Satisfaction and willingness-to-pay for water services in rural northern Ghana: Do we need intermediary steps toward safely managed services?

Universal access to safely managed water, defined as water from an improved source that is accessible on premises, available when needed, and free from contamination, remains far off in many low-resource settings. Progress toward safely managed services may include intermediate steps focused on improving some service attributes over others. However, knowledge surrounding households service preferences remains limited. This study explored satisfaction with existing water service characteristics and willingness-to-pay for hypothetical improvements in water supply. We conducted surveys with 1,748 households among 120 rural communities in northern Ghana. While few households (<2%) had safely managed water services, approximately half (52%) had at least basic access (i.e., an improved source where collection time is within 30 minutes). Satisfaction with existing water services was associated with source type, accessibility, availability, and perceived safety. For example, respondents who always had drinking water available in sufficient quantities had almost three times the odds of being satisfied (odds ratio [OR]: 2.66, 95% CI: 1.94-3.66), similar to respondents able to collect water within 30 minutes (OR: 3.09, 95% CI: 2.28-4.19) and those with on-premises water access (OR: 2.90, 95% CI: 1.26-6.66). Accessibility and water quality were particularly high priorities. Using discrete choice experiments, we estimated participants were willing to pay 3.6-4.9 times more for on-premises piped connections (compared with handpumps 30 minutes away) and chlorination (compared with no treatment). To a lesser extent, households were willing to pay for improved reliability, increased availability, and shorter collection times (10 vs. 30 minutes). Accordingly, we considered the possibility of introducing an intermediate service level: "proximate access", defined as using an improved source where water is collected within 10 minutes, available when needed, and (possibly) free from contamination. Such a category may provide feasible intermediate improvements to advance progress toward more highly valued safely managed services in rural, low-resource settings.