Health Benefit-Cost Effectiveness of Water, Sanitation and Hygiene Improvements

By Nachiket Mor

In any discussion of primary health and interventions to promote health at the community level, the issue of Water, Sanitation and Hygiene Promotion invariably comes up. And, while access to water and the dignity afforded by latrines, may be regarded almost as a basic human right, for the purposes of debating healthcare intervention choices, it becomes important to examine the costs of such provision and compare them with the health benefits that result from it, so that in the event that limited resources are made available, the most cost effective intervention may be prioritised.

Professor Dale Whittington has extensively studied this issue and in a paper for the Copenhagen Consensus 2008 summarises his own findings and those of others:

1. Health Benefits from the provision of water, sanitation and hygiene promotion services are estimated to be between Rs. 30 to Rs. 45 per family per month. These are computed based on data from Delhi Slums in which Cost of Illness (COI) is estimated based on the amount of money required to treat the illness after it happens. While the Delhi Slum work is based on Typhoid, Professor Whittington cites other work to estimate similar numbers for Diarrhoea.
2. Cost of provision of piped water (network water) is estimated to be Rs. 1,800 per month per household assuming consumption of full required quantum of water or Rs. 450 per month assuming that the low-income households consume the minimal required per month.
3. Cost of bore-well water in rural areas is estimated at Rs. 100 per household per month while the cost of clean water using a bio-sand filter has been estimated at Rs. 65 per household per month.
4. Cost of Community Lead Total Sanitation (CLTS) campaigns has been estimated to be Rs. 15 per household per month.

This analysis suggests that if only health benefits were to be considered then none of the water provision efforts would be considered to be cost-effective but clearly efforts to improve sanitation and hygiene practices through behaviour change work would be quite beneficial and cost effective.

The World Bank’s Disease Control Priorities in Developing Countries (2nd edition: DCP2) looks at this issue from a DALY (Disease-Adjusted Life Years) perspective and finds that preventing diarrhoea provides more than 98% of the health benefits and that while the cost of promoting oral rehydration therapy (ORT) is Rs. 1,000 per DALY the cost effectiveness other water supply interventions is much higher at:

1. Hand Pumps: Rs. 4,230 / DALY
2. House Connection: Rs. 10,000 / DALY
3. Construction of Latrines: Rs. 12,150 / DALY

Like Professor Whittington, the DCP2 also finds that promotion of basic sanitation and hygiene is highly cost effective (Rs. 150 / DALY to Rs. 500 / DALY) relative to ORT and that all of the water supply interventions are much more expensive.

This analysis suggests that other than expenses related to the promotion of good hygiene and sanitation practices as a part of general health promotion messaging, resources for improved water and sanitation may best be found from other parts of the budget and other community resources and not directly from the health budget, particularly in resource constrained settings.