The health benefits of clean drinking water, sanitation facilities and hygienic practices, like hand washing, are well known. But health is rarely the primary motivation for developing water and sanitation facilities, nor is it the health sector that usually pays for them. What are the real costs and benefits for human health of providing these services?

Researchers from the London School of Hygiene and Tropical Medicine have analysed the evidence to see whether water, sanitation and hygiene should be funded public health efforts.

The greatest health benefit is the reduction of diarrhoeal diseases, which are major causes of death among children in developing countries. The incidence of other diseases is also reduced, while further benefits are seen in social and mental well-being.

Considering the available evidence on costs and benefits for health, the following findings emerge:

• Health workers often focus on water quality, whereas ease of access and quantity of water available is equally or more important, since much disease transmission occurs because of lack of water available to use in the home (to wash away bacteria, for instance).
• The greatest reduction of diarrheal infections occurs where water is available in the household or very close to it.
• People are willing to pay for improved availability of water because it saves them a lot of time, which can be converted to income.
• They are also willing to pay for the status, comfort and security that comes with a private latrine, which need not be expensive or require a sewage system. All types of properly constructed and maintained latrines can reduce rates of disease at equal rates.
• Hygiene promotion schemes, especially those that promote hand washing, have a positive long term impact on both diarrhoea and respiratory disease, the two main causes of child death globally.

Improving quality and access to water, providing consistently used and maintained basic sanitation, and simple hygiene promotion could reduce the health and socio-economic costs of disease by three to four percent. For the health sector, paying for relatively inexpensive promotion and advocacy, this is very cost-effective, far more so than oral rehydration.  In order to achieve and improve on this cost-effectiveness certain principles should be followed:

• avoid subsidies for sanitation, which limit the numbers of facilities built, encourage the introduction of unaffordable systems and distort the market
• enact and enforce national and local regulation to encourage the take up of sanitation, for example by requiring landlords to provide sanitation for tenants
• make a single government authority responsible for sanitation
• encourage increased household water supplies by minimising one-off installation fees and recouping costs through monthly tariff increases
• promote hand washing, which has the greatest impact in hygiene improvements
• encourage a local, low-cost sanitation industry
• focus on the provision of a secure, reliable supply of water in, or very near to, each household.

For most people, the health benefits of these services are secondary to other benefits, for example, time saved in water collection. Users and sectors other than health pay the majority of costs. The health sector can further improve on the health benefits that result through advocacy, regulation and promotion, which have some small costs attached.

Source(s):
‘Water Supply, Sanitation and Hygiene Promotion’, Disease Control Priorities Project, Working Paper No. 28, by Sandy Cairncross and Vivian Valdmanis, July 2004 Full document.

Funded by: The Disease Control Priorities Project - a joint effort of The World Bank, the Fogarty International Center of the National Institutes of Health, the Bill & Melinda Gates Foundation, and the World Health Organization.

id21 Research Highlight: 6 June 2005

Further Information:
Sandy Cairncross
Department of Infectious and Tropical Diseases
London School of Hygiene and Tropical Medicine
Keppel Street
London WC1E 7HT England

Tel: +44 (0)20 7927 2637
Fax: +44 (0)20 7637 4314
Contact the contributor:  sandy.cairncross@lshtm.ac.uk

London School of Hygiene and Tropical Medicine, UK

Other related links:
The Case for Marketing Sanitation

Patronage, politics and toilets

'Who buys Latrines, Where and Why?' WSP Field Note

Beyond the source: keeping water clean in developing countries

The challenges of financing sanitation