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

Alana Potter and Melanie Carrasco IRC 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. 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 latrines2. Hand washing with soap or substitute after defecation and before

handling food3. 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 toolsCost and effectiveness of hygiene promotion components, WASHCost Mozambique, Alana Potter


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 categoriesCost and effectiveness of hygiene promotion components, WASHCost Mozambique, Alana Potter


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 detailCost and effectiveness of hygiene promotion components, WASHCost Mozambique, Alana Potter


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 a contribution to monitoring hygiene outcomes and inputs

Technology

hygiene promotion components

relatedhygiene promotion interventions

hygiene promotion

hand washing

hygiene cost

collection vessel

service levelscost

washcost mozambique