is currently working with both Ministries of Health and the private sector to introduce zinc and ORS as the preferred treatment for pediatric diarrhea in Benin, Madagascar, and Pakistan. POUZN’s program in Nepal was completed in 2008.

In collaboration with the Benin Ministry of Health and UNICEF, POUZN is introducing a diarrhea treatment kit (DTK) containing two sachets of a new, orange flavored low-osmolarity ORS and 10 tablets of zinc as a treatment for diarrhea through both private and public health channels. POUZN is building upon PSI’s successful ORS marketing program and its close distribution links with both public and private sector pharmaceutical wholesalers. The program targets communities in seven major catchment areas throughout the country and has partnered with USAID’s two major bilateral programs, IMPACT and PISAF, and a UNICEF-funded, PSI-implemented, zinc pilot public sector program in two departments. Development of training modules and delivery of the training at all administrative levels has been carried out in collaboration with the MOH’s Department of Family Health. The POUZN team and its NGO partners from the USAID and UNICEF projects have developed integrated diarrheal disease prevention IEC materials, tailored to local knowledge and literacy levels, that are being used in all community outreach activities. Mass media campaigns for diarrhea treatment focus on selling a new and improved ORS product along with zinc that will treat diarrhea as well as lengthen the period between bouts of diarrhea.

In March 2006, the Cambodian Ministry of Health and PSI, in coordination with WHO and with financial support from USAID, launched a demonstration project to introduce a diarrhea treatment kit (DTK), containing both ORS and zinc branded as OraselKIT®, in selected districts of two provinces of Cambodia. In February 2007, POUZN staff, together with USAID and WHO, evaluated that pilot and has prepared a report detailing the results and lessons learned. The assessment report on this successful pilot, reaching numerous rural families through commercial retail outlets and two partner NGOs working in each of the target districts, the Reproductive and Child Health Alliance (RACHA) and the American Red Cross/Cambodian Red Cross, is now available on this website by clicking here.

The Government of Madagascar’s Ministry of Health and Family Planning (MOHFP), was one of the first health ministries in the world to embrace the new diarrhea treatment protocol introduced by WHO and UNICEF in 2004, introducing zinc as a diarrhea treatment through public sector clinics at both health center and community levels in 12 districts in 2007. The POUZN project complements the Ministry’s program by introducing two prepackaged zinc and ORS products through the private sector. These diarrhea treatment products have been “bundled” together to encourage greater ORS use, which is very low nation-wide. A full-price diarrhea treatment kit (HyraZinc) is being introduced through the commercial pharmaceutical system to be sold in pharmacies and rural depots de medicaments throughout the country. In addition, a subsidized diarrhea treatment kit (ViaSûr) is being sold by community-based distribution agents in 45 districts with high rates of diarrheal disease. A national mass media campaign will commence in January 2010 to promote the correct use of zinc and ORS together as the appropriate and safe treatment for diarrhea. The mass media campaign is being complemented by interpersonal communication conducted by partner NGOs at the village/household level in partnership with USAID’s SantéNet2 project which addresses child health improvements through a “champion commune” program.

For three years, POUZN worked closely with the Government of Nepal to address the significant impact of diarrhea on the health of children, mobilizing public and private sectors for the introduction of pediatric zinc, along with oral rehydration therapy. During the first phase of the program, the project introduced zinc in both the public and private sectors in the three districts of Kathmandu, Bhaktapur and Lalitpur. During this phase, POUZN worked closely with four Nepalese pharmaceutical manufacturers, enabling them to develop, register, manufacture and bring to market for sale several pediatric zinc products. Nepalese pharmaceutical manufacturers were encouraged and supported to produce and distribute zinc tablets that would meet the quality standards set by the Nepal Government Department of Drug Administration as well as other international drug testing agencies (e.g. United States Pharmacopeia - USP). Four products have been introduced into the Nepalese market since May 2007. Behavior change communication messages were developed and aired through mass media targeting public sector employees and private sector providers, pharmacists and child caregivers in order to increase the use of ORS and pediatric zinc and reduce the provision of often ineffective and unnecessary diarrhea treatments. A national umbrella campaign logo was developed to promote all pediatric zinc products that are part of the Nepal Government program. 2,243 public sector employees (central, district and community levels) and 1,660 private sector providers and pharmacists were trained to promote pediatric zinc supplements with ORS as the first line treatment for uncomplicated diarrhea in children under five years of age.

National scale-up of the program to urban and peri-urban areas throughout the country (Phase-II) began in October 2007 with expansion of the program into 27 community-based IMCI districts covering about 50% of country’s population. During Phase II product distribution and the media campaign were expanded to national coverage and over 4000 additional private sector providers and pharmacists were trained to promote zinc as the first line treatment for childhood diarrheas. In January 2008, U.S. Pharmacopeia provided technical assistance to all three zinc manufacturers to prepare them to bring their production facilities to international pharmaceutical Good Management Practices to qualify to participate in international tenders. A country brief, describing this successful project and results of the endline survey and providing lessons learned is available on this website by clicking here.

Pakistan, according to the 2007 Demographic and Health Survey, has one of the highest rates of diarrhea prevalence (22%) in the developing work. The presence of an active zinc manufacturing industry in Pakistan, together with ongoing public efforts to increase the use of zinc for diarrhea treatment, offers opportunity for significantly increasing the use of zinc together with ORS for the treatment of diarrhea whether sought through the public or the private sector and for building a sustainable commercial market for zinc. POUZN’s program in Pakistan focuses on demand creation—educating both potential consumers (caregivers of children under five) and providers (both general practitioners and pediatricians) through both mass media and training about the new WHO/UNICEF recommendations that zinc and ORS be administered to all children with uncomplicated diarrhea as the standard case management for diarrhea.