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What Does it Cost to Trigger and Sustain Sanitation Behaviors?

Plan International USA has recently published a bottom-up costing process and cost analysis of four Community-led Total Sanitation interventions in Ghana and Ethiopia.

Cost evidence informs policies, program design and scale-up, and research. Such evidence has been lacking for water, sanitation, and hygiene (WASH) programs that are participatory, involve capacity building, or target behavior change. Improving this evidence is a priority, as meeting the Sustainable Development Goals (SDGs) will necessitate both a scale-up of efforts to meet universal targets, and a shift in the means of implementation toward capacity building, local participation, and behaviors.

WASH and other public health programs have characteristics that make costing difficult: complex institutional arrangements, cross-subsidies, flexible implementation, and local investments. Complex institutional arrangements spread costs across organizations, resulting in inconsistent and incomplete financial tracking. Cross-subsidies arise when programs share resources (such as vehicles or training). Participatory, behavior-change programs are inherently flexible, extensively adapted, and field activities often do not match workplans or budgets. Local actors and communities contributing time or money (“local investments”) are common in participatory behavior-change programs. Community-led total sanitation (CLTS) – a community-wide behavior change approach – epitomizes these costing challenges, yet most attempts to cost CLTS have applied blunt (and inaccurate) costing approaches.

Typically, costing methods are either top-down or bottom-up. Top-down costing involves dividing a program’s budget or total expenditures by the number of units (villages, households, individuals) targeted or reached. It is appealing due to its use of minimal, routinely collected data (budgets, expenditures, population targeted or reached), and simple analysis. Bottom-up costing involves tracking implementation to calculate costs and assign them to activities. It is more time-consuming, complex, and expensive, which could explain its scarcity.

With funding from the Bill & Melinda Gates Foundation, and in partnership with the Water Institute at the University of North Carolina, Plan International USA has recently published a bottom-up costing process and cost analysis of four CLTS interventions in Ghana and Ethiopia. We normalized costs by population targeted and disaggregated by intervention, geographic area, actor, time, and cost category. Costs were separated out and compared between “conventional” CLTS and CLTS facilitated by local actors (Natural Leaders in Ghana and Teachers in Ethiopia).

Some highlighted findings:

  • In Ghana, conventionally-facilitated CLTS incurred program costs of $30.34 per household, rising to $81.56 when Natural Leader training was added. The difference was mostly due to the costs for accommodation and meals at training venues used when building the capacity of Natural Leaders to adopt CLTS. In Ethiopia, equivalent conventional CLTS program costs were $19.21 per household targeted, dropping to $14.15 for Teacher-facilitated CLTS.
  • The aggregate local investment (financial costs and unpaid value-of-time for local actors and community members) in Ghana was $7.93 per household targeted in villages receiving conventional CLTS, and a substantially higher $22.36 in villages where Natural Leaders were trained. Similar costs in Ethiopia were $3.41 per household targeted in villages receiving conventional CLTS, and a lower $2.35 where teachers facilitated.
  • Training was four percent of the program cost for conventionally-facilitated CLTS in Ghana, rising to a relatively high 58 percent of program cost where Natural Leaders were trained. Equivalent program cost figures in Ethiopia for training were much narrower in range – 56 percent for conventional CLTS and 61 percent for Teacher-led CLTS.
  • Typically, the WASH sector views CLTS as a very low or no-cost approach; our work systematically tracks and accounts for all costs incurred in delivering community-wide sanitation behavior change outcomes. The value from this study is the rigor with which these costs have been established, following an extensive field-based tracking of activities throughout implementation. Significantly, the study makes the distinction between program costs and local investment costs; the former are nearly always overlooked or underestimated, yet are significant aspects of program delivery.
  • While the project did not have a rigorous analysis of cost-effectiveness at its heart, we can make a link between these costs and the outcomes that the projects drove. As an example, in Ghana, Natural Leader CLTS led to significant decreases (in the order of 20 percentage points reduction) in open defecation rates, when compared to conventional CLTS.

This is the first study to provide comprehensive, accurately tracked, disaggregated costs for any WASH behavior change program. This study provides insight into the cost of project management, training, and facilitation, all of which are ubiquitous among participatory or behavior change public health projects, making these findings relevant beyond WASH. The evidence provided by this study is particularly important given that the SDGs emphasize capacity building, local participation, and public finance to leverage other investments, including local actor and community investments.

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