Cost-effectiveness analysis of hygiene promotion interventions

This paper is a review of studies on cost-effectiveness analysis (CEA) of hygiene promotion as part of, or in addition to, water, sanitation and health programmes. The authors critically review the two main methodologies: general sector studies using DALYs (Disability Adjusted Life Years) and evaluations of specific projects or programmes.

Studies using DALYs to measure cost-effectiveness of hygiene promotion have very different findings. Research methods are complex and involve assumptions that are not easy to prove. Project and programme evaluation show the importance of evaluating all aspects, including inputs, processes, outputs and effectiveness of the interventions. Evaluations often focus on inputs and outputs and far less on the effectiveness in terms of measurably changed conditions and practices. It must also be carefully decided which results to measure: direct results, sustained results or also health impact. Health impacts are difficult to measure without using qualified health staff. Moreover, it makes no sense to measure impacts without first establishing that a critical mass of good conditions and practices has been achieved and sustained.

The authors conclude that:

• hygiene promotion has a substantial positive impact on people’s health, in particular on the reduction of diarrhoeal diseases;
• hygiene promotion is more cost-effective than other water and sanitation interventions;
• effectiveness is greatest in combination with improved and affordable and accepted water and sanitation services;
• more priority should be given to hygiene promotion as a separate component in a water and/or sanitation programme, or as a project or programme on its own.

They advise that:

• CEA becomes part of every proposal for and evaluation of water, sanitation and hygiene interventions. This makes it possible to compare hygiene promotion approaches and methods in terms of cost-effectiveness. The most cost-effective forms of hygiene promotion can then be retained and replicated. This way, CEA can ensure best ‘value for money’ to help achieve the MDGs;
• Project and programme planners become more aware of CEA methods and tools and their suitability for including in projects and programmes;
• A clear, simple and scientifically sound step-by-step methodology and manual for CEA studies is developed that can be used in projects and programs and produce valid data to better know the cost-effectiveness of different hygiene promotion interventions.

The development of such a practical CEA handbook and its testing in field situations are urgently needed.

Christoffers, Trea and Christine Sijbesma, 2004. Cost-effectiveness analysis of hygiene promotion interventions. Paper presented at the first Global Wash Forum organised by the Water and Sanitation Collaborative Council in Dakar, Senegal from 29th Nov to 3rd Dec 2004.

This paper is a background report for WELL Briefing Note 14. Both the full text of the background paper and the note are available online as PDF on the WELL website.