Presentation of a methodology IRC is using for assessing cost effectiveness of hygiene interventions. By Amélie Dubé and Mélanie Carrasco for the hygiene track of the 2014 WASH Sustainability Forum, RAI, Amsterdam, The Netherlands. 30 June - 1 July 2014.

1. Supporting water sanitation
and hygiene services for life
1st June, 2014
2014 WASH Sustainability forum
Cost-effectiveness of hygiene
interventions
A methodology
Amélie Dubé
Mélanie Carrasco

2. Outline
1. Objectives and scope
2. Methodological aspects
• Costs
• Behaviour changes
• Data collection
3. Practical example
COST EFFECTIVENESS OF HYGIENE INTERVENTIONS

3. 1. Objectives and scope

4. Objectives
This methodology has been used to assess:
1. What is the behaviour outcome of hygiene interventions
2. How much does it cost to reach that outcome
By doing so, it aims at:
• Contributing to effective policy making and budgeting at all levels,
• Advocating for improved long-term investment in hygiene,
• Strengthening sector knowledge on the topic.
Ensure a sustainable behaviour change in population
Who should use this methodology ?
 Project implementers
 Service authorities
COST EFFECTIVENESS OF HYGIENE INTERVENTIONS

5. What do we mean by measuring
effectiveness?
COST EFFECTIVENESS OF HYGIENE INTERVENTIONS
Time Year 1 Year X
Scope of the
methodology
Good
Acceptable
Bad
Behaviour
Intervention
Intervention
Intervention
HEALTH
IMPACTS

6. – 2. The methodology
The costs
The behaviours
The data
The limitations

7. The costs

8. Looking at the costs
EXERCISE 1
You are planning and budgeting for an hygiene components to be
effective and last for the next five years
1. What costs will you need to plan for and budget?
2. Write each cost on a post-it (one cost per card)
COST EFFECTIVENESS OF HYGIENE INTERVENTIONS

9. Costs components
COST EFFECTIVENESS OF HYGIENE INTERVENTIONS

10. Looking at the costs
EXERCICE 1 (cont’d)
Please categorise your identified costs according to the life-cycle cost
components in the pie chart
Q&A
COST EFFECTIVENESS OF HYGIENE INTERVENTIONS

11. The behaviour changes

12. Behaviour indicators
EXERCICE 2
Buzz groups: if you could choose only two indicators to measure
behaviour change, which ones would you choose?
COST EFFECTIVENESS OF HYGIENE INTERVENTIONS

13. Behaviour indicators chosen
We cannot look at all the behaviours…
Our pick:
• Hand-washing with soap (after defecation/before eating)
• Use of safe sanitation facilities
• Domestic water management (from source to consumption)
…by households members
COST EFFECTIVENESS OF HYGIENE INTERVENTIONS

14. What do we mean by measuring
effectiveness?
COST EFFECTIVENESS OF HYGIENE INTERVENTIONS
Year 1 Year 2 Year 3 Year X
Time
Intervention
Intervention
Intervention
HEALTH
IMPACTS
Good
Acceptable
Bad
Behaviour
Improved
Basic
Limited
Not Effective
BehaviourEffectiveness
levels

15. Handwashing with soap (or
substitute) at critical times
Improved
A handwashing facility is available
Water for handwashing is not re-
contaminated by handwashing
Soap is available and used by household
members for handwashing
All household members wash their hands
at two critical times
Limited
Water for handwashing is not poured away
after washing and is re-contaminated
Soap is not available and/ or is not used
by household members for handwashing
Some household members wash their
hands at least one of the two critical times
Uneffective
Handwashing station is not available and
household members do not wash their
hands.
Behaviour 2
Hand washing
with soap at
critical times

16. Hand washing
with soap at
critical times

17. Domestic water management
from source to consumption
Improved
Domestic water always comes from an
improved source
The collection and storage vessels are
covered
Water is drawn using a vessel or tap
Basic
Domestic water always comes from an
improved source
The collection and storage vessels are
not covered AND/OR
Water is not drawn using a vessel or tap
Limited
Drinking water does not always come
from an improved source
Uneffective
Drinking water never comes from an
improved source
Behaviour 3
Domestic water
management
(from source to
consumption)

18. Domestic water
management
(from source to
consumption)

19. Faecal containment and
latrine use
Improved
All household members use a
latrine all the time
The latrine used separates users
from fecal waste
Basic
All or some household members
use a latrine some or most of the
time
The latrine used separates users
from fecal waste
Limited
The latrine does not provide
adequate separation between
users and fecal waste
All or some household members
use a latrine some or most of the
time
Uneffective Open defecation
Behaviour 1
Fecal
containment
and latrine use

20. Feacal
containment
and latrine use
Not
effective
Improved

21. Using the flow charts
EXERCICE 3 – per table:
1. Based on the example presented, fill-in the flowchart on your table
with help of the effectiveness ladder
2. Q&A and discussion

22. Data collection and limitations

23. Data collection
COST-EFFECTIVENESS OF HYGIENE INTERVENTIONS
• Households survey : Comprehensive survey, f2f and observations on
behaviours and costs data collection
– Paper based or via mobile technology (app)
• Cost survey : To be submitted to implementing agencies (NGOs,
local/national health and WASH authorities) involved in the intervention
– Paper based/Excel
• Other information on the intervention and on other present and past
intervention taking place in the intervention area

24. Limitations
• This approach rules out scenarios that could also
be considered as hygienic behaviour (e.g. burying
feces or using public latrines which are better than
open defecation)
• Economic costs for HH (sums spent on accessing
water from an improved source, time spent building
latrines etc..) are not taken into account
• It doesn’t take into account “interferences” from
other past or present overlapping interventions

25. 3. Practical example
Results from Ouahabou in Burkina Faso
Sustainability and ways forward

26. The example of Ouahabou, Burkina Faso
Burkina Faso :
• Human Development Index : 183/187 in 2012
(UNDP, 2013)
• Improved sanitation coverage in rural areas: 0,8
%; Water access in rural areas : 60% (Gov BKF,
2011)
The intervention (2011-2014) :
• Sanitation and hygiene programme, in 12 rural
communes
• CLTS like approach + subsidies for the poorest
• HH promotion campaigns for hygienic practices
Ouahabou village:
• 6,000 inhab; 822 HH surveyed

27. Data collection roll-out
November 2011 February 2012 November 2012May 2012
Stagesofthe
intervention
Data
collected
 Household costs
and behaviours
data
 Intervention
(implementing
NGO) costs
Baseline
Survey
CLTS
workshop 1
CLTS
workshop 2
Hygienic campaign in each HH
Mid-termSurvey
(continuing)
 Household costs
and behaviours
data

28. Looking at the implementer’s costs
USD 2012
Costs components NGO Cost for the village
of Ouahabou cost/household
Capital expenditure
(software) CapExS 239$ /year 0.29$ /year
Capital expenditure
(hardware) CapExH 43$ /year 0.05$/year
Recurrent expenditure
OpEx 54$/month 0.07$/month
Support costs NA NA
Cost of capital NA NA

29. EXAMPLE PRESENTATION TITLE
HH costs of hand-washing with soap
Before the
intervention
(Nov 2011)
After the
intervention
(Nov 2012)
Average cost of soap/HH 4.07 4.38
Average cost of soap but without a
latrine/HH 3.18 3.67
Average cost of soap and with a
latrine/HH 4.81 5.03
HH cost of latrine building and maintenance
Nb new latrines built since Nov 2011 69
Avrage CapEX /HH 22.38
OpEx /month /HH 0.39
Looking at household costs
USD 2012

30. Flow chart analysis
An example from Burkina Faso
Sensibilisation
on the type of
HW « facility »
and on the need
for sufficient
water made a
diffrence here

31. Hand washing with soap
89%
9%
2%
1%
69%
25%
4%
2%
0% 20% 40% 60% 80% 100%
Not effective
Limited
Basic
Improved
Population in Ouahabou (%)
Intervention
After
Before

32. Changes in fecal containment and latrine use
100%
0%
0%
0%
94%
1%
1%
4%
0% 20% 40% 60% 80% 100%
Not effective
Limited
Basic
Improved
Population in Ouahabou (%)
Intervention
After
Before

33. Domestic water source and management
24%
59%
3%
13%
31%
50%
5%
14%
0% 20% 40% 60% 80% 100%
Not effective
Limited
Basic
Improved
Population in Ouahabou (%)
Intervention
After
Before

34. Such changes…. for these costs?
Costs components
(USD, 2012) Implementer’s
cost /HH
HH cost
(average)
CapEx (S and H) 0,34$/HH 22,38$/HH
OpEx 0,07$/month/HH 5$/month/HH
• Conclusion: Low investment on facilities (CapEx) shows little
effect on behaviour change.
• For a latrine, HH spent 65 times more than the implementing
NGO!!
• On average HH spend 5$/month to maintain their “good”
behaviours, ie : to buy soap and maintain their latrines.

35. The added value of this methodology
• It provides a good indication of whether an
intervention is successful or not,
• It identifies where the bottle necks are in the
sequencing of behaviour changes,
• It indicates not only the costs involved to
obtain such a change, as it looks at the
sources of financing.
Currently being used and further developed in Bhutan, Bangladesh,
Ethiopia, Uganda, Sierra Leone and Burkina Faso…

36. How about sustainability?
Given the opportunity, the methodology can indicate (un)sustainable
behaviour changes and its associated costs
…but it doesn’t solve the bigger issues such as :
• How to ensure the regularity of hygiene interventions for
sustainable changes in populations?
• Who should finance and implement them?
• What is (should) be the role of public health, health and education
authorities in WASH-related hygiene interventions?
• How to (better) support populations (households) in maintaining
these behaviours?
EXAMPLE PRESENTATION TITLE

37. Visiting address
Bezuidenhoutseweg 2
2594 AV The Hague
The Netherlands
Postal address
P.O. Box 82327
2508 EH The Hague
The Netherlands
T +31 70 3044000
info@ircwash.org
www.ircwash.org
Supporting water sanitation
and hygiene services for life
Thank you!