Cost-Effectiveness of Hygiene Promotion

Cost effectiveness of hygiene promotion
A contribution to monitoring hygiene
outcomes and inputs
Alana Potter and Melanie Carrasco
IRC International Water and Sanitation Centre

Outline
1. Why hygiene cost effectiveness?
2. Financing hygiene promotion
3. Costs and services
4. Methodology
5. Testing results and findings – Burkina, Ghana,
Mozambique
6. Conclusions
7. Recommendations
Cost and effectiveness of hygiene promotion components, WASHCost Mozambique, Alana Potter
Monitoring Sustainable WASH Service Delivery Symposium

1. Why hygiene cost-effectiveness?
• Contributing to a credible evidence base on the
cost-effectiveness of hygiene promotion:
– Helps advocate and substantiate continued and
improved investment in hygiene promotion
– Strengthens sector knowledge on the kinds of
interventions that are effective
– Helps with quality assurance of HP interventions
• Hygiene behaviour changes need to be measurable
to monitor (and manage), and to demonstrate
effectiveness

1. Why hygiene cost-effectiveness?
• We all know that unless improved water and
sanitation services are used hygienically, health and
socioeconomic benefits will not be realised.
• We have limited knowledge of financial benchmarks
for water and sanitation improvement, even less for
hygiene improvement.
• Planners and policy makers ask:
– Why invest in hygiene promotion?
– What works, where, and why?
– How much is enough?
– How do we know inputs are achieving outcomes?

2. Financing hygiene promotion
• Like rural sanitation, hygiene practices are viewed as
a private good, and public resources are used to
leverage household investments. The link between
funds and outcomes becomes less clear.
• HP has public and private costs and benefits. The
suggested principle is that public funds (taxes and
transfers) should be used to maximise public
benefits and private funds (“tariffs”) should be
used for arguably private elements such as soap,
individual latrines, etc.

3. Costs and service levels
• Costs of/ finances for what?
• W&S service levels developed by WASHCost to enable cross
country comparison, to generate useful cost data linked to
commensurate service levels, and for advocacy purposes.
• But is hygiene promotion a service?
• HP can be seen as a public or environmental health
function and therefore as part of a service led (ideally) by
public or environmental health departments, or by the
sanitation provider or utility.
• However, water and or sanitation infrastructure-related
hygiene promotion is usually an ‘intervention’ that happens
in project cycles.

3. Costs and service levels
• Although hygiene promotion interventions are conceptually
part of broader public and environmental health services,
they are rarely planned, managed and or implemented in
an integrated manner.
• Improved integration of water and sanitation-related
hygiene promotion interventions within a framework of
broader public and environmental health services will
strengthen the overall impact of WASH services.
• Realistic scope for testing HCE methodology: focussed on
WASH related HP interventions, so we developed and
tested hygiene effectiveness levels, not service levels.

Working Papers 6 & 7
1 – Context of the study

3. Methodology
• Focus on 3 key hygiene behaviors (based on literature
review) to assess the effectiveness of a hygiene promotion
intervention:
1. Faecal contamination and use of latrines
2. Hand washing with soap or substitute after defecation
and before handling food
3. Drinking water source and management of drinking
water at household level
• Based on these 3 indicators, a hygiene effectiveness ladder
was developed

Hygiene effectiveness ladder (summary)

Hygiene effectiveness ladder
Effectiveness
level
Faecal containment and
latrine use
Handwashing with
soap/substitute
Drinking water source
and management
Improved
• All household members
use a latrine all the time
• The latrine used
separates users from
faecal waste
• Accessible designated
handwashing facility
• Sufficient water is
available for
handwashing
• Water for handwashing
is poured/ not re-
contaminated by
handwashing
• Soap or substitute
available and used
• All household members
wash their hands with
soap/ substitute at
critical times
• Protected water sources
are always used
• Collection vessel (if
necessary) is regularly
cleaned with soap or
substitute
• Water storage vessel (if
necessary) is covered
• Water is drawn in a safe
manner
Basic
• All or some household
members use a latrine
some or most of the
time
• When there is no access
to a latrine, faeces are
generally buried
• The latrine separates
users from faecal waste
• Protected water sources
are always used
• Collection vessel (if
necessary) is regularly
cleaned with soap or
substitute
• Water storage vessel (if
necessary) is uncovered
and/or
• Water is not drawn in a
safe manner

Hygiene effectiveness ladder cont.
Effectiveness
level
Faecal containment and
latrine use
Handwashing with
soap/substitute
Drinking water source
and management
Limited
• The latrine does not
provide adequate faecal
separation and/or
• All/some family
members generally do
not bury faeces when
not using a latrine
and/or
• All family members
practice burying faeces
• Most household
members wash their
hands after defecation
but not at other critical
times and/or
• Water for handwashing
is not poured and the
same water is used
each time and/or
• No soap or substitute is
available and/or is not
used for handwashing
• Protected drinking
water sources are not
always used and/or
• Collection vessel is not
cleaned (not collected
safely)
Not effective Open defecation
Household members
have no specific place
to wash their hands and
usually do not wash
their hands after
defecation
Drinking water never
comes from an improved
source

Flowcharts: decision-making tools

Costs of hygiene interventions
• The analysis includes ALL costs of the intervention:
– At various stages: before (start-up), during
(implementation) and after (maintenance) completion
of the intervention
– By different stakeholders: implementers, households
and support costs (district and national)
– For different types of costs: financial costs (monetary
investments) and economic costs (time spent)
2 – Conceptual background

Cost categories
Cost Category Definition
Capital Expenditure
Hardware (CapExH)
The capital invested in constructing fixed assets, e.g. handwashing
facilities.
Capital Expenditure
Software (CapExS)
One-off work with stakeholders prior to the implementation, e.g. training
trainers
Costs of Capital (CoC) Costs of interest payments on loans, e.g. loans for household latrines
Operating Expenditure
(OpEx) Operating and minor maintenance expenditure, e.g. monitoring costs
Capital Maintenance
Expenditure (CapManEx)
Expenditure on asset renewal, replacement and rehabilitation, e.g.
replacing handwashing facilities, re-training community members
Expenditure on Direct
Support (ExpDS)
Post-construction support activities for local-level stakeholders, users or
user group, provided at the district level, e.g. costs for supporting
community-based organizations at the district level

Cost categories in more detail

Steps
First step: data collection on key behaviors and costs
• At HH effectiveness level before and after the
intervention:
– Household surveys
– Observational data
• With implementers and districts:
– Interviews
– Project documents (budget and reports)
• Market price data

Steps
Second step: data analysis
– Assess hygiene behaviour changes before and after
implementation per household
– Place costs collected into categories (e.g. CapEx,
CapManEx, etc..)
 Compare costs against effectiveness of the intervention
in hygiene behaviour change

Cost-effectiveness of the intervention
• An investment of 5 USD/ person/ year resulted in:
– 5% increase in basic latrine use:
• All or some household members use a latrine some or most of the time
• When there is no access to a latrine, faeces are generally buried
• Latrine separates users from faecal waste
– 28% increase in basic hand washing:
• Accessible designated handwashing facility
• sufficient water is available for handwashing
• water for handwashing is poured/ not re-contaminated by handwashing
• soap or substitute available and used
• All household members wash their hands with soap/ substitute at critical times
– 57% increase in basic drinking water management
• protected water sources are always used
• Collection vessel (if necessary) is regularly cleaned with soap or substitute
• Water storage vessel (if necessary) is uncovered and/or water is not drawn in a safe
manner

Conclusions from the studies
• HP is most effective when implemented in the context of
integrated WASH improvement
• Results wrt % change across 3 core indicators enables the
comparison of the relative effectiveness of different HP
interventions in facilitating three key hygiene behaviours:
– faecal containment and latrine use,
– hand washing and
– drinking water management.
• This nuance can help implementers and or districts to
adapt the intervention based on gaps

Recommendations
• 3 key hygiene behaviours can be integrated into routine
periodic monitoring of sustainable hygiene behaviour
change, linked to corrective action
• As always, monitoring challenges is also an institutional
challenge: better integration between W&S related
hygiene promotion interventions and health services.
Harmonisation of indicators and systems reduces
monitoring costs and resource requirements
• Separate out and account for hygiene promotion
investments (beyond the implementer) and outcomes –
assists with advocacy, learning, management, better
monitoring of efficacy, and linking costs with effectiveness
enables choices

Recommendations
• Behaviour outcomes yes, but what about health impacts?
• Correlate with diarrhoeal incidence
• From monitoring the cost-effectiveness of hygiene
promotion interventions to monitoring the outcomes and
impacts of hygiene services, linked to public and or
environmental health
• Given the multiplicity of variables affecting health
(including hygiene practices), what about collaboration
and harmonisation of indicators and monitoring systems
with environmental and public health?
• Equity – are the poor being reached and are they
benefitting? (correlate HCE with poverty data)
• Compare interventions and countries

Cost-Effectiveness of Hygiene Promotion

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