health economics, Quality of Service, Sanitation, SanQoL, welfare economics

Quality of Service vs. Quality of Life – ways of measuring sanitation outcomes

[These are very much half-formed thoughts, so critique is welcome. I may well refine it as I think about this more and discuss with people. I bashed this out during LSHTM Environmental Health Group’s ‘writing group’, which I recommend as a group process to force you to write…]

In a previous post I explored the concept of sanitation-related quality of life (SanQoL). In that post I distinguished between “quality of service” (and/or infrastructure) and quality of life. The present post expands a bit on that distinction.

1. Different ways of measuring “quality”

Consider these three questions for assessing the concept of privacy:

  1. [observe] Does the bathroom* lock from the inside?
  2. [ask respondent] Does the bathroom you usually use lock from the inside?
  3. [ask respondent] Can you use the bathroom without people interrupting you?

Here’s a different angle on privacy:

  1. [observe] What is the main material of the bathroom’s walls?
  2. [ask respondent] What is the main material of the walls of the bathroom you usually use?
  3. [ask respondent] Can you use the bathroom in private, without being seen?

All these are like ones in surveys I’ve been involved in over the years. In each case, the ‘A’ questions involve an enumerator (who is not a user of the bathroom) observing infrastructure and making a judgement. In the ‘B’ and ‘C’ questions, the enumerator asks a respondent user, who goes through a cognitive process to respond.

The main distinction between ‘B’ and ‘C’ is that ‘B’ questions are asking about the infrastructure / service, and ‘C’ questions are asking about the person’s experience in using the bathroom. I would argue that this is at the heart of a distinction between ‘quality of service’ (QoS) and ‘quality of life’ (QoL). I would argue that, ‘A’ and ‘B’ are measuring QoS and ‘C’ is measuring QoL, and I expand on this below. For ‘C’ to be measuring QoL, we need to hypothesise (i) that things like privacy, safety, dignity etc.  affect QoL, and (ii) that sanitation affects those concepts. However, there are plenty of studies that support these hypotheses.

2. Infrastructure only tells you so much

There are also some attributes of SanQoL which cannot be proxied by questions or observations about presence or quality of infrastructure. These include shame, pride, safety, all of which are about perception rather than infrastructure.

For example, consider these ‘C’-type questions:

  • Can you use the bathroom without feeling ashamed for any reason?
  • When visitors come, do you ever feel embarrassed providing this bathroom for them to use?
  • Are you able to feel safe while using the bathroom?
  • How often do you use a bucket at night for due to fear of using the bathroom?

I’m not arguing that QoS approaches are not useful. Infrastructure is important, and observations can be rapid and useful. I’m just trying to show how QoS and QoL approaches measure different things. Of course, there are also other aspects of QoS which are about users not infrastructure (number of users, distance from house to toilet etc.). And some composite QoS measures may incorporate items which measure QoL.

There is also the issue of questions about user satisfaction with the service, which go in a slightly different box unless they directly measure QoL attributes. For example, you can ask “how satisfied are you with the cleanliness of the toilet”, which is arguably still about infrastructure rather than QoL. Where the distinction is less clear is with questions like: “how satisfied are you with the level of privacy?”. More on this another time. In short, I would argue that to be measuring QoL the question has to specifically be measuring functionings (as with the widely-used EQ-5D , SF-36 or WHOQOL-Bref) or capabilities (as with the ICECAP-A)

3. Are QoS and QoL distinct?

Above, I wrote that the ‘A’ and ‘B’ questions are measuring QoS and the ‘C’ questions are measuring QoL. But how distinct are these concepts really? It is possible to argue that the ‘C’ questions are really part of QoS as well. However, I think it makes more sense to see them mostly as separate things, as what is being measured is fundamentally different.

‘C’ questions are not really measuring the service itself – they are measuring a person’s perception of how that service affects them. More specifically, given the capability-based formulation of the questions, they are measuring what a person is able to do with respect to their sanitation practices.

Here’s an example. Imagine a pit latrine with slab shared between 4 households, with no roof and some fairly dodgy walls, that is not kept particularly clean. It is easy to imagine that service being experienced completely differently by different people (e.g. a 30-year old man as opposed to a 16-year old woman or an infirm 80-year old of either sex). As a consequence, while QoS measures might give the same result, each individual’s SanQoL might be markedly different.

Therefore, both toilet and user characteristics matter for SanQoL. However, these are far from its only determinants. Population density, levels of community security, environmental conditions, trust between neighbours etc. will all affect SanQoL but not most measures of QoS.

I tend to think of it a bit like the below diagram, in which SanQoL is considered a multidimensional construct defined as “the aspects of overall quality of life which are directly affected by sanitation practices.” There is a slight overlap between SanQoL and QoS. This is because, while some QoS measures cover infrastructure only, other composite measures could conceivably include some aspects of user experience that is not directly about infrastructure.

Picture1
Figure 1: Relationships between measures of QoL, SanQoL and QoS

4. Conclusion

This post has just scratched the surface of a complex issue, I am characterising QoS measures in a certain way, when they are certainly many and various. My main point is that QoL measures measure something fundamentally, that is, they the user’s experience of how using a service affects things they have reason to value (discussed in the previous post), rather than infrastructure. In a subsequent post I’ll aim to discuss some specific QoS and QoL measures to illustrate these points.

 

* As a Brit it pains me to use such an Americanism… but it is for good reason. SanQoL does not distinguish between sanitation practices that people carry out, in the given place they call the bathroom, toilet, casa de banho, sintina, choo, charpi etc. As it is conceivable that people bathe in that space (as they do in the Maputo setting I’m working in), then “bathroom” is more appropriate than “toilet”.

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