Why is WASH economics so far behind health economics?

The more I read on health economics, the more I realise how far WASH economics is “behind”, especially on economic evaluation. I mean this in terms of methods, the extent/level of debate on key questions, and the size/engagement of the community of people working on it. The “how” question (in what ways it is behind, in my view) will be addressed in a subsequent post – this one focuses on the “why”.

In some ways, the fact that it is behind is unsurprising, for at least three reasons:

1. In most poor countries, health spending is far greater than WASH spending.  See data on www.governmentspendingwatch.org . The same is true for aid spending on WASH versus health. Both of these lead to more people working on health issues in general.

2. The scope of possible interventions is smaller in WASH, so prioritisation is (wrongly) considered less of an issue.  A health decision-maker has to compare potentially thousands of interventions which could be undertaken, across hundreds of diseases and conditions. For WASH, we would be hard-pressed to count more than 30-50 possible interventions, until we get into the realm of different approaches to the same intervention (one day I’ll make a list…).  It is possible for a government to decide what the national rural sanitation intervention is, for example. They might consider a couple of options as part of strategy development, then that’s that for 5+ years. This means that prioritisation between WASH interventions has been considered (wrongly, in my view) as a second-order issue, and rarely seems to be as evidence-based as in the health sector.

3. There is not really a WASH economics discipline in rich countries. WASH has slid dramatically down the agenda in rich countries over the past 100 years. Household spending on tariffs remains significant (about US$ 500 per household per year in the UK), but the problem is “solved”. Everything works – people pay their bills and don’t even think about it. By contrast, not everything in health works in rich countries. It remains a huge political issue and delivering health services (with associated problems of prioritisation) remain a challenge. So there are lots of health economists in rich countries, but hardly any WASH economists outside utilities and an associated small band of researchers. This lack of a distinct “discipline” arguably spills over to poor countries. This is important – in health economics many methods applied in poor countries were developed in rich ones. At LSHTM many ideas percolate across, since there are health economists in the faculty working on both rich and poor countries.

Do you agree? What other reasons are there?

The real question is why are there not more WASH economists in low and middle-income countries, not to mention more debate on WASH economics questions. There are plenty of countries where access to WASH services remains a huge problem. In these countries,  prioritisation of investments is still a highly relevant policy question, but rarely is it tackled in as evidence-based way as in the health sector.