Water water everywhere, not a drop to drink? Information and enabling access to clean water

Over 50 million people in India are exposed to arsenic-contaminated water, leading to adverse health outcomes – especially for children. Yet, the demand for private, safe drinking water remains low in the affected areas. Based on an experiment in Assam, this article demonstrates how combining water quality awareness interventions with a reduction of transactional complexity in obtaining related government benefits can help address the issue.

India, together with Bangladesh, has the largest population in the world exposed to arsenic poisoning through groundwater. More than 50 million people across 35 districts of India, especially in the states of Assam and West Bengal, are exposed to arsenic-contaminated water (Shaji et al. 2021). Around 50% of the arsenic-affected population are children and likely contributors to India’s high infant mortality rate of 30 deaths per 100 live births (Asadullah and Chaudhury 2011). Children are highly susceptible to arsenic poisoning due to lower immunity and a greater proportion of water in their bodies than adults. Drinking arsenic-contaminated water during pregnancy is also associated with stillbirths and adverse child growth outcomes (Watanabe et al. 2007, Kile et al. 2016). However, it is possible for mothers to protect their children from arsenic by increasing the duration and intensity of breastfeeding, since arsenic in breast milk is negligible regardless of arsenic exposure from drinking water (Keskin, Shastry and Willis 2017, Garcia Salcedo et al. 2022).

In 2019, the Jal Jeevan Mission (JJM) was launched by the Government of India, with the aim to provide regular supply of safe drinking water to rural households at affordable prices. However, being a demand-driven water supply scheme, it relies on the initiative of the village water user committees and households to apply for private tap water and maintain the infrastructure. While the model is likely to work in most Indian states, the demand for private water remains low in the rural regions of Assam, due to the abundance of alternate sources of water (Assam is a water-surplus state) and the cultural dependence on groundwater.

Why is there a lack of demand for government-supplied tap water in rural Assam?

Theoretically, one could think of at least three reasons for a low demand for tap water. First, households make choices based on their knowledge of the health production function¹(Gronau 1997) and in case there is incomplete information, households may make suboptimal choices. Consistent with this, Madajewicz et al. (2007) found that randomly chosen households in Bangladesh who were informed that their water was arsenic-contaminated were 37% more likely to switch sources. Second, poor households may be financially constrained leading to underinvestment in household infrastructure including water supply. Third, government schemes that provide universal access to necessities, such as electrification, gas, and water supply involve substantial transactional complexity that may be too burdensome for households to navigate (Blankenship et al. 2020). While liquidity constraints are important determinants of demand for water quality in areas where alternative cheaper sources of water are not available and people have to walk for miles to access water, this is not a constraint in the geography that we are focusing on – according to the 76^th round of the National Sample Survey (NSS),10.5% of rural households in India spend over 30 minutes collecting water, as compared to 10 minutes, on average, in Assam (lowest in India). Thus, in our study, we focus on the two remaining constraints, namely, information and transaction costs.

The experiment

In November 2021, we partnered with the National Health Mission (NHM), Government of Assam, and the Public Health Engineering Department (PHED) to conduct a randomised controlled trial in Titabor block of Jorhat district in Assam. According to government data, Titabor has arsenic concentration between 194 to 491 micrograms per litre, much beyond the WHO safety limit of 50 micrograms per litre, and with most of the population highly dependent on tube wells and borewells for their water needs. The NHM provided the listing of households with young children (0-6 years) and pregnant women in Titabor based on data collected by Accredited Social Health Activists (ASHA)². The villages were randomised into one ‘control’ (no intervention) and two ‘treatment’ groups (subject to intervention), namely, an information treatment and an ‘information plus transaction costs’ treatment group, for a total of 2,064 households across more than 80 villages.

The information group was shown a video in the local language informing them about arsenic in groundwater, the health impact of arsenic on children and pregnant women, alternative sources of safe drinking water, and the importance of breastfeeding to safeguard young children from exposure to arsenic-contaminated water. The second treatment group, in addition to the video, was given administrative information and detailed information about the procedure to apply for a private government supplied water connection. They were also helped in filling out and submitting the application form.

Key findings

The treatment increased arsenic specific awareness and knowledge and the information treatment alone was sufficient to increase adoption of water safety practices; there was a 12-percentage point increase in usage of community tap water, rainwater harvesting or bottled water. Interestingly, only the combined treatment showed a positive significant increase (of 128%) in demand for piped water relative to the control group. This shows that information alone is not sufficient to translate into higher demand for water. Rather, it needs to be combined with simple paperwork and less complex administrative requirements to induce more household demand for water.

Further, mothers and pregnant women in the combined treatment were more likely to increase both the probability and frequency of breast-feeding after the intervention. For the combined intervention, the probability of breastfeeding rose by 4 percentage points and the duration of planned breastfeeding increased by 2.6 months. While women in both treatment groups were able to evaluate the benefits of breastfeeding, the combined treatment impacted breastfeeding behaviour because the women were able to also evaluate time costs since they were now more aware of the time costs of obtaining safe drinking water.

Finally, we find that female-headed households and low-income households were more likely to observe their child being sick post the information intervention. Our intervention also led to an increase in willingness to pay for water among poor households.

Policy implications

Our results suggest a simple cost-effective strategy to increase the take-up of government water supply schemes. There is a need to combine water quality awareness with a reduction of transaction costs, through simplification of the paperwork and submission processes, and easing of administrative constraints. This will help in increasing demand for public water schemes and improve overall health and well-being of the intended beneficiaries.

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Notes:

A health production function is a function showing the maximum impact a variety of factors (such as education, income, information levels, and so on) can have on the health of an individual or family.
ASHAs are community health workers – usually women – instituted by the Ministry of Health and Family Welfare as part of the National Rural Health Mission.