Estimating the costs and health benefits of water and sanitation improvements at global level Laurence Haller, Guy Hutton and Jamie Bartram ABSTRACT Laurence Haller (corresponding author) Institute F.-A. Forel, University of Geneva, Switzerland Tel.: +41 22 950 92 10 Fax: +41 22 755 13 82 E-mail: Laurence.haller@terre.unige.ch Guy Hutton Swiss Tropical Institute, Basel, Switzerland Tel.: +41 61 271 5900 Jamie Bartram World Health Organization, Geneva The aim of this study was to estimate the costs and the health benefits of the following interventions: increasing access to improved water supply and sanitation facilities, increasing access to in house piped water and sewerage connection, and providing household water treatment, in ten WHO sub-regions. The cost-effectiveness of each intervention was assessed in terms of US dollars per disability adjusted life year (DALY) averted. This analysis found that almost all interventions were cost-effective, especially in developing countries with high mortality rates. The estimated cost-effectiveness ratio (CER) varied between US$20 per DALY averted for disinfection at point of use to US$13,000 per DALY averted for improved water and sanitation facilities. While increasing access to piped water supply and sewage connections on plot was the intervention that had the largest health impact across all sub-regions, household water treatment was found to be the most cost-effective intervention. A policy shift to include better household water quality management to complement the continuing expansion of coverage and upgrading of services would appear to be a cost-effective health intervention in many developing countries. Key words | cost-effectiveness analysis, sanitation, water and sanitation costs, water and sanitation improvements, water supply INTRODUCTION Despite progress in recent decades, a significant proportion of the world’s population still does not use some form of improved water supply and sanitation. In 2004, an estimated 1.1 billion people were without access to safe water sources and 2.6 billion people lacked access to basic sanitation (WHO & UNICEF 2006). Poor access to safe water supply and sanitation services results in major threats to human health. Burden of disease analysis suggests that lack of access to a safe water supply, sanitation and hygiene is the third most significant risk factor for poor health in developing countries with high mortality rates (WHO 2002). Diarrhoea is the main disease associated with unsafe water and sanitation and is responsible for the deaths of 1.8 million people every year, 90% of which are children under five (WHO 2004). It is estimated that 1.6 million deaths per year are attributed to unsafe water supply and sanitation. This figure includes 88% of the deaths due to diarrhoeal diseases world-wide – which is considered to be the attributable fraction of diarrhoea due to unsafe water supply and sanitation (WHO 2002) – and 100% of the deaths from trachoma, schistosomiasis, ascariasis, trichuriasis and hookworm disease. Several other water and sanitation – related diseases are not accounted for in this figure, for example vector-borne diseases such as malaria and Japanese encephalitis which are linked to the development of water projects like dams or intensified irrigation schemes; and diseases related to chemical contamination such as unsafe concentrations of arsenic or fluoride in drinking water. The United Nations Millennium Declaration confirmed the central role of water in sustainable development and in efforts to eradicate poverty (UN 2000). Compelling evidence has demonstrated that improving the use of safe water, sanitation facilities and better hygiene behaviour results in a doi: 10.2166/wh.2007.008 467 Q WHO 2007 Journal of Water and Health | 05.4 | 2007 Downloaded from https://iwaponline.com/jwh/article-pdf/5/4/467/396785/467.pdf by guest on 30 May 2020