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Optimizing Household Chlorination Marketing Strategies: A Randomized Controlled Trial on the Effect of Price and Promotion on Adoption in Haiti
Michael Ritter
Michael Ritter
Department of Civil and Environmental Engineering, Tufts University, Medford, Massachusetts;
Deep Springs International, Léogâne, Haiti
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Deep Springs International, Léogâne, Haiti
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Eveline Camille
Eveline Camille
Deep Springs International, Léogâne, Haiti
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Christophe Velcine
Christophe Velcine
Deep Springs International, Léogâne, Haiti
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Rose-Kerline Guillaume
Rose-Kerline Guillaume
Deep Springs International, Léogâne, Haiti
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Daniele Lantagne
Daniele Lantagne
Department of Civil and Environmental Engineering, Tufts University, Medford, Massachusetts;
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Household water treatment can reduce diarrheal morbidity and mortality in developing countries, but adoption remains low and supply is often unreliable. To test effects of marketing strategies on consumers and suppliers, we randomized 1,798 households in rural Haiti and collected data on purchases of a household chlorination product for 4 months. Households received randomly selected prices ($0.11–$0.56 per chlorine bottle), and half received monthly visits from sales agents. Each $0.22 drop in price increased purchases by 0.10 bottles per household per month (P < 0.001). At the mean price, each 1% drop in price increased purchases by 0.45% (elasticity = 0.45). There is suggestive evidence that household visits by some sales agents increased purchases at mid-range prices; however, the additional revenue did not offset visit cost. Choosing the lowest price and conducting visits maximizes chlorine purchase, whereas slightly raising the retail price and not conducting visits maximizes cost recovery. For the equivalent cost, price discounts increase purchases 4.2 times as much as adding visits at the current retail price. In this context, price subsidies may be a more cost-effective use of resources than household visits, though all marketing strategies tested offer cost-effective ways to achieve incremental health impact. Decisions about pricing and promotion for health products in developing countries affect health impact, cost recovery, and cost-effectiveness, and tradeoffs between these goals should be made explicit in program design.
Author Notes
Financial support: This research was partially supported by the National Science Foundation (0966093). Data entry was made possible through the gracious support of the Gangarosa International Health Foundation and College of Charleston.
Authors’ addresses: Michael Ritter, Department of Civil and Environmental Engineering, Tufts University, Medford, MA, and Deep Springs International, Jolivert, Haiti, E-mail: michael.ritter2@gmail.com. Eveline Camille, Christophe Velcine, and Rose-Kerline Guillaume, Deep Springs International, Jolivert, Haiti, E-mails: partnership@deepspringsinternational.org, christovel2003@outlook.com, and info@deepspringsinternational.org. Daniele Lantagne, Department of Civil and Environmental Engineering, Tufts University, Medford MA, E-mail: daniele.lantagne@tufts.edu.
ProCite
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Reference Manager
BibTeX
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-
1.
World Health Organization, United Nations Children’s Emergency Fund (UNICEF), 2015. Progress on Sanitation and Drinking Water: 2015 Update and MDG Assessment. Geneva, Switzerland: WHO. Available at: http://www.unicef.org/publications/files/Progress_on_Sanitation_and_Drinking_Water_2015_Update_.pdf. Accessed September 26, 2016.
-
2.
Onda K, LoBuglio J, Bartram J, 2012. Global access to safe water: accounting for water quality and the resulting impact on MDG progress. Int J Environ Res Public Health 9: 880–894.
-
3.
Clasen T, Haller L, 2008. Water Quality Interventions to Prevent Diarrhoea: Cost and Cost-Effectiveness. Geneva, Switzerland: World Health Organization. Available at: http://www.who.int/water_sanitation_health/economic/prevent_diarrhoea.pdf. Accessed September 26, 2016.
-
4.
Fewtrell L, Kaufmann RB, Kay D, Enanoria W, Haller L, Colford JM, 2005. Water, sanitation, and hygiene interventions to reduce diarrhoea in less developed countries: a systematic review and meta-analysis. Lancet Infect Dis 5: 42–52.
-
5.
Clasen T, Schmidt WP, Rabie T, Roberts I, Cairncross S, 2007. Interventions to improve water quality for preventing diarrhoea: systematic review and meta-analysis. BMJ 334: 782.
-
6.
Clasen T, 2015. Household water treatment and safe storage to prevent diarrheal disease in developing countries. Curr Environ Health Rep 2: 69–74.
-
7.
Clasen T, Roberts I, Rabie T, Schmidt WP, Cairncross S, 2006. Interventions to improve water quality for preventing diarrhoea (review). Cochrane Database Syst Rev 3: CD004794. Available at: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004794.pub3/epdf. Accessed September 26, 2016.
-
8.
Quick R, Kimura A, Thevos AK, Tembo M, Shamputa I, Hutwagner L, Mintz E, 2002. Diarrhea prevention through household-level water disinfection and safe storage in Zambia. Am J Trop Med Hyg 66: 584–589.
-
9.
Quick R, Venczel LV, Mintz E, Soleto L, Aparicio J, Gironaz M, Hutwagner L, Greene KD, Bopp C, Maloney K, Chavez D, Sobsey MD, Tauxe RV, 1999. Diarrhoea prevention in Bolivia through point-of-use water treatment and safe storage: a promising new strategy. Epidemiol Infect 1222: 83–90.
-
10.
Luby S, Agboatwalla M, Hoekstra RM, Rahbar MH, Billhimer W, Keswick B, 2004. Delayed effectiveness of home-based interventions in reducing childhood diarrhea, Karachi, Pakistan. Am J Trop Med Hyg 71: 420–427.
-
11.
Crump JA, Otieno PO, Slutsker L, Keswick BH, Rosen DH, Hoekstra RM, Vulule JM, Luby SP, 2005. Household based treatment of drinking water with flocculant-disinfectant for preventing diarrhoea in areas with turbid source water in rural western Kenya: cluster randomised controlled trial. BMJ 331: 478.
-
12.
Rosa G, Clasen T, 2010. Estimating the scope of household water treatment in low- and medium-income countries. Am J Trop Med Hyg 82: 289–300.
-
13.
Cayemittes M, Busangu MF, Bizimana JdD, Barrere B, Severe V, Cayemittes V, Charles E, 2013. Enquete Mortalite, Morbidite et Utilisation des Services EMMUS-V. Petion-Ville, Haiti: Institut Haitien de l’Enfance and Calverton, MD: MEASURE DHS ICF International. Available at: http://www.mspp.gouv.ht/site/downloads/EMMUS V web.pdf. Accessed September 26, 2016.
-
14.
Population Services International (PSI), 2012. Enquete de suivi sur les determinants de l’utilisation des produits de traitement de l’eau au niveau des menages ayant des enfants de moins 5 ans en Haiti. Washington, DC: PSI. Available at: http://pdf.usaid.gov/pdf_docs/PA00JWZJ.pdf. Accessed September 26, 2016.
-
15.
Hulland K, Martin N, Dreibelbis R, DeBruicker Valliant J, Winch P, 2015. What Factors Affect Sustained Adoption of Safe Water, Hygiene and Sanitation Technologies? A Systematic Review of Literature. London, United Kingdom: EPPI-Centre, Social Science Research Unit, UCL Institute of Education, University College London. Available at: https://eppi.ioe.ac.uk/cms/LinkClick.aspx?fileticket=FNNRVPIRw9g%3D&tabid=3475. Accessed September 26, 2016.
-
16.
Dupas P, 2011. Health behavior in developing countries. Annu Rev Econ 3: 425–449.
-
17.
Dupas P, 2009. What matters (and what does not) in households’ decision to invest in malaria prevention? Am Econ Rev 99: 224–230.
-
18.
Cohen J, Dupas P, 2010. Free distribution or cost-sharing? Evidence from a randomized malaria prevention experiment. Q J Econ 125: 1–45.
-
19.
Dupas P, 2014. Short-run subsidies and long-run adoption of new health products: evidence from a field experiment. Econometrica 82: 197–228.
-
20.
Hoffmann V, 2009. Intrahousehold allocation of free and purchased mosquito nets. Am Econ Rev 99: 236–241.
-
21.
Kremer M, Miguel E, 2007. The illusion of sustainability. Q J Econ 122: 1007–1065.
-
22.
Spears D, 2014. Decision costs and price sensitivity: field experimental evidence from India. J Econ Behav Organ 97: 169–184.
-
23.
Harvey P, 1994. The impact of condom prices on sales in social marketing programs. Stud Fam Plann 25: 52–58.
-
24.
Ashraf N, Berry J, Shapiro JM, 2010. Can higher prices stimulate product use? Evidence from a field experiment in Zambia. Am Econ Rev 100: 2383–2413.
-
25.
Blum A, Null C, Hoffmann V, 2014. Marketing household water treatment: willingness to pay results from an experiment in rural Kenya. Water 6: 1873–1886.
-
26.
Kremer M, Miguel E, Mullainathan S, Zwane AP, Null C, 2011. Social Engineering: Evidence from a Suite of Take-up Experiments in Kenya. Available at: http://eml.berkeley.edu/~emiguel/pdfs/chlorinedispensers.pdf. Accessed September 26, 2016.
-
27.
Luoto J, Mahmud M, Albert J, Luby S, Najnin N, Unicomb L, Levine DI, 2012. Learning to dislike safe water products: results from a randomized controlled trial of the effects of direct and peer experience on willingness to pay. Environ Sci Technol 46: 6244–6251.
-
28.
Ashraf N, Jack BK, Kamenica E, 2013. Information and subsidies: complements or substitutes? J Econ Behav Organ 88: 133–139.
-
29.
Null C, Kremer M, Miguel E, Hombrados JG, Meeks R, Zwane AP, 2012. Willingness to pay for cleaner water in less developed countries: systematic review of experimental evidence. International Initiative for Impact Evaluation, Systematic Review 006. Available at: http://www.3ieimpact.org/media/filer_public/2012/05/28/sr006.pdf. Accessed September 26, 2016.
-
30.
Contzen N, Mosler HJ, 2013. Impact of different promotional channels on handwashing behaviour in an emergency context: Haiti post-earthquake public health promotions and cholera response. J Public Health 21: 559–573.
-
31.
Curtis V, Kanki B, Cousens S, Diallo I, Kpozehouen A, Sangare M, Nikiema M, 2001. Evidence of behaviour change following a hygiene promotion programme in Burkina Faso. Bull World Health Organ 79: 518–527.
-
32.
Kassegne S, Kays MB, Nzohabonayo J, 2011. Evaluation of a social marketing intervention promoting oral rehydration salts in Burundi. BMC Public Health 11: 155.
-
33.
Levine R, 2007. Case 8: Preventing diarrheal deaths in Egypt. Case Studies in Global Health: Millions Saved. Sudbury, MA: Jones and Bartlett Publishers.
-
34.
Hirschhorn N, 1985. Saving children’s lives: a communication campaign in Egypt. Dev Commun Rep 51: 13–14. Available at: http://files.eric.ed.gov/fulltext/ED288513.pdf. Accessed September 26, 2014.
-
35.
Wang W, MacDonald VM, Paudel M, Banke KK, 2011. National scale-up of zinc promotion in Nepal: results from a post-project population-based survey. J Health Popul Nutr 29: 207–217.
-
36.
Armstrong JRM, Abdulla S, Nathan R, Mukasa O, Marchant TJ, Kikumbih N, Mushi AK, Mponda H, Minja H, Mshinda H, Tanner M, Lengeler C, 2001. Effect of large-scale social marketing of insecticide-treated nets on child survival in rural Tanzania. Lancet 357: 1241–1247.
-
37.
Evans WD, Pattanayak SK, Young S, Buszin J, Rai S, Bihm JW, 2014. Social marketing of water and sanitation products: a systematic review of peer-reviewed literature. Soc Sci Med 110: 18–25.
-
38.
Parker AA, Stephenson R, Riley PL, Ombeki S, Komolleh C, Sibley L, Quick R, 2006. Sustained high levels of stored drinking water treatment and retention of hand-washing knowledge in rural Kenyan households following a clinic-based intervention. Epidemiol Infect 134: 1029–1036.
-
39.
Freeman MC, Quick RE, Abbott DP, Ogutu P, Rheingans R, 2009. Increasing equity of access to point-of-use water treatment products through social marketing and entrepreneurship: a case study in western Kenya. J Water Health 7: 527–534.
-
40.
O’Reilly CE, Freeman MC, Ravani M, Migele J, Mwaki A, Ayalo M, Ombeki S, Hoekstra RM, Quick R, 2008. The impact of a school-based safe water and hygiene programme on knowledge and practices of students and their parents: Nyanza Province, western Kenya, 2006. Epidemiol Infect 136: 80–91.
-
41.
Migele J, Ombeki S, Ayalo M, Biggerstaff M, Quick R, 2007. Diarrhea prevention in a Kenyan school through the use of a simple safe water and hygiene intervention. Am J Trop Med Hyg 76: 351–353.
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