Economic evaluation of an urban sanitation intervention in Maputo, Mozambique

Lead Research Organisation: London School of Hygiene & Tropical Medicine
Department Name: Public Health and Policy

Abstract

The research will develop robust estimates of the economic performance of a sanitation intervention in Maputo, Mozambique. The intervention is the construction of community sanitation blocks and shared latrines, implemented by the international NGO Water and Sanitation for the Urban Poor. I will be carrying out costing studies linked to the on-going 'Maputo Sanitation' (MapSan) trial of this intervention, which one of my proposed co-supervisors leads for LSHTM. MapSan has a Controlled, Before-and-After (CBA) study design, and is carrying out three rounds of data collection. Their robust data on health effects of the intervention will be one of my two key data sources. The other will be my own primary data collection focusing on estimating the costs of the intervention. I will combine these data sources to calculate cost-effectiveness indicators. In addition, I will develop an innovative composite measure of sanitation outcome based on the concept of wellbeing, building on work in this area by my supervisor Dr Giulia Greco. Sanitation is a key aspect of housing, and thus fits into one of the ESRC's five priorities for 2016-2020. The research fits into two of the ESRC's strategic areas as follows:

Fostering research and innovation - there are very few (<5) robust economic evaluations of sanitation interventions globally, and none in Sub-Saharan Africa. Furthermore, there is no existing measure of sanitation outcome based on wellbeing. These are two key innovative aspects of the research.
Facilitating partnerships and realising impact - several key partnerships will be developed through this research: (i) between the health economics group and environmental health group within LSHTM (which are in different faculties and rarely collaborate), (ii) between LSHTM and WSUP (the NGO implementing the intervention), and (iii) between LSHTM and MINSAUDE, the Mozambican Ministry of Health. The study has potential for impact both in Mozambique (through better understanding of sanitation costs and therefore better investment planning) and elsewhere (through better comparative information on economic performance of sanitation interventions).

In addition, it is supporting the "capability" aspect of ESRC's strategy by investing in my research skills. I have developed a plan for skills development with my supervisor which includes a programme of training within and outside LSHTM (in addition to the core researcher training provided by the UBEL DTP). The high-priority skill areas I intend to work on through the studentship include:

Economic evaluation - this is the core methodology of my research area. It will be covered through an LSHTM module and an advanced course in economic evaluation at the University of York which I will fund through my ESRC RTSG.
Epidemiology and Statistics - these skills are required to work with the health outcome data. They will be gained through 4 LSHTM modules taken over the course of the first two years, and supplemented by an IFS course in year 2 (funded through my ESRC RTSG).

Studentship Projects

Project Reference Relationship Related To Start End Student Name
ES/P000592/1 01/10/2017 30/09/2027
1922289 Studentship ES/P000592/1 01/10/2017 20/10/2020 Ian Ross
 
Description === PhD thesis abstract ===

Recent trials of basic sanitation interventions in low- and middle-income countries have identified little or no health impact, despite improving access to toilets and their quality. However, qualitative studies frequently report that toilet users value broader benefits for privacy, safety and status. Economic evaluations have not included these benefits, in the absence of means to measure them quantitatively, potentially leading to misallocated resources. The aim of this research was to develop and apply an approach to measuring and valuing quality of life in the economic evaluation of sanitation interventions. This is a paper-style thesis which incorporates five papers linked by short pieces of supporting material.

By integrating qualitative and quantitative methods from health economics, this thesis outlines the development and application of a measure of "sanitation-related quality of life" (SanQoL). The thesis finds that the benefits of an urban sanitation intervention for toilet users' quality of life can be quantitatively measured and valued, working alongside the Maputo Sanitation trial in Mozambique. Attributes of the measure are first identified in qualitative research using the capability approach. The validity and reliability of the ensuing SanQoL measure are assessed using psychometric analytic methods.

The SanQoL measure captures the degree of achievement of five sanitation-related capabilities: privacy, safety, health, shame and disgust. Rescaling with user-derived weights results in SanQoL index values ranging from zero (no sanitation capability) to one (full sanitation capability). These index values can be used to weight sanitation-adjusted person years (SAPYs), a proposed measure of the value of sanitation. After estimating the effect of a shared, urban sanitation intervention on SanQoL, that effect is applied in a cost-effectiveness analysis using the novel SAPY measure as the outcome. This thesis demonstrates how measuring and valuing toilet users' quality of life brings new insights to the effectiveness and cost-effectiveness of sanitation interventions.
Exploitation Route The SanQoL measure can support future cost-effectiveness and cost-benefit analyses and provide a more complete accounting of the cost-consequence relationship for sanitation. The SanQoL measure could also be used in impact evaluation or in routine programme monitoring to assess the performance of interventions. The results of validity and reliability investigations reported here provide evidence that this measure can be used for assessing sanitation-related quality of life in urban settings of low- and middle-income countries, but further testing in other settings is required.
Sectors Other

 
Title SanQoL index 
Description An index of sanitation-related quality of life 
Type Of Material Physiological assessment or outcome measure 
Year Produced 2021 
Provided To Others? Yes  
Impact Now used in 6 countries 
URL https://washeconomics.com/sanqol/
 
Title Data for: "Sanitation-related Quality of Life (SanQoL) in Maputo, Mozambique" 
Description A dataset of 424 individuals across 272 clusters (compounds) who gave written informed consent to participate in a study of sanitation-related quality of life in the Nhlamankulu district of Maputo, Mozambique in May 2019. The dataset contains variables on compound code, socio-demographic information, sanitation infrastructure, SanQoL outcomes, ranking of SanQoL attributes, mental wellbeing outcomes, and asset ownership. The dataset is made available in two forms: an open access instance that has been processed to anonymise participants; and a fuller version that contains additional variables. 
Type Of Material Database/Collection of data 
Year Produced 2021 
Provided To Others? Yes  
Impact n/a 
URL https://doi.org/10.17037/DATA.00002442
 
Description BBC World Service interview 
Form Of Engagement Activity A press release, press conference or response to a media enquiry/interview
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Public/other audiences
Results and Impact In 2022, I was interviewed by the BBC World Service "Health Check" programme about my paper in BMJ Open about the impact of a sanitation intervention on quality of life.
Year(s) Of Engagement Activity 2022
URL https://www.bbc.co.uk/sounds/play/w3ct32x1