Cost-Benefit Analysis of Sanitation

Equity and efficiency are both important considerations when it comes to evaluating intervention choices. In resource-constrained situations, one obviously wants to invest in an intervention which gives more “bang for the buck”. While a rights-based approach to development may consider the access to sanitation facilities and the dignity it affords, a basic human right, it may also be important to compare the costs of provision and the benefits arising from it.

The World Bank’s Disease Control Priorities in Developing Countries (DCP2) takes the perspective of Disability-Adjusted Life Years (DALYs), and looks at the expected reductions in diarrhea resulting from the provision of various levels of Water, Sanitation and Hygiene and arrives at the cost-effectiveness figures.

While the cost of oral rehydration therapy (ORT) to prevent diarrhea mortality is worked out to be USD 23/DALY, the construction of latrines is found out to be ~USD 270/DALY, well-above the World Bank’s cost-effectiveness recommendation cut-off (USD 150/DALY). On the other hand, ‘software’ interventions focussing on health and hygiene promotion were highly beneficial to health and cost-effective, ranging from USD 3.35/DALY to USD 11.15/DALY.

Often viewed solely on the basis of health grounds, sanitation provision is dismissed as too costly. But I strongly feel that this analysis simply doesn’t provide the full picture. In computing cost effectiveness of capital-intensive interventions like building sanitation infrastructure, we might want to consider the benefits over a longer term as opposed to amortising costs over a 5-year period. Also, there may no direct answer to the sanitation cost-effectiveness problem, and it may be that sanitation projects might clear the cost-benefit test if people want the projects and put a high priority on local ownership and operation and maintenance (Whittington 2008, 2010).

In other words, it may also be that these are not passing the cost-benefit test because they often fall into disuse, as a result of which benefits from it begin to decline. This is why Project Sammaan becomes all the more relevant.

While we propose communal sanitation as a solution for urban physical space constraints, as well as cost-constraints, we also try and solve the end-mile issues of sustainable management of the facilities and changing behaviour. Ultimately, I think the benefits of provision of sanitation infrastructure accrue beyond the realm of health. It is a health issue, but also a privacy and dignity issue, a gender rights issue, and an urban planning issue.

The reality of the fact that, according to the 2011 Census of India, less than half of India’s people live without using any kind of toilet or latrine, or that half of all the 1.1 billion people in the world who defecate in the open live in India, only strikes me harder with every visit to the field. Simply facility provision will not help – overcoming the “collective action” problem inherent in shared facilities, and enacting behaviour change will be the real challenge.