The COVID-19 pandemic has not only highlighted the critical importance of hygiene in mitigating disease transmission, but has also drawn attention to hygiene inequities and knowledge gaps. Initially the pandemic necessitated a rapid increase in the availability of handwashing facilities and led response actors to scale-up hygiene promotion. As we move into a more protracted phase of the response, WASH sector actors have the opportunity to advocate for greater investment in hygiene programming, both to control the spread of COVID-19, improve resilience to future outbreaks and to reduce the burden of chronic health challenges like diarrhoeal disease. However, this new momentum around hygiene has also highlighted that we still know little about the costs of hygiene interventions and the cost-effectiveness of different types of hygiene programming.
In this resource, we provide a summary of what is known about the economic case for handwashing. The content of this resource is designed to aid decision makers as they develop costed national hygiene roadmaps or as they advocate for greater investment in hygiene. The resource explains what types of costs are normally involved in hygiene programming, the state of national hygiene funding, types of economic analyses (cost-benefit vs cost-effectiveness) and what is known about the returns on investment from hygiene programmes. Lastly it includes actions that implementers can take to advance our understanding of hygiene programming costs and benefits.
What is known about the costs of hygiene programming?
The costs of hand hygiene programmes involve more than the cost of soap and water. There are two major cost components at the time of intervention delivery:
- the cost of promotional activities (often termed ’software’), such as door-to-door visits, community meetings, radio/TV advertising, communication materials, human resources, and associated management costs,
- the cost of ‘hardware’ consumables and equipment, such as handwashing facilities, soap, or hygiene kits. Here are two examples of hygiene kits that are offered by UNICEF and Red Cross.
There are also costs that occur later on across the intended lifespan of the handwashing station including the replacement of consumables such as soap and water, equipment repair and replacement, and human resources to attend to the replenishment of soap, water supply, and cleaning (tank, contact surfaces). Maintenance of promotional activities may also be required.
Determinants of costs
Costs associated with hygiene programmes are highly context-specific, making it challenging to provide benchmark cost figures. The cost per person of delivering programmes is likely to vary and may depend on at least the following factors:
- The nature and intensity of promotion activities
- The quantity, quality and durability of hardware delivered
- Economies of scale (e.g. delivering a programme to 50,000 people may have a lower cost per person than delivering it to 1,000, if fixed costs are high)
- Local economic factors in the country and setting (e.g. markets, staff salaries, macroeconomic factors, and the remoteness of the location).
- Whether and how hygiene promotion is integrated with sanitation and water interventions, which may increase or reduce efficiency depending on the context.
The ways costs are measured
The cost estimate will be different depending on whether it is measured as a financial or economic cost or whether costs are calculated from the provider or societal perspective. The two ways of defining costs are defined below:
Financial costs - The value of resources that are directly ‘paid for’
Economic costs - This includes the financial costs together with any other resources that contribute to the programme irrespective of payment (e.g. the value of land provided for free or time and equipment that has been donated in-kind).
The two main perspectives are:
Provider perspective - only include costs that are borne by the service provider (e.g. the agency delivering and/or paying for the intervention).
Societal perspective - this includes the provider costs plus any costs borne by other stakeholders (e.g. soap purchased by households, or the time they devote to participation in promotion activities).
Many studies and resources report provider financial costs, which is what a service provider would actually pay to deliver a hygiene intervention. However, the relative size of additional costs included under the societal perspective may have an important influence on whether an intervention is successful. For example, interventions which are highly costly for users may have low rates of uptake and adherence.
World Bank costing model
One synthesis of cost evidence is a World Bank costing model covering 140 countries. The authors reviewed literature on intervention costs and estimated the cost of ‘basic hygiene’, meaning the availability of a hand-washing station in the household with soap and water present. The graph below presents median values from the study’s raw data, for the initial hardware costs, initial software costs and subsequent recurrent costs, separately for urban and rural areas. Considering financial costs from the provider perspective and based on this graph, it might cost a provider about USD 5-6 per person (USD 25-30 for a five-person household) to deliver a fully-subsidised hand-washing station (hardware) and promote hygiene (software). These figures are in 2015 prices. The recurrent cost represents the annual household-borne cost of soap and water, which is not included under a provider perspective. Note that software is approximately twice the cost of hardware. This shows that one should not underestimate both the short and long term software resources required to facilitate handwashing behaviour.
Source: Author’s analysis based on data from Hutton & Varughese (2016)
It is necessary to be cautious when interpreting such estimates. First, these are median values of a wide distribution. The interquartile range (representing the middle 50% of estimates) was USD 3-16 per person for urban areas, and USD 3-8 for rural ones. Second, while the study included the cost of software, the type and intensity of the programmatic approach will have varied between the studies, which is not discussed in the review. Third, the estimates are based on a relatively small number of studies, and the process of extrapolation between countries could be driving a lot of the apparent variation. Finally, investing in lower-cost interventions might compromise effectiveness. This document provides guidance on planning for the costs of hygiene interventions. The following case study gives an overview of a wide-ranging, large-scale intervention in Burkina Faso which focused on hygiene promotion rather than delivering hardware and may have benefited from economies of scale.
Case study: handwashing with mothers in Burkina Faso
The study in urban Burkina Faso, just mentioned, undertook rigorous costing of a large-scale hygiene promotion programme in urban Burkina Faso, which targeted 37,000 mothers of children under the age of three. The intervention, described in detail in a separate paper, comprised:
The cost of establishing the programme and running it for three years was estimated to be USD 14 per mother from the provider perspective, and USD 22 from the societal perspective (these figures are adjusted for inflation and reflect the rate in 2019 USD). It is not easy to assess this as a per person or a per household cost because even though mothers were the primary target of the programme, other household members and teachers would have also benefited from some aspects of the intervention, and such benefits were not rigorously tracked by the study.
Regarding the costs of hygiene programmes, four messages are to be emphasised:
- Organisations planning hygiene initiatives related to COVID-19 should estimate their intervention costs carefully and document any assumptions about costs to be borne by other stakeholders (especially economic costs borne by households, to ensure their relative size can be considered).
- When using cost data generated by others, it is important to read documents carefully to assess what might be included and excluded (e.g. the perspective), and whether costs are reported per person, per household, per village, or some other denominator. These details are highly relevant to accurate transfer of cost estimates to other programmes, for planning purposes.
- Organisations delivering hygiene programmes should be encouraged to calculate and share cost estimates to compare and contrast, learn from one another, and to enable others to use the data for planning. Of particular importance are actual expenditures, which can be quite different from planned costs.
- Care should be taken in transferring cost estimates across different contexts, e.g., urban and rural, or countries with different levels of economic development. This is true because of both scale aspects that relate to population distribution and density, and to the costs of resources such as staff time.
What is known about the state of national handwashing funding?
Most countries report having a hygiene policy and/or plan, though these are often part of broader WASH sector strategies rather than standalone documents or plans. Of 109 countries responding to a UN survey, 79% reported having national policies for hygiene and 73% reported having a plan. However, few governments have sufficiently funded these policies. Of the 80 countries with plans, only 60% reported having calculated the costs of implementing them. Only 5% of those with a hygiene plan reported having sufficient funds to implement them, compared to 10% of countries with a plan for improving sanitation and drinking water. Furthermore, countries were less likely to have plans for hygiene than for sanitation and drinking water, and less likely to have estimated the cost of a hygiene component if they had one.
Few governments have dedicated hygiene budgets. Only 17% of the 109 countries responding to the UN survey reported their hygiene budget and/or expenditures. Furthermore, even where specific hygiene budgets exist, they are typically small. As the graph below shows, among the 18 countries reporting government hygiene expenditure, only 4% of total WASH expenditure was allocated to hygiene. The same is likely to be true of WASH programmes funded by donors and NGOs, with hygiene often being de-prioritised and proportionally less funded than water and sanitation components. According to a World Bank study, the price tag for achieving the basic hygiene target in the SDGs is indeed substantially lower than for basic sanitation or basic water. There is no guidance on the optimal balance for resources within WASH sub-sectors, and the extent to which their SDG price tags should be covered by public finance as opposed to household investments varies. At the moment there is still relatively little known about how much is being spent on hygiene and the relative impact of different types of investment. Greater transparency and monitoring of hygiene programme costs could be a major asset to the sector.
Regarding what is known about the state of national handwashing funding, two messages are to be emphasised:
- Hygiene is less likely than other elements of WASH to have a specific, funded plan. The findings of the UN report cited above can be used to advocate for more specific plans and separate budgets for hygiene, particularly in the context of the COVID-19 pandemic and beyond.
- Advocating to governments to include a specific budget line for annual hygiene programming (regardless of the status of plans) increases accountability and transparency. Donors and other funders should also be more transparent about their hygiene activities, allocations and expenditure.
How do analysts compare return on investment for public health interventions?
Advocating for more funding for hygiene can be supported by clear communication of the return on investment from hygiene programmes. Two types of studies can be used to make this case: cost-benefit analysis (CBA) and cost-effectiveness analysis (CEA). These analyses can be used to advocate for more funding for hygiene, or to compare alternative hygiene programme options and designs. Both require more attention and focus on measuring costs, on the one hand, and programme outcomes, on the other.
Cost-benefit analysis: This approach combines all the benefits or consequences of a programme (e.g. saved time, disease reduction) and assigns “value” to them in monetary terms (e.g. US dollars or other currency). Commonly-used methods exist for putting such a monetary value on lives saved (mortality risk reduction), disease averted (morbidity), and avoided healthcare costs. In CBA, monetised benefits are then compared to the cost of an intervention, and a ‘benefit-cost ratio’ is calculated. This ratio can be thought of as what you get back if you invest $1 in the programme. If the ratio is greater than 1, the intervention delivers more benefits than costs and is economically beneficial; such a conclusion can help provide a reason to invest in it. In this way, CBA can be useful in advocating for more funding for hygiene, when benefits clearly exceed costs. In addition, the benefit-cost ratios of different types of intervention options can be compared, allowing decision-makers to determine which of the options is most efficient, although other factors should be taken into consideration, such as equity, the relative size of net benefits, and the number of beneficiaries reached. One reason for choosing CBA is that it is appealing to many decision-makers, especially in planning departments of governments, including the Ministry of Finance. It is the most common method of economic analysis outside the health sector.
Cost-effectiveness analysis: This approach compares the health benefit that can be achieved by an intervention (e.g. cases of diarrhoea averted or number of deaths averted) to its cost. CEA does not monetise this health benefit into a currency measure, but rather compares interventions based only on their relative cost in achieving a specific measure of health gain. Examples of health indicators that are used to compare interventions include the ‘cost per case of diarrhoea averted’ and ‘cost per death averted’. Some CEA studies use a combined measure of morbidity and mortality– the “disability-adjusted life year” (DALY). Importantly, CEA at the level of health outcomes is only used in the health sector (though different cost-effectiveness calculations can be constructed in other sectors, e.g. cost per tonne of CO2 mitigated). Hygiene-specific metrics at the level of outputs can be useful, such as ‘cost per additional person washing their hands’, though strictly speaking this is a cost metric rather than cost-effectiveness. The results of CEA on their own (without comparison to other interventions) are intuitively less useful than CBA for advocating for more funding for a sector in general. However, they are important for allocating funds efficiently within a sector.
Both CBA and CEA analyses can be used to compare hygiene interventions. Which one is deemed most valuable, for either planning of interventions or advocacy, will ultimately depend on the audience. CEA might have more traction with the Ministry of Health, for example, or within an organisation that is dedicated to hygiene programming but trying to choose among different designs. Other sectors or Ministries of Finance will likely find CBA more useful since it allows for more general comparisons.
What is known about returns on investment in hygiene?
Returns on investment can be assessed in monetary terms using cost-benefit analysis (CBA), or in terms of disease cases or deaths averted using cost-effectiveness analysis (CEA).
The economic benefits of hygiene
There are three main ways in which practicing hygiene behaviour can have economic benefits. The first is in provision of direct health gains, such as avoided deaths and avoided cases of diseases (e.g. COVID-19). Systematic reviews have identified that handwashing with soap can result in a reduction in diarrhoeal disease by about 30% and a reduction in acute respiratory infections by about 21%. Various studies are also able to quantify the ‘cost of illness’, such as for diarrhoea. Second, there can be indirect health benefits, such as the value of time lost if a person is sick or caring for a person who is sick. Third, there is economic value in improving quality of life, through feelings of dignity, pride, or cleanliness, though these have not been quantified in existing literature. While relatively little evidence exists on the relationship between COVID-19 and handwashing and its effects, several studies explore how hand hygiene can limit influenza transmission and seasonal coronavirus in various contexts.
Cost-benefit studies of hygiene programmes
There are few CBA and CEA studies for hygiene programmes, relative to those that exist for drinking water or sanitation programmes. In particular, there are no such studies in humanitarian settings, despite ‘hygiene kits’ and associated hygiene promotion often being at the top of the list for interventions in such settings. It is plausible that returns on hygiene investments in humanitarian settings might be higher in the short-term than interventions in stable settings, due to heightened disease risk and vulnerability. However, any impacts are also likely to be less sustained, and intervention costs may be higher in crisis settings. Studies in this area are required.
One high-quality cost-benefit study which synthesises evidence on the effectiveness of interventions and their costs across settings applied a hypothetical model developed for a typical low-income country setting. This is a particularly useful study because the authors incorporate both rates of uptake (the proportion of people targeted by a programme who change their behaviour) and of subsequent adherence (the proportion of people who changed their behaviour who continue to practice the new behaviour). Their model has different scenarios for ‘low’, ‘medium’ and ‘high’ performance on these two factors to account for real-world variation. They simulate different hygiene programme scenarios where 20-60% of the target population initially take up the new behaviour (rate of uptake), and of that population, 20-80% continue to practice it over the duration of the intervention (subsequent adherence). Under the authors’ ‘medium’ scenario for uptake and adherence, results from 10,000 simulations of the model show a base case benefit-cost ratio of 2.1 (a return on investment of about $2 for $1 invested). The benefit-cost ratio was greater than 1 in 80% of their simulations. The scenario with higher uptake and adherence suggests a return of $6 for $1 invested, and for lower uptake/adherence a return of only $0.9. It is important to emphasise that this is a hypothetical study, with data collated from review of many studies. There is a serious lack of cost-benefit studies of real-world handwashing interventions, based on empirical evidence on what actually happened in a given setting. Benefit-cost ratios may also be higher if studies included health benefits beyond diarrhoea, such as for acute respiratory infections, which this study did not do.
It would be beneficial to future hygiene decision-making if implementers filled this gap in evidence by conducting cost-benefit analyses of hygiene programmes, and particularly by collecting the required data during design and implementation. Advocacy targeting implementers who design and implement hygiene programmes, as well as donors who fund such studies, would help to advance understanding of hygiene programming costs and benefits, and guide design of more effective and economically-beneficial programs.
Cost-effectiveness studies of hygiene programmes
A high-quality cost-effectiveness study of an empirical intervention in Burkina Faso evaluated a handwashing promotion intervention in terms of its uptake and behaviour change among mothers of young children. Combining these estimates with secondary data on health risk reduction, the authors concluded that the intervention cost USD 51 per case of diarrhoea averted, compared to no intervention. Such results are hard to interpret alone. The Disease Control Priorities (DCP) project synthesises results from individual cost-effectiveness studies into combined assessments of the cost-effectiveness of health interventions, standardised according to the disability-adjusted life years (DALYs) averted benefit metric. Based on the above CEA study, DCP authors estimated a range for handwashing cost-effectiveness of USD 90–225 per DALY averted (2012 prices). Their graph below, which compares the relative cost-effectiveness of various child health interventions, identifies handwashing as a highly cost-effective intervention and on a similar level to oral rehydration therapy and most childhood vaccinations.
Regarding what is known about the return on investment in hygiene programming, four messages are to be emphasised:
- There is good evidence that handwashing with soap can prevent diarrhoea, acute respiratory infections and other infectious diseases. Preventing deaths and disease has economic value to nation states as well as to individuals. Handwashing with soap has the biological potential to remove and kill SARS-CoV-2 but evidence about the proportionate reduction of COVID-19 infection associated with hand hygiene remains limited and under investigation.
- On average, conservative estimates suggest that hygiene promotion can bring a return of $2 for every $1 invested. However, returns may be higher if unmeasured benefits were included, and are highly dependent on uptake and adherence. For example, the scenario in the referenced study with high uptake and adherence suggests a return of $6 for $1 invested.
- There is a real need for more field-based cost-benefit studies of real-world hygiene interventions to improve the evidence base.
- Comparative cost-effectiveness studies identify handwashing as a ‘highly cost-effective’ intervention for child health, on a similar level to oral rehydration therapy and most childhood vaccinations.
What can I do during the pandemic to advocate for handwashing investment, and improve the state of knowledge?
There are a number of things, which hygiene stakeholders can do in light of the COVID-19 pandemic, including:
- Advocating for handwashing investment (both hardware and software)
- Collecting better cost data for existing hygiene programmes to build a better case for such investment
- Context-specific advocacy linked to local priorities
Advocate for handwashing investment
Hygiene stakeholders can draw attention to studies showing that:
- handwashing programmes can deliver a $2 return on a $1 investment, or substantially more with high levels of uptake and adherence
- handwashing programmes have similar cost-effectiveness to that of immunisation and oral rehydration therapy
In most countries, far more time, effort and money is spent on immunisation than on hygiene promotion. Substantial plans, budgets, and policies exist for vaccination programmes whereas these are lacking for hygiene programmes. Furthermore, vaccination programmes are typically undertaken on a rolling basis with dedicated budgets and staff, while few hygiene programmes are designed with sustainability in mind.
Collect better cost data
In comparison to other interventions in water supply or sanitation, there is very little evidence on the costs and the return on investment for hygiene programming. Information about costs is useful not only for informing the modelling of return on investment, but also for justifying, developing plans or prioritising intervention strategies for similar or other country settings. Actors can improve the state of knowledge by collecting data on the costs of their programmes and interventions. These can be shared publicly, or can be studied in partnership with researchers to ensure better understanding of intervention costs in the future.
Context-specific advocacy linked to local priorities
There are useful toolkits for advocacy that provide general guidance, as well as specific strategies for hygiene. The most effective advocacy is based on a strong analysis of what the problem is, who has power to change things, and which levers to pull to influence those people. This could involve an analysis of why hygiene is currently neglected and identifying who within government, civil society, donors or the private sector may be in a position to strengthen their focus on hygiene. It may be wise to link hygiene advocacy to domestic political and economic priorities. Arguments will be more persuasive if based on local or regional data and examples. Advocacy can also help actors appreciate the range of health and wellbeing benefits of handwashing, and to highlight how hygiene plays a key role in the prevention of future outbreaks. Policy briefs produced by the World Bank’s 'Economics of Sanitation Initiative’, while focused on sanitation and now slightly outdated, can provide some useful materials and data. Undertaking an internal cost-benefit analysis may seem daunting, but WHO guidance and reference case methods exist on how it can be undertaken. Recent data on handwashing facilities in households, schools and health facilities can be found from WHO and UNICEF here. Data on diarrhoeal disease morbidity and mortality can be found here. Other useful contextual data about diarrhoeal disease and acute respiratory infections can be found in Demographic and Health Surveys which exist for many countries.
When conducting advocacy on the need for hygiene promotion, it is useful to combine economic and health data with other types of information that can show the ‘full value and experience’ of hygiene. This should include capturing the experiences of community members who have benefited from hygiene programmes. Sharing examples of how other neighbouring countries have improved the state of hygiene can also inspire governments and communities to take greater action. This report from WaterAid captures hygiene progress across Southern Africa and makes direct comparisons between different countries in order to spark policy change.
Author: Ian Ross
Review: Marc Jeuland, Guy Hutton, Robin Lloyd
Last Update: 15.12.2020