Mudaka
At baseline, a total of 843 households, representing 845 mothers and 1,328 under-five children, were surveyed in Mudaka. Average household size was 6.88 people, and almost a third (31%; n = 259) of mothers had less than one year of formal education, with only 22% (n = 184) having secondary education. At follow-up, 287 households, 288 mothers and 359 under-five children were surveyed, with similar average household sizes (6.90); 6% of households were Asili member families, and 46% (n = 133) were Asili user families. Overall household retention in Mudaka was 34% (287/843); local instability and widespread internal displacement contributed to difficulties in locating families at follow-up.
Households in Mudaka were segmented into three clusters (Fig. 2) by market segmentation analysis. All of the clusters contained households from different parts of Mudaka. Asili use ranged from 20% of households in Cluster 1 to 65% of households in Cluster 3. Asili membership was less frequent than Asili use across all clusters but did show a similar trend, as Clusters 2 and 3 reported higher proportions of Asili membership compared to Cluster 1, at 8% and 6% respectively.
Electricity, land ownership, mobile phone ownership, and maternal education were highest in Cluster 3 and lowest in Cluster 1. Comparing households in Cluster 3 to Cluster 1 across these variables, electricity was almost five times as prevalent (37% vs 8%), land ownership was almost 20% higher (57% vs 40%), mobile phone ownership was almost 10% higher (56% vs 64%), and the proportion of mothers who completed secondary education or higher was double (36% vs 18%).
Animal ownership, which was not stratified in the data, and food insecurity were highest in Cluster 1, at 62% and 57% respectively. Clusters 2 and 3 showed lower proportions of both, with animal ownership at 53% for Cluster 2 and 49% for Cluster 3, while food insecurity was reported at 56.6% in Cluster 2 and 49% in Cluster 3.
The trends in these proxy measures of wealth suggest that Asili use decreases with declining wealth. This finding was reflected by participants in focus group discussions in Mudaka:
The biggest challenge in accessing Asili's services is the high price at its clinic and its standpipes.
While many participants expressed concerns about the high cost of using Asili’s services, some of them viewed this cost as marginal compared to the benefit of having healthier children:
…we cannot benefit from its [Asili’s] services without having money, but I emphasize that it has improved the health of my children because my children do not get as sick as before thanks to access to clean water and its cost, I do not spend a lot of money on care.
Panzi
In Panzi, a total of 890 households, with 892 mothers and 1,459 under-five children, were surveyed at baseline. An average of 7.04 people lived in each household; almost a third of mothers (29%; n = 256) completed primary school and almost half (44%; n = 387) completed secondary education. During follow-up data collection, a total of 513 households, representing 513 mothers and 832 under-five children, were surveyed; 1% of households were Asili members, and 43% reported using Asili services. Average household size at follow-up, 7.21 people, was similar to baseline. Overall household retention in Panzi was 58% (513/890) for similar reasons as in Mudaka, though Panzi’s more urban location and shorter time period between enrollment and follow-up likely allowed for higher retention.
In market segmentation analysis, households in Panzi were divided into three clusters (Fig. 3). Asili use ranged from 32% in Cluster 1 to 52% in Cluster 3. Asili membership in Panzi was less common than use; only 1–2% of any cluster were members. All three clusters contained households from different areas.
In Cluster 3, 64% of mothers in Cluster 3 reported having secondary or post-secondary education. In comparison, in Cluster 1, 25% of households had electricity, 83% of households had a mobile phone, and only 37% of mothers had secondary or post-secondary education.
Land and animal ownership, as well as food insecurity, were all highest in Cluster 1, at 25%, 36%, and 49% respectively. Cluster 3 had lower levels of all three variables, with land and animal ownership at 18% and 24% respectively and food insecurity at 38%, the lowest level across the three clusters. By contrast, electricity and mobile phone ownership were highest in Cluster 3, at 59% and 86% respectively.
Finally, flooring material varied by cluster. In Cluster 1, 58% of households had dirt floors, and 36% had cement floors. In Cluster 3, these proportions were inverted, with 54% of households having cement floors, and 37% of households having dirt floors.
As in Mudaka, trends across these characteristics—for example, highest proportion of electricity use, mobile phone ownership, and cement flooring in Cluster 3—indicate that use of Asili services in Panzi is associated with higher levels of wealth. One focus group participant asserted:
We did not use its services because of the lack of money, but if we had money, its services will be used without problem.
A second respondent stated:
The price of water remains the biggest challenge that drives us to not access Asili's services.
As in Mudaka, some survey respondents explained that although the cost of accessing services was high, they may save money overall due to the high quality of care provided at Asili clinics:
…Before when children were sick, we brought them in unreliable health structures and which did not give them good medications, and this led to relapses and so parents had to spend at all times. But with the arrival of Asili the child gets sick and he goes to Asili for healing only once.