The elusive effect of water and sanitation on the global burden of disease
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TOPIC: The elusive effect of water and sanitation on the global burden of disease

The elusive effect of water and sanitation on the global burden of disease 18 Jun 2014 10:34 #8989

  • bracken
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Dear all,
I recently read the attached paper and found it fascinating. In a way it challenges the conventional wisdom that there is a de facto improvement in the burden of disease resulting directly from improved sanitation, hygiene and / or water supply interventions and calls for better and, more importantly, long term epidemiological monitoring of the situation.
As the paper states "A good sanitation marketing campaign may require 5 -10 years to achieve a marked increase in latrine coverage with the potential impact on health". National governments may even have difficulty committing to this kind of time scale, never mind donors.
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The following user(s) like this post: arno, Marijn Zandee, Florian, JKMakowka

Re: The elusiv effect of water and sanitation on the global burden of disease 18 Jun 2014 12:14 #8991

  • JKMakowka
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I would rather say that the conclusion of the article is that despite (very flawed) evidence that water & sanitation improvements have relatively little impact, it is still one of the most important health interventions. However due to the complexity of the issue (short term & conceptually limited) scientific studies fail to measure that.

While the article is more of an opinion piece, I very much agree with it... but how to advocate for a shift of public investment without so called "hard evidence" is one of the main issues the WASH sector is facing.
Krischan Makowka
“You never change things by fighting the existing reality. To change something, build a new model that makes the existing model obsolete” - Buckminster Fuller

Re: The elusive effect of water and sanitation on the global burden of disease 18 Jun 2014 16:18 #8993

  • bracken
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I think there a few issues brought up in the editorial which have been and remain very important regarding the WASH sector.

Firstly, and from my experience I would very much agree with this, is that within the framework of development cooperation sanitation in particular is still seen more of a convenience issue than a direct health intervention. This has of course led to the use of demand driven approaches and meeting the non-health related needs of the users / households and other market oriented approaches, all of which can only be welcomed, but does tend to "steal" the issue from the health sector somewhat - or in other words, it often lets health ministries of the hook with regard to their clear responsibility in supporting the improvement of general health conditions through supporting the improvement of sanitation and hygiene. Often the ministry of health isn't even directly involved in interventions at all. We can hardly expect then rigorous health monitoring when marketers are involved and not health professionals.

Secondly I find it interesting to see how biased monitoring and reporting of impacts easily attracts funders, desperate to report some kind of success. This not only applies to the handwashing and household treatment examples given, but I think also to the CLTS "bubble" of incredible numbers of ODF villages, and to a large extent to many UDDT projects over the last 10 years that reported through rose-tinted glasses. Fronts then build not along evidence based results but on ideological lines and energy is lost for actual progress. Given how quickly good results can obtain funding one can understand the tendency to optimistic reporting (as well as the fact that those involved really do believe they are making a dramatic difference), but it doesn't excuse it.
The whole childhood enteropathy discussion risks being sucked into this kind of debate I fear.

And yet the question remains - how to support a shift towards greater investment in the sector? Its not easy, less so knowing that "the literature on the impact of water supply, sanitation and hygiene is unreliable in its entirety".
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Re: The elusive effect of water and sanitation on the global burden of disease 19 Jun 2014 13:14 #8999

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Well, one could say that the entire focus on the health aspects is what brought the difficulties in measuring the impacts, as compared to the relative ease in the case of drugs (double bind tests etc.).

And certainly most people in developing countries seem more interested in the non-health benefits of water & sanitation infrastructure.

My point is basically, that other basic infrastructure projects seem to face much less scrutiny (well intended or not), i.e. huge amounts of public investments go into transportation and power infrastructure and you rarely hear of double-blinded impact studies and such for those.

I am for example sure that a in-depth study would reveal a horrible price/impact ration for road construction (as compared to rail-ways for example), yet it is one of the most well funded activities.

Similarly rural electrification often has very limited impact beyond some lightning and entertainment (for the richer), which could be provided much cheaper with decentralized solutions (e.g. solar powered).

Yet similarly to water & sanitation infrastructure the long term benefits of both are probably also quite significant but difficult to measure.
Krischan Makowka
“You never change things by fighting the existing reality. To change something, build a new model that makes the existing model obsolete” - Buckminster Fuller

Re: The elusive effect of water and sanitation on the global burden of disease 19 Jun 2014 13:19 #9000

  • Florian
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JKMakowka wrote:
I am for example sure that a in-depth study would reveal a horrible price/impact ration for road construction (as compared to rail-ways for example), yet it is one of the most well funded activities.

Similarly rural electrification often has very limited impact beyond some lightning and entertainment (for the richer), which could be provided much cheaper with decentralized solutions (e.g. solar powered).


I'm sure rural roads and elecrification have huge impacts on rural economy, generating income and alleviating poverty. As does water supply.

Very interesting discussion, but I need to read that article properly first...
Florian Klingel
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Last Edit: 19 Jun 2014 16:54 by Florian.

Re: The elusive effect of water and sanitation on the global burden of disease 20 Jun 2014 10:13 #9005

  • bracken
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I'd agree with you Florian. The Cost / Benefit analysis of rural roads (and even electrification) is probably relatively easy to perform simply by looking at rural economies, access to markets for agricultural goods and so on, and its easy to demonstrate the "bankability" of infrastructure projects in general.
Its much harder to show the effects of behavioural changes in society and even harder when there is a subjective eye on the monitoring of results (as needs to be done for sanitation and hygiene). The bias in reporting impacts seems at the moment somehow inevitable.

I saw this morning that IRC have picked up on this story on their relaunched E-Source weekly, adding some recent figures for their impact on the GBD of poor sanitation and hygiene. (Interesting too that they also mention environmental enteropathy in this context.) However the criticism remains the same. As the original author of the paper said when contacted to comment on the new WHO figures:

"The main problem with this review and analysis of the burden of disease attributable to poor water and sanitation are the same as with previous attempts: the included studies have substantial methodological problems. The effect estimates are largely a summary of the almost inevitable bias and confounding present in most of the included studies. The review may have been politically necessary to counter the even more questionable estimates from the recent Global Burden of Disease Study. However, one should be under no illusion as to the validity of the findings. While water and sanitation are likely to fundamentally improve people's lives, wellbeing and health in poor settings, epidemiological research may not be the right tool to prove this."

See here: www.ircwash.org/news/elusive-health-impa...-f9dd48ec3d-21332705
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Last Edit: 20 Jun 2014 10:20 by bracken.

Re: The elusive effect of water and sanitation on the global burden of disease 20 Jun 2014 14:24 #9008

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bracken wrote:
I'd agree with you Florian. The Cost / Benefit analysis of rural roads (and even electrification) is probably relatively easy to perform simply by looking at rural economies, access to markets for agricultural goods and so on, and its easy to demonstrate the "bankability" of infrastructure projects in general.
Its much harder to show the effects of behavioural changes in society and even harder when there is a subjective eye on the monitoring of results (as needs to be done for sanitation and hygiene). The bias in reporting impacts seems at the moment somehow inevitable.


I totally agree (and never meant to say anything else) that rural roads and electrification probably have a big impact (although I think railways are more cost effective).

What I mean is that those investment areas never had the kind of scrutiny applied to it. It is just considered to be working and some rather simplified economic analysis probably also shows that they have the intended impact.

However I am sure if one would start doing these kind of double bind etc. studies focussing on a single factor over a short period of time, the same kind of results as in WASH would come up, i.e. either badly designed and overly optimistic studies, or ones that fail to show a significant impact.
Take for example rural electrification: initially all it does is to allow some richer people to have a fridge and a TV... yet no-one really denies that the overall long term effects of it can probably lift people out of poverty.

The issue is really summed up by the original author's comment that a certain approach "may not be the right tool to prove" the impact of infrastructure improvements (or hygiene behaviour change interventions).

That said, I think it is good that these questions a raised and the fact of failure to show impact with such test-tools is thought provoking and should not just lead to a discarding of such tools without an alternative.
Krischan Makowka
“You never change things by fighting the existing reality. To change something, build a new model that makes the existing model obsolete” - Buckminster Fuller
Last Edit: 20 Jun 2014 20:39 by JKMakowka.

Re: The elusive effect of water and sanitation on the global burden of disease 20 Jun 2014 21:45 #9013

  • christian.rieck
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Very interesting discussion. I have also read the article and got renewed confirmation that health impacts are difficult to measure for practical reasons. Nicely summarised by Schmidt. Nevertheless as the Schmidt says rightly and what also Patrick says is that non-health impacts are equally if not more important depending on the context and aim of intervention. So justifying WASH interventions soley by health impacts are not the best way and anyway shortsighted.

At GIZ we conducted a deskstudy and had many discussions with reserach partners about this topic. There is surely potential to make WASH project more effective, also with regard to health impact. If there are proper indictors on adequate use of toilets and handwashing devices (at userinterface level) and also a functioning sanitation chain with safe disposal or reuse at the end, it should be a good proxy for assumed health impacts.

In the scenario of schools there is actually good evidence on health impacts. For example the longitudinal study of the Fit for School programme in the Philippines by GIZ has shown impressive improvements of BMI, dental health and school attendance of primary school children. The simple interventions of daily handwashing, toothbrushing and bi-annual deworming have proofed to be effective measures for the Philippines. see the study here www.biomedcentral.com/1471-2458/13/256

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Re: The elusive effect of water and sanitation on the global burden of disease 22 Jun 2014 08:56 #9021

  • dietvorst
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Great discussion, I will ask Wolf-Peter Schmidt, the author of the "The elusive effect of water and sanitation on the global burden of disease", if he wants to join in.

As Schmidt mentions in his editorial, it would be much better to focus on the socioeconomic benfits of WASH. That being said, the current figure "For every $1 invested in water and sanitation, $4 is returned in economic returns (Hutton, 2012)" would need to be "downgraded" as the calculations are partly based (10-25%) on assumed health care savings (WHO/HSE/WSH/12.01).

Interesting to note, is that the much discussed CLTS evaluation study commissioned by Plan Australia, actually found that health was the most cited motivator for initially building a latrine in both ODF and OD households and for maintaining a latrine in ODF households.

Maybe we should move away from "demand creation" to asking people (men, women, children, disabled etc) what their priorities are. If that's some form of WASH (and often it is), half our work is done. Beware the tyranny of experts.
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Re: The elusive effect of water and sanitation on the global burden of disease 24 Jun 2014 14:06 #9053

  • bracken
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I'm not sure if there is necessarily a justification for downgrading the return on investment figures simply because they are based in part on health care saving.
These health care savings will almost certainly occur, even if the necessary monitoring methodologies and structures do not currently exist to exactly quantify them.

I suppose the challenge lies in identifying suitable indicators and proxies that can be used to measure other noticeable improvements in living standards as a result of WASH interventions in the field, and which are not necessarily reliant on self-assessment of households or of the programme implementers. It seems to me that much of the problem comes directly from the bias in this method of assessement and the rose coloured glasses of all involved. This is then further complicated by the difficulty in carrying out trials monitoring health indicators

The Philippines study from GIZ certainly looks impressive at first glance (particularly to me, as I am not a health professional) and surely merits a closer look. Would of course be interesting to hear Wolf-Peter Schmidt's opinion on it.
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Re: The elusive effect of water and sanitation on the global burden of disease 25 Jun 2014 11:42 #9074

  • dietvorst
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Christian wrote

At GIZ we conducted a deskstudy and had many discussions with reserach partners about this topic


Dear Christian, could you please share this study on WASH impact with us? I could not find it immediately on the GIZ website.

Bracken wrote:

I'm not sure if there is necessarily a justification for downgrading the return on investment figures simply because they are based in part on health care saving. 
These health care savings will almost certainly occur, even if the necessary monitoring methodologies and structures do not currently exist to exactly quantify them. 


I would argue that downgrading the figures is justified when you consider the limited resources available for investing in development interventions. Otherwise you raise the false expectation that investing in a single intervention like WASH will automatically lead to large economic benefits in the form of improved productivity.

Similarly we like to think that there is a causal link between improved social services, including WASH, and peace. The millions invested in social services in South Sudan up to the end of 2013 have not brought peace because of underinvestment in security, good governance and employment for young men/former liberation fighters.
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Re: The elusive effect of water and sanitation on the global burden of disease 25 Jun 2014 12:21 #9076

  • JKMakowka
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If return of investment figures from health interventions are based on flawed and overly optimistic studies (which most likely they are) then they certainly need to be downgraded.

However one maybe almost too common-sense fact (but seemingly still overlooked) is that these interventions are always to be seen in a complex setting. There can not be a direct causal relation in the sense that there are so many other factors that can effect the outcome. For example, even the best household/personal hygiene practises and WASH infrastructure will not show much effect if people do unprotected manual work in rice paddies flooded with highly polluted river water.
In most cases WASH services are also not the last but one of the first of many interventions to allow good development and thus returns from later interventions (like electrification) are probably overstated comparatively.

dietvorst wrote:

Similarly we like to think that there is a causal link between improved social services, including WASH, and peace. The millions invested in social services in South Sudan up to the end of 2013 have not brought peace because of underinvestment in security, good governance and employment for young men/former liberation fighters.


Anecdotal evidence actually points in the opposite direction, e.g. that improved social services by "outsiders" lower the cost of conflict and often prolong it (Edit: article link).


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Krischan Makowka
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Last Edit: 26 Jun 2014 12:30 by muench.
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