We recommended a $38.8 million grant to Evidence Action to support the Indian government in providing clean water by setting up in-line chlorination in two states, Andhra Pradesh and Madhya Pradesh.

This isn’t a grant designed to directly deliver a service or commodity; instead, Evidence Action will use the funding to work in close partnership with state and local governments, providing technical assistance to support the delivery of the program. Providing all rural households with access to clean, piped water is a major priority for the Indian government. In-line chlorination, which uses a device to automatically disinfect water by adding chlorine as the water passes through a pipe, is a way to make drinking water safe.

We believe this grant may not only increase access to chlorinated water in the states it directly supports, but also inspire other states to adopt similar practices. A core part of the program’s theory of change is that governments in locations outside the grant area may take up a program they might not otherwise adopt. This is the first very large grant we’ve made where that’s been an important consideration. We think the upside is unusually high—if successful, this grant could eventually lead to tens or even hundreds of millions of additional people receiving safe water—but it’s also riskier than most of our grants, as there are a number of ways the program could fail to have the desired impact. Our hope is that this grant will reduce mortality and improve health at a very large scale.

The rest of this post describes the importance of clean water, the benefits of partnering with government, why we think this opportunity has such a large potential upside, our estimate of the program’s cost-effectiveness, and some of our uncertainties. You can read the full rationale for the grant here.

Why is clean water important?

Consuming contaminated water can lead to intestinal infections that are sometimes fatal. The evidence we’ve reviewed suggests that improving water quality also reduces mortality from causes not directly linked to water quality, such as respiratory infections (more here).

We estimate that this program will reduce overall mortality by about 4% among people reached with in-line chlorination. Given that we anticipate the program may reach tens of millions of people over the course of around a decade, the impact could be huge—our very uncertain best guess is 75,000 deaths averted.

For a detailed review of how we estimate the reduction in mortality, see this section of our grant page and this section of our research report on water quality.

Why partner with the government, and why now?

In 2019, the Indian federal government took on an enormous project, Jal Jeevan Mission, with a mandate to bring clean, piped water to every rural household in India.

It’s challenging to set up systems to ensure that water is not just accessible but also clean; in-line chlorination is a promising technology to accomplish this. We think that Evidence Action can help increase the number of households reached by in-line chlorination by providing support to the government for work like:

• Installing the optimal in-line chlorination devices for each context (including, e.g., choosing between electric and non-electric devices, and between devices that use liquid chlorine and those that use chlorine tablets)
• Designing effective monitoring and evaluation systems, and troubleshooting problems that come up
• Training staff to implement in-line chlorination at the local level
• Establishing standard operating procedures for installing, maintaining, refilling, and monitoring the devices

Jal Jeevan Mission is a major national priority, and our sense is that the Indian government is very interested in working with Evidence Action to scale in-line chlorination.

Evidence Action also seems especially well-placed to support this program. It has experience scaling up water chlorination programs in Africa and is a pioneer in implementing in-line chlorination. Additionally, Evidence Action is already working with the Indian government to provide technical assistance (on school-based deworming and iron and folic acid supplementation programs, through Evidence Action’s Deworm the World and Equal Vitamin Access programs, respectively).

What gives this project such high upside?

This kind of partnership between a nongovernmental organization and a government body creates the opportunity to leverage government resources for higher impact. This grant is large—$38.8 million—but is a small fraction of the overall $44 billion committed by the government to Jal Jeevan Mission. Government investment of this scale means philanthropic support can be focused on providing technical assistance at the national and state level rather than on providing in-line chlorination itself.

We also see an exciting possibility of other states taking up in-line chlorination because of this grant. We expect Evidence Action to help the government develop standard operating procedures and monitoring and evaluation protocols for running in-line chlorination programs. Once these have been established, we think it will become easier for additional states to take up the program, and thus more likely they will do so.

One promising step in that direction is that Jal Jeevan Mission asked Evidence Action to lead a National Symposium on Safe Water and Chlorination Initiatives and invited state-level water officials from across the country to attend. Evidence Action has also participated in a number of additional national-level trainings. These initiatives and others like them may make it more likely that other states take up in-line chlorination, though we don’t yet know whether this has had an impact. If other states take up the program, Evidence Action may be able to provide similar technical assistance in those new areas.

How cost-effective does this grant seem?

Our cost-effectiveness estimate for this grant is much more uncertain than for our top charities. We used the cost-effectiveness estimate as one factor, but not the only factor, in our decision-making. We strongly weighed qualitative factors like the apparent level of government interest, Evidence Action’s enthusiasm about the opportunity relative to other programs it could take on, and expert views on the plausibility of the theory of change.

The goal of influencing other states makes the theory of change for this grant different than for most of our grants. In our analysis, about half the expected value of the grant comes from the two states where we’re funding Evidence Action’s work, and the remaining half is the expected value of prompting other states to take on in-line chlorination.

For this grant investigation, we devoted a lot of time to speaking to experts, including traveling to India to speak with government officials and discussing the grant with over twenty external contacts. These conversations helped us sense-check our assumptions. For example, we make assumptions about how many more people would be reached by in-line chlorination with Evidence Action’s support than in the absence of their technical assistance. The conversations also helped us better understand how policy change occurs in India.

Our best estimate is that this grant is 22x cash—i.e., we estimate that each dollar spent on this grant will create as much value as roughly $22 in unconditional cash transfers to people living in poverty. The expected value of this grant is an additional 26 million people receiving chlorination for ten years; that figure includes subjective adjustments for both the upside discussed above and downsides like the risk of the program being discontinued. Some of the most uncertain factors in our analysis are discussed in the next section.

What are we most uncertain about?

Our uncertainties are described in more detail on the full grant page. Here, we describe just a few key questions.

What is the effect of chlorination on mortality?

We have several outstanding questions about the effect chlorination has on mortality in general, and on mortality in India more specifically. Estimating this effect involves:

• Reviewing experimental evidence on the mortality reduction in children under five.
• Extrapolating that evidence and considering observational evidence to estimate an effect on mortality in people over the age of five.
• Considering data on water quality and diarrheal disease from India specifically, and reviewing evidence on water contamination in neighboring countries to help triangulate.

We discuss these estimates in more detail on our grant page. We’re quite uncertain about our estimates. For example, we think there’s a 50% chance that chlorination reduces mortality for all ages by somewhere between 1% and 7% (and a 50% chance that it reduces mortality by more or less than that range). If mortality were reduced by 1%, the program would have a cost-effectiveness of 5x cash, and if mortality were reduced by 7% the program would have a cost-effectiveness of 37x cash—so our assumptions here have a big impact on the bottom line!

Will the program fail to get off the ground or be discontinued?

We think there’s a relatively high chance (around 35%) that Evidence Action’s program is discontinued within two years, based on our general understanding that technical assistance programs are often discontinued. For the program to succeed, it will require government buy-in, infrastructure development, and the rollout of a new technology. To mitigate the risk of discontinuation, we set up “gates” that the program must pass in order for us to continue to provide funding. If the program is discontinued in Andhra Pradesh or Madhya Pradesh, we will also explore the possibility of rolling existing grant funding over to other states.

Will this program encourage other states to adopt in-line chlorination?

As mentioned above, around half the modeled benefits of the grant come from the possibility of other states implementing the program. Policy change is difficult to predict, and we’re particularly unsure how likely this is. Our estimates are based on Evidence Action’s experience scaling up school-based deworming in India, which is a different type of program (for example, it doesn’t require setting up infrastructure) and therefore may not predict outcomes for in-line chlorination.

How many people would access chlorinated water in the absence of Evidence Action’s support?

Our estimate of the pace of scale-up is based on historical trends of water treatment. However, it’s possible the government’s interest in water chlorination will change in the future. For example, interest may increase as people learn about the results of a recent meta-analysis on the effect of water treatment, including chlorination, on mortality.

We don’t know how good our estimates are for the parameters described above. We think it’s important to include them in our analysis so that the judgment calls we’re making are explicit. As the program develops, we’ll be able to learn more.

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We look forward to seeing what the Indian government and Evidence Action accomplish through this partnership. Our hope is that in-line chlorination will be adopted widely and that its implementation will be long-lasting, allowing many millions of people to access clean water.