Academic journal article Bulletin of the World Health Organization

Cost Effectiveness of a Latrine Revision Programme in Kabul, Afghanistan

Academic journal article Bulletin of the World Health Organization

Cost Effectiveness of a Latrine Revision Programme in Kabul, Afghanistan

Article excerpt


WHO estimates that diarrhoeal diseases are the third leading cause of infectious disease-related mortality, claiming approximately 2.2 million lives annually (1). Children under 5 years account for an estimated 2 million deaths and 1.5 billion bouts of diarrhoea annually (1).

Numerous studies have examined the impact of improvements in water and sanitation facilities on diarrhoeal disease (2-6). Most of them have reported positive effects (4), although many of them have encountered methodological problems (7). A review from more than 28 countries reported a 26% median reduction in morbidity and a 55% reduction in all-cause child mortality rates among the most rigorous studies. A 65% median reduction in diarrhoeal-specific mortality rates was also reported, although this was based on only three studies. Reductions in morbidity due to other diseases were also observed, suggesting that water and sanitation interventions can improve a range of health outcomes (4).

Despite this, funding for these interventions has declined, primarily because the interventions are perceived to be less cost-effective than other primary health care approaches to diarrhoeal disease (8-10). Although the health benefits of other primary care interventions are widely acknowledged (5, 11), critics argue that water and sanitation interventions are still appropriate approaches to reducing rates of morbidity and mortality in general (9, 12, 13). Critics also argue that their cost-effectiveness has typically been underestimated because their positive indirect and long-term health effects are generally ignored (2, 8, 9). Better information on cost-effectiveness can assist policy development with respect to these interventions (14).

In August 1996, the International Committee of the Red Cross (ICRC) initiated a sanitary intervention in Kabul, Afghanistan. The intervention involved the construction of a new latrine or renovation of an existing latrine, resulting in both cases in a latrine providing approximately 2.1 [m.sup.3] of faecal matter storage, an underground soaking pit for urine, venting with nylon mesh, and a removable door allowing quarterly faecal matter evacuation.

The intervention was limited to 5 of 15 Kabuli districts. These districts comprised a total of 26 "project areas" areas defined for programme administration. All households in these districts were given the opportunity to participate in the programme. Construction costs were borne by both the ICRC and household owners, with ICRC providing materials and owners providing labour and recycled materials from old latrines whenever possible. By October 1998, 22 211 latrines had been constructed, providing an improved latrine for just over 57% of the five districts' 393 266 inhabitants. Other organizations also conducted latrine interventions in Kabul (such as German Agro Action), but these were generally focused elsewhere in Kabul and not well-represented in these five districts.

We assessed the cost-effectiveness of ICRC's sanitation intervention on paediatric diarrhoeal mortality. A case-control study enabled the impact of the programme on diarrhoeal morbidity to be estimated through multivariate modelling. Inferred reduction in diarrhoeal mortality was estimated from cause-specific mortality data derived from a stratified cluster sample that employed a verbal autopsy methodology. Finally, cost-effectiveness was calculated in terms of direct and indirect intervention costs per death averted. This study provides detailed cost data and contributes to recent demands for cost-effectiveness analyses of humanitarian interventions (15).


Programme effect

A case-control study design assessed the risk for diarrhoeal disease associated with the intervention. Cases and controls were recruited from five Afghani Red Crescent dispensaries over a 4-week period beginning on 26 September 1998. All children presenting at these dispensaries during this period were eligible for inclusion. …

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