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.
Want to learn more about the economics of hygiene programmes?
- What is known about the state of national handwashing funding?
- How do analysts compare return on investment for public health interventions?
- What is known about returns on investment in hygiene?
- What can I do during the pandemic to advocate for handwashing investment, and improve the state of knowledge?
Author: Ian Ross
Review: Marc Jeuland, Guy Hutton, Robin Lloyd
Last Update: 15.12.2020