Cost effectiveness of hygiene promotion A contribution to monitoring hygiene outcomes and inputs
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Cost effectiveness of hygiene promotion A contribution to monitoring hygiene outcomes and inputs

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By Alana Potter and Melanie Carrasco.

By Alana Potter and Melanie Carrasco.
Prepared for the Monitoring Sustainable WASH Service Delivery Symposium, 9 - 11 April 2013, Addis Ababa, Ethiopia

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  • We manage what we measure.. and we monitor what we’re measured against.
  • Note plus user education
  • Gap for future research
  • WASHCost Working Paper 6 developed the conceptual approach of cost-effectiveness of hygiene interventions and argued for the need to move from an intervention approach toward a service delivery approach in order to ensure sustainable sanitation service delivery Working Paper 7 developed a methodology and tools to assess this cost-effectiveness The methodology (WP7) was tested in Burkina, Mozambique and Ghana, published in 2013 as Briefing Notes
  • Explain that: we have 5 levels For each level, each of the 3 key indicators (HW, use of latrines and safe water) is characterized But how to put HH assessed in the frame of a study/project in each of the category?
  • Explain that: we have 5 levels For each level, each of the 3 key indicators (HW, use of latrines and safe water) is characterized But how to put HH assessed in the frame of a study/project in each of the category?
  • Explain that: we have 5 levels For each level, each of the 3 key indicators (HW, use of latrines and safe water) is characterized But how to put HH assessed in the frame of a study/project in each of the category?
  • To do so, we use a decision-making tool: a flowchart, that has been developed for each of the 3 key hygiene behaviours. (Describe the flow chart through an example along the logical chain) For each HH, and depending on the answer to the questions, a category will emerge: no effectiveness, limited, etc.
  • Focus on the main ones: CapEx, CapManEx, OpEx
  • Focus on the main ones: CapEx, CapManEx, OpEx

Cost effectiveness of hygiene promotion A contribution to monitoring hygiene outcomes and inputs Cost effectiveness of hygiene promotion A contribution to monitoring hygiene outcomes and inputs Presentation Transcript

  • Cost effectiveness of hygiene promotionA contribution to monitoring hygieneoutcomes and inputsAlana Potter and Melanie CarrascoIRC International Water and Sanitation Centre
  • Outline1. Why hygiene cost effectiveness?2. Financing hygiene promotion3. Costs and services4. Methodology5. Testing results and findings – Burkina, Ghana,Mozambique6. Conclusions7. RecommendationsCost and effectiveness of hygiene promotion components, WASHCost Mozambique, Alana PotterMonitoring Sustainable WASH Service Delivery Symposium
  • 1. Why hygiene cost-effectiveness?• Contributing to a credible evidence base on thecost-effectiveness of hygiene promotion:– Helps advocate and substantiate continued andimproved investment in hygiene promotion– Strengthens sector knowledge on the kinds ofinterventions that are effective– Helps with quality assurance of HP interventions• Hygiene behaviour changes need to be measurableto monitor (and manage), and to demonstrateeffectivenessCost and effectiveness of hygiene promotion components, WASHCost Mozambique, Alana PotterMonitoring Sustainable WASH Service Delivery Symposium
  • 1. Why hygiene cost-effectiveness?• We all know that unless improved water andsanitation services are used hygienically, health andsocioeconomic benefits will not be realised.• We have limited knowledge of financial benchmarksfor water and sanitation improvement, even less forhygiene 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?Cost and effectiveness of hygiene promotion components, WASHCost Mozambique, Alana PotterMonitoring Sustainable WASH Service Delivery Symposium
  • 2. Financing hygiene promotion• Like rural sanitation, hygiene practices are viewed asa private good, and public resources are used toleverage household investments. The link betweenfunds and outcomes becomes less clear.• HP has public and private costs and benefits. Thesuggested principle is that public funds (taxes andtransfers) should be used to maximise publicbenefits and private funds (“tariffs”) should beused for arguably private elements such as soap,individual latrines, etc.Cost and effectiveness of hygiene promotion components, WASHCost Mozambique, Alana PotterMonitoring Sustainable WASH Service Delivery Symposium
  • 3. Costs and service levelsCost and effectiveness of hygiene promotion components, WASHCost Mozambique, Alana PotterMonitoring Sustainable WASH Service Delivery Symposium• Costs of/ finances for what?• W&S service levels developed by WASHCost to enable crosscountry comparison, to generate useful cost data linked tocommensurate service levels, and for advocacy purposes.• But is hygiene promotion a service?• HP can be seen as a public or environmental healthfunction and therefore as part of a service led (ideally) bypublic or environmental health departments, or by thesanitation provider or utility.• However, water and or sanitation infrastructure-relatedhygiene promotion is usually an ‘intervention’ that happensin project cycles.
  • 3. Costs and service levelsCost and effectiveness of hygiene promotion components, WASHCost Mozambique, Alana PotterMonitoring Sustainable WASH Service Delivery Symposium• Although hygiene promotion interventions are conceptuallypart of broader public and environmental health services,they are rarely planned, managed and or implemented inan integrated manner.• Improved integration of water and sanitation-relatedhygiene promotion interventions within a framework ofbroader public and environmental health services willstrengthen the overall impact of WASH services.• Realistic scope for testing HCE methodology: focussed onWASH related HP interventions, so we developed andtested hygiene effectiveness levels, not service levels.
  • Working Papers 6 & 7Cost and effectiveness of hygiene promotion components, WASHCost Mozambique, Alana PotterMonitoring Sustainable WASH Service Delivery Symposium1 – Context of the study
  • 3. Methodology• Focus on 3 key hygiene behaviors (based on literaturereview) to assess the effectiveness of a hygiene promotionintervention:1. Faecal contamination and use of latrines2. Hand washing with soap or substitute after defecationand before handling food3. Drinking water source and management of drinkingwater at household level• Based on these 3 indicators, a hygiene effectiveness ladderwas developedCost and effectiveness of hygiene promotion components, WASHCost Mozambique, Alana PotterMonitoring Sustainable WASH Service Delivery Symposium
  • Hygiene effectiveness ladder (summary)Cost and effectiveness of hygiene promotion components, WASHCost Mozambique, Alana PotterMonitoring Sustainable WASH Service Delivery Symposium
  • Hygiene effectiveness ladderCost and effectiveness of hygiene promotion components, WASHCost Mozambique, Alana PotterMonitoring Sustainable WASH Service Delivery SymposiumEffectivenesslevelFaecal containment andlatrine useHandwashing withsoap/substituteDrinking water sourceand managementImproved• All household membersuse a latrine all the time• The latrine usedseparates users fromfaecal waste• Accessible designatedhandwashing facility• Sufficient water isavailable forhandwashing• Water for handwashingis poured/ not re-contaminated byhandwashing• Soap or substituteavailable and used• All household memberswash their hands withsoap/ substitute atcritical times• Protected water sourcesare always used• Collection vessel (ifnecessary) is regularlycleaned with soap orsubstitute• Water storage vessel (ifnecessary) is covered• Water is drawn in a safemannerBasic• All or some householdmembers use a latrinesome or most of thetime• When there is no accessto a latrine, faeces aregenerally buried• The latrine separatesusers from faecal waste• Protected water sourcesare always used• Collection vessel (ifnecessary) is regularlycleaned with soap orsubstitute• Water storage vessel (ifnecessary) is uncoveredand/or• Water is not drawn in asafe manner
  • Hygiene effectiveness ladder cont.Cost and effectiveness of hygiene promotion components, WASHCost Mozambique, Alana PotterMonitoring Sustainable WASH Service Delivery SymposiumEffectivenesslevelFaecal containment andlatrine useHandwashing withsoap/substituteDrinking water sourceand managementLimited• The latrine does notprovide adequate faecalseparation and/or• All/some familymembers generally donot bury faeces whennot using a latrineand/or• All family memberspractice burying faeces• Most householdmembers wash theirhands after defecationbut not at other criticaltimes and/or• Water for handwashingis not poured and thesame water is usedeach time and/or• No soap or substitute isavailable and/or is notused for handwashing• Protected drinkingwater sources are notalways used and/or• Collection vessel is notcleaned (not collectedsafely)Not effective Open defecationHousehold membershave no specific placeto wash their hands andusually do not washtheir hands afterdefecationDrinking water nevercomes from an improvedsource
  • Flowcharts: decision-making toolsCost and effectiveness of hygiene promotion components, WASHCost Mozambique, Alana PotterMonitoring Sustainable WASH Service Delivery Symposium
  • Costs of hygiene interventions• The analysis includes ALL costs of the intervention:– At various stages: before (start-up), during(implementation) and after (maintenance) completionof the intervention– By different stakeholders: implementers, householdsand support costs (district and national)– For different types of costs: financial costs (monetaryinvestments) and economic costs (time spent)Cost and effectiveness of hygiene promotion components, WASHCost Mozambique, Alana PotterMonitoring Sustainable WASH Service Delivery Symposium2 – Conceptual background
  • Cost categoriesCost and effectiveness of hygiene promotion components, WASHCost Mozambique, Alana PotterMonitoring Sustainable WASH Service Delivery SymposiumCost Category DefinitionCapital ExpenditureHardware (CapExH)The capital invested in constructing fixed assets, e.g. handwashingfacilities.Capital ExpenditureSoftware (CapExS)One-off work with stakeholders prior to the implementation, e.g. trainingtrainersCosts of Capital (CoC) Costs of interest payments on loans, e.g. loans for household latrinesOperating Expenditure(OpEx) Operating and minor maintenance expenditure, e.g. monitoring costsCapital MaintenanceExpenditure (CapManEx)Expenditure on asset renewal, replacement and rehabilitation, e.g.replacing handwashing facilities, re-training community membersExpenditure on DirectSupport (ExpDS)Post-construction support activities for local-level stakeholders, users oruser group, provided at the district level, e.g. costs for supportingcommunity-based organizations at the district level
  • Cost categories in more detailCost and effectiveness of hygiene promotion components, WASHCost Mozambique, Alana PotterMonitoring Sustainable WASH Service Delivery Symposium
  • StepsFirst step: data collection on key behaviors and costs• At HH effectiveness level before and after theintervention:– Household surveys– Observational data• With implementers and districts:– Interviews– Project documents (budget and reports)• Market price dataCost and effectiveness of hygiene promotion components, WASHCost Mozambique, Alana PotterMonitoring Sustainable WASH Service Delivery Symposium
  • StepsSecond step: data analysis– Assess hygiene behaviour changes before and afterimplementation per household– Place costs collected into categories (e.g. CapEx,CapManEx, etc..) Compare costs against effectiveness of the interventionin hygiene behaviour changeCost and effectiveness of hygiene promotion components, WASHCost Mozambique, Alana PotterMonitoring Sustainable WASH Service Delivery Symposium
  • Cost-effectiveness of the interventionCost and effectiveness of hygiene promotion components, WASHCost Mozambique, Alana PotterMonitoring Sustainable WASH Service Delivery Symposium• 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 safemanner
  • Conclusions from the studiesCost and effectiveness of hygiene promotion components, WASHCost Mozambique, Alana PotterMonitoring Sustainable WASH Service Delivery Symposium• HP is most effective when implemented in the context ofintegrated WASH improvement• Results wrt % change across 3 core indicators enables thecomparison of the relative effectiveness of different HPinterventions 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 toadapt the intervention based on gaps
  • RecommendationsCost and effectiveness of hygiene promotion components, WASHCost Mozambique, Alana PotterMonitoring Sustainable WASH Service Delivery Symposium• 3 key hygiene behaviours can be integrated into routineperiodic monitoring of sustainable hygiene behaviourchange, linked to corrective action• As always, monitoring challenges is also an institutionalchallenge: better integration between W&S relatedhygiene promotion interventions and health services.Harmonisation of indicators and systems reducesmonitoring costs and resource requirements• Separate out and account for hygiene promotioninvestments (beyond the implementer) and outcomes –assists with advocacy, learning, management, bettermonitoring of efficacy, and linking costs with effectivenessenables choices
  • RecommendationsCost and effectiveness of hygiene promotion components, WASHCost Mozambique, Alana PotterMonitoring Sustainable WASH Service Delivery Symposium• Behaviour outcomes yes, but what about health impacts?• Correlate with diarrhoeal incidence• From monitoring the cost-effectiveness of hygienepromotion interventions to monitoring the outcomes andimpacts of hygiene services, linked to public and orenvironmental health• Given the multiplicity of variables affecting health(including hygiene practices), what about collaborationand harmonisation of indicators and monitoring systemswith environmental and public health?• Equity – are the poor being reached and are theybenefitting? (correlate HCE with poverty data)• Compare interventions and countries