Academic journal article Bulletin of the World Health Organization

A Reassessment of the Cost-Effectiveness of Water and Sanitation Interventions in Programmes for Controlling Childhood Diarrhoea

Academic journal article Bulletin of the World Health Organization

A Reassessment of the Cost-Effectiveness of Water and Sanitation Interventions in Programmes for Controlling Childhood Diarrhoea

Article excerpt


Cost-effectiveness analysis (CEA) is commonly used as a major criterion for the allocation of resources within health programmes and related research activities. Child health programmes sponsored by the U.S. Agency for International Development (USAID) and other organizations generally rely on oral rehydration therapy (ORT) for the control of infant and childhood diarrhoeal disease and do not include water supply and sanitation (WSS) interventions. A principal reason for this is that WSS interventions are not perceived to be cost-effective, nor are they considered the responsibility of health service providers and donor- or NGO-financed child survival programmes. The origins of this view can be traced to an influential article by Walsh & Warren, (1). Using the logic of cost-effectiveness and the goal of decreasing infant and child mortality, Walsh & Warren argued against a broad public health strategy in favour of a strategy of selective primary health care: with a limited budget, select only the most cost-effective interventions to achieve maximum health impact. In the analysis presented by Walsh & Warren, the gross disparity between the cost-effectiveness of WSS, estimated at US$ 3600 per death averted (approximately US$ 10000 in 1996 prices), and selective primary health care, estimated at US$ 200-250 per death averted (US$ 600-750 in 1996 prices), seemed a strong justification for ignoring WSS interventions.

This article argues that the conclusions about WSS interventions made by Walsh & Warren are incorrect because they assumed that the full cost of the WSS infrastructure should be paid by the health programme. While the infrastructure component of WSS has an impact on child health, providing infrastructure is not the responsibility of the health sector or child health programmes. If the WSS interventions that are the responsibility of the health sector are identified, and only their costs assigned, health-sector WSS interventions are more cost-effective than generally perceived and are comparable to those for ORT (2).

The consensus treatment of WSS is not to dismiss it as unimportant but to treat it as an exception for the purposes of CEA (3-5). Feachem states the following:

"Special difficulties are inherent in applying cost-effectiveness analysis to interventions having multiple benefits, and water supply and sanitation present these difficulties in an extreme form (Berman, 1982, Briscoe 1984). In addition to their impact on diarrhoea rates among young children, these interventions may avert diarrhoea in other age groups, reduce the incidence of other infectious diseases and have a variety of benefits unrelated to health." (3)

Briscoe's suggested approach was to separate private and social benefits and argue that, from a government perspective, the costs relevant to the cost-effectiveness calculation are those of WSS, minus the amount that users are willing to, and should, pay themselves (6, 7). Our alternative approach, which relates to the potential for using WSS-related interventions as part of child survival programmes, is to focus on WSS interventions that can be implemented by the health sector and limit the costs to those coming directly from the health programme budget, while retaining the use of an appropriate health impact measure of effectiveness. "Improving water supplies and sanitation" and "promotion of personal and domestic hygiene" have been distinguished as two separate types of intervention, each with its own costs and effects (8). The effectiveness of each appears to be enhanced by the presence of the other. Even if there is no positive synergy between "software" and "hardware" interventions (i.e., if their joint effect is the same or less than the sum of the separate effects), a CEA that uses only the costs over which the health programme decision-maker has some control will yield results that are more informative and useful for allocating health programme resources. …

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