Why invest in water, sanitation and hygiene? Most schoolchildren would need only a few seconds to find an answer. Of course, water and sanitation are human rights, and hygiene has a vital role in preventing infectious disease, as COVID-19 has highlighted all too clearly. So why is progress in ensuring everyone, everywhere has access to these essential services so stubbornly slow? The latest data from WHO/UNICEF shows that in 2020 around 1 in 4 people lacked safely managed drinking water in their homes and nearly half the world’s population lacked safely managed sanitation. At the onset of the pandemic, 3 in 10 people worldwide could not wash their hands with soap and water within their homes.
One of the reasons is that those that hold the purse strings (outside of households)—heads of government, finance ministers, development ministers, businesses—have other priorities or, surprisingly, remain unpersuaded. Few if any African governments have achieved the longstanding commitment eThekwini, renewed at Ngor) to allocate 0.5% of GDP to sanitation and hygiene. Roads and power lines are often favoured, at least where public finances are not overwhelmed by repayments on multilateral, bilateral or private debt.
Donors too seem ready to look elsewhere, despite six years ago signing on the dotted line to help achieve SDG 6 (universal water, sanitation and hygiene – WASH) and SDG 17 (global partnership for development) by 2030, as well as the SDGs dependent on 6, such as 1 (reducing poverty), 3 (health), 4 (education), and 5 (gender equality). The UK for example thinks that in the midst of a global pandemic—the worst for 100 years—it’s the right time to cut its WASH budget by 80%. What would a schoolchild, say, in a Bangladeshi or Ethiopian school without decent toilets, make of that? Policy-makers must have forgotten the lessons of history, when investment in sanitation back in the nineteenth century brought such huge improvements in London’s and the country’s health—long-lasting benefits still enjoyed by today’s generations.
So what might change this thinking? The new report from WaterAid, based on research by Vivid Economics, aims to do this, challenging the mindsets of the decision-makers who think mainly in terms of $’s, £’s and €’s. It confirms the multiple benefits of achieving universal access to safe WASH services, unlocking potentially trillions of dollars of value over the next two decades. Health outcomes are improved through reduction in diarrhoeal disease, helminths, dehydration, antimicrobial resistance and mental anxiety; this in turn reduces out-of-pocket health expenditure for poor households; environmental outcomes are improved through reduced pollution and contamination of land, water resources and eco-systems; and social and economic outcomes through reduced time in collecting water, especially for women and girls, improved productivity and opportunities for the circular economy. Basic, safely managed and climate-resilient services are all shown to deliver significant net benefits, as below in Figure 1. Universal access to safely managed sanitation can deliver US$86 billion in net benefits (benefits minus the cost of interventions) each year.
There is a time element to this as well. As finance and economy ministers think about how best to re-start their economies in the midst of recession, we show that investment in WASH meets the key criteria for a successful fiscal stimulus. WASH infrastructure and services can be timely, targeted, temporary and transformational, improving health, productivity, gender and employment outcomes across the whole economy. So, we are calling for substantial increases in WASH investment in 2021 and 2022—alongside crucial efforts to fund and roll-out vaccine programmes globally—as part of a healthy and green economic recovery from COVID-19.
Case studies in Burie, Ethiopia, and Shyamnagar, Bangladesh, show the type of intervention, which could form part of this fiscal stimulus, and the transformational impact this could have for marginalised, climate-vulnerable communities, particularly for women and girls.
The analysis relies on a Benefit-Cost Analysis (BCA) of achieving universal access to WASH services. The BCA quantifies the impacts of WASH programmes by placing an economic value on both the cost and the benefit, allowing policy-makers to judge if it is an efficient use of resources. The Benefit-Cost Ratio (BCR) is equal to the total benefits of achieving universal access to WASH divided by the total costs of achieving universal access. BCRs are set out in the table below.
But BCA, whilst a useful analytical tool, has its limitations. The main focus of the report is on the economic benefits of health and social outcomes from WASH, averted Disability-Adjusted Life Years, averted health-care expenditure and productivity gains from time saved collecting water or finding a site to defecate. The climate-resilient scenario includes the reduced repair or restoration costs following a disaster. The structure of the BCA means that some of the inter-dependencies between the costs and benefits of achieving WASH services are not captured, however. An example might be the efficiency gains from investing in multiple services simultaneously—combining the installation of toilets with hygiene behaviour change campaigns.
Also a BCA cannot easily include the society- and economy-wide transformations that improved human health and economic opportunities can achieve, as witnessed by countries like Singapore and South Korea. Our estimates should therefore be seen as lower bound. We nevertheless think that the ratios generated—whether it is a US$15-21 return for US$1 invested in basic hygiene, or the “heavier infrastructure lift” of climate-resilient safely managed water (US$1.6 -1.9 return for every dollar invested)—represent good value for money and should be central to efforts to “build back better” from the pandemic.
Where can the money come from? We argue that it’s time to re-think our global spending priorities and to fund global public goods—including universal access to WASH, vaccine programmes and pandemic preparedness, urgent action on climate change—at the levels they now require. Instead of subsidising fossil-fuel industries—US$580 billion a year in G20 countries, adding to already extensive arms and military budgets (US$1.7 trillion globally), or embarking on space missions to Mars—we think we should be focusing on more immediate needs. COVID-19, Ebola, SARS show how poor sanitation conditions and hygiene practices in one part of the world can have rapid, tragic and long-lasting global impacts. It is time now for world leaders north and south to invest in what really matters: the human rights of billions of people worldwide currently denied access to safe water, sanitation and hygiene. Time to place common interest before self-interest.