Child Diarrhea 

 
You can read about our methodology for estimating cost-effectiveness here

The most cost-effective methods of reducing diarrhea focus on cleaning water to break the transmission of diarrheal disease. Though the technology exists to deliver uncontaminated, chlorinated water to households through pipes, such methods are usually prohibitively expensive in the developing world, and policymakers should consider more cost-effective options. Point-of-use chlorination, where households add disinfectant after water has been collected from the source, kills germs and also avoids the problem of re-contamination during transport and storage. One of the most cost effective ways to reduce diarrhea is via free delivery of chlorine through dispensers at water sources.

Worldwide, diarrheal disease is the third leading cause of death among children under 5 years old1. More than 4,500 children die every day from diarrheal disease2, and even more are afflicted with diarrhea incidents which can leave them dehydrated and malnourished and may have longer term impacts on cognitive and physical development. Though diarrhea mortality has dropped in the past decades thanks to cheap and effective oral rehydration treatments, diarrhea morbidity has remained quite high and continues to affect children in the developing world.

Diarrheal diseases are spread when water becomes contaminated with fecal matter and is passed into the mouth, either through drinking, bathing, or touching one’s face with dirty hands. Many programs focus on cleaning contaminated water before it is ingested, and sanitation projects can also reduce the diarrhea burden by preventing fecal matter from contaminating groundwater.

Unfortunately, nearly 2.6 billion people lack any improved sanitation facilities, and 1.1 billion people have no access to an improved water source3. According to the Millennium Development Goals, the United Nations aims to halve the proportion of people without sustainable access to safe drinking water and basic sanitation by 2015.

Individual-level interventions, which are aimed at promoting behaviors such as handwashing or chlorinating water, are a popular method of promoting cleanliness and reducing disease. Many chlorination and handwashing products are already available on the market, generally costing a very small fraction of household income. However, extremely low uptake of these inexpensive technologies indicates how difficult it is to get people to change their behavior. In a Kenyan survey, 75% of households were familiar with individual chlorination of water, 70% reported knowing that drinking dirty water caused diarrhea, but only 5% of households said that their main drinking water supply was chlorinated.

Infrastructure improvements can circumvent the need for behavioral changes, by improving water sources such as boreholes or springs, to prevent contamination from groundwater. However, there is some behavioral “cost” in that individuals must still maintain these projects, patching concrete on encased springs or cleaning out wells. Individuals may be unwilling to perform such maintenance work, allowing source improvements to fall into disrepair and decreasing their effectiveness at reducing contamination.

1 World Health Organization. Joint Monitoring Program for Water Supply and Sanitation. Water for Life: Making it Happen. France: WHO. Print.
2 ibid
3 ibid

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Diarrhea Incidents Averted per $1000 Spent

You can read about our methodology for estimating cost-effectiveness here
Evaluations Cost Effectiveness Academic Papers
Incidents Averted
Chlorine Treatment
1 Source Dispensers in Kenya Dispensing chlorine for free at community water sources led to large improvements in water quality. 494 Policy green
2 Home Delivery of Chlorine in Kenya

Delivering chlorine for free to Kenyan households is an effective way of reducing diarrhea.

333 Policy green
4 Home Delivery of Chlorine in Pakistan

Delivering chlorine to homes for free, in addition to giving a clean storage container, was less effective at reducing diarrhea in Pakistan.

115 Luby, Agboatwalla, Sobel 2001 green
Source Improvements
3 Spring Cleaning in Kenya

Encasing water sources in concrete reduces contamination from groundwater, and helps reduce diarrheal disease.

305 Kremer, et al. 2009 Policy blue
Changing Behavior
5 Handwashing and Soap in Pakistan

Though handwashing can effectively reduce diarrheal disease, intensive promotion of handwashing with free distribution of soap is extremely expensive.

71 Luby, Agboatwalla, Painter, 2004 yellow

Piped water that delivers uncontaminated, chlorinated water to households can reduce diarrhea by up to 95%, but is prohibitively expensive for most of the developing world, at an estimated cost of $20 per month for a household , suggesting policymakers should consider more cost-effective options.

Dispensing chlorine for free at community water sources is an easy way to promote the practice of chlorinating water 1, and no major behavioral change is required because chlorination is integrated with the act of gathering water. Source dispensers, in combination with paid community promoters, increased chlorine usage by 57 percentage points in communities in Kenya, and prevented an estimated 494 diarrheal incidents per $1,000 spent. The actual cost of this intervention is likely to be even lower if the program were scaled up, as the cost of producing dispensers will fall when mass produced and increased dispenser density will reduce chlorine distribution costs. It is possible to achieve slightly higher cost-effectiveness with unpaid promoters, but there is considerably lower take-up of chlorination.

Another method of preventing diarrhea is to encase water springs in concrete, preventing contamination from groundwater 3. In the first year after protecting springs in Busia, Kenya, diarrhea was significantly reduced, at a cost of approximately $1,000 per spring. However, infrastructure improvements suffer from issues with maintenance – an estimated 50% of the boreholes dug in the 1980s and kept up through community based maintenance models are not currently functional in this area. For this reason, infrastructure programs such as drilling boreholes or community wells may not be as effective as interventions using individual chlorination.

Home chlorination is another popular option for cleaning water. Door-to-door chlorine marketing programs in Pakistan 4 and Kenya 2 prevented anywhere from 115 to 333 diarrheal incidents per $1,000 spent. Though handwashing can also be an effective means of reducing the fecal-oral transmission of diseases, there are not currently proven ways to change handwashing behavior in a cost-effective way. An intervention which promoted handwashing in urban Pakistani slums was able to reduce diarrheal disease by 28% 5, but in its pilot form it required provision of free soap and several visits weekly from program workers, and was expensive, preventing only 71 diarrheal incidents per $1000 spent.

Notes on Cost-Effectiveness Calculations:

1 The dispenser system that was piloted consisted of dispenser hardware, a supply of chlorine and a local community member (paid) elected to encourage chlorine use and refill and maintain the dispenser. Cost of dispenser expected to fall if program were scaled-up, due to mass production. Because study used change in chlorination as the outcome measure, we translated this into expected reduction in diarrheal incidents using global averages for baseline annual incidents and effects of chlorination on incidence. Graph “whiskers” are based on a varying number of households per spring: the study average was 31, and the high and low estimates reflect cost-effectiveness at 46 and 16 households per spring, respectively. Cost-effectiveness was calculated using the average diarrhea incidence for children in developing countries as baseline incidence- baseline incidence would be higher in countries with lower levels of water improvement.

2 Because study used change in chlorination as outcome measure, we translated this into expected reduction in diarrheal incidents using global averages for baseline annual incidents and effects of chlorination on incidence. Graph “whiskers” are based on a varying number of households per spring: the study average was 31, and the high and low estimates reflect cost-effectiveness at 46 and 16 households per spring, respectively. Cost-effectiveness calculated using the average diarrhea incidence for children in developing countries as baseline incidence- baseline incidence would be higher in countries with lower levels of water improvement.

3 Impact calculated taking into account the fact that some households switched to protected water sources. Graph “whiskers” are based on a varying number of households per spring: the study average was 31, and the high and low estimates reflect cost-effectiveness at 46 and 16 households per spring, respectively. Cost-effectiveness was calculated using the average diarrhea incidence for children in developing countries as baseline incidence- baseline incidence would be higher in countries with lower levels of water improvement.

4 Because study used change in chlorination as outcome measure, we translated this into expected reduction in diarrheal incidents using global averages for baseline annual incidents and effects of chlorination on incidence. Cost-effectiveness calculated using the average diarrhea incidence for children in developing countries as baseline incidence- baseline incidence would be higher in countries with lower levels of water improvement.

5 Program costs based on a pilot program that was intended primarily to test the effect of handwashing on diarrhea incidence.

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