economic evaluation, health economics, Sanitation, SanQoL

Better lives with better toilets – SanQoL translated for public engagement

[I was chuffed to be joint winner in the ESRC ‘Better Lives’ writing competition with the below piece intended for a general audience. The Guardian published an abridged version. Deadlines are 80% of writing, for me at least… so I would recommend competitions like this for forcing oneself to write to a hard deadline for public engagement, not something researchers often have to do. A more researcher-facing post on SanQoL is here.]

Imagine not having somewhere safe to go to the toilet. Really imagine it – leaving your house and defecating behind a bush or a building. It’s hard to bend your mind to consider that, if you’ve had access to a clean, comfortable bathroom since you were a child. However, around the world, 900 million people have no option but to defecate in the open. A further 1.4 billion use a toilet that doesn’t meet World Health Organisation standards for ‘basic’ toilets, meaning that it could still be a direct source of disease.

Fortunately, lots of investment is being made in sanitation in poorer countries – many billions of pounds in fact. Right now, somewhere, a municipal official is drafting their budget and a charity worker is writing a funding proposal. There are hundreds of ways that money could be spent. However, we don’t know enough about whether money is being spent on the right programmes. Inefficient choices are certainly being made.

How can I know this? Aren’t there established economic techniques for comparing ways to spend the money? There are, but they predominantly focus on health, alongside some consideration of time savings and avoided costs. This is a problem because health is not the thing people value most about sanitation. When researchers ask people the reasons why they invested in a toilet, health is usually far down the list. Concerns about privacy, safety, or pride are usually at the top. Together, we can call these improvements in quality of life in general. Excluding them from economic comparisons is a glaring omission.

Economists are very concerned with what people value in their lives. We think that the highest valued changes are the most important when deciding between project A and project B. So why don’t we just measure privacy, safety, etc., and plug that into the economic models alongside health? The challenge is that these things are not easily measured – they are subjective perceptions and vary from person to person. There’s also the problem of how to select the different elements, and then the problem of weighting them. These problems are not insurmountable – such quality of life measures exist for comparing programmes in health or social care. For example, the NHS in the UK makes huge funding decisions based on ‘quality-adjusted life years’. This measure takes account of how people value changes in health, by weighting life years with a ‘health-related quality of life’ scale. However, nobody has yet developed one for sanitation programmes.

That’s where my research comes in. I’m working on a measure for sanitation-related quality of life, building on the experience of health. The challenge is to measure this by asking people less than 10 questions, so it is manageable for regular use. The questions need to reflect what people value most about having a toilet. My work is based in Mozambique which is one of the poorest countries in the world. In collaboration with a local research team, we started by interviewing people living in slum settlements in the capital city, Maputo, both on their own and in groups. These were ordinary men and women, young and old. They all used different kinds of toilets, some good, some terrible.

An unimproved shared toilet in Maputo, Mozambique

First we asked them what was important for a good life – people often mentioned having enough food, having a good house, and having happy children. Then we asked about how a good toilet or bad toilet contributed to each of those things. Many interesting and important stories emerged, some happy, some sad. One young woman talked about privacy: “Anyone that passes can peep at you if you are going to urinate or defecate.” An older man talked about no longer feeling embarrassment when entertaining relatives: “When visitors come to see us now, they won’t feel bad when entering the toilet”. By systematically analysing these conversations, I identified a list of issues that kept coming up. The list of issues was too long, so I narrowed it down by showing people sets of three options and asking them to choose which was the most important. By doing this lots of times with many people, it is possible to exclude the least important items, and use statistical techniques to develop weights for those that are left.

So how will this improve people’s lives? My measure of sanitation-related quality of life can be used to compare different investment options. It can be used by the municipal planners deciding where the billions of pounds are spent. Through using it, they can know which types of investments improve quality of life the most, by focusing on what people value about sanitation. Considered alongside data on costs, health and engineering considerations, this can make for more efficient use of public funds. That means more people using a toilet which makes them proud, safe and comfortable.

This research is part of the MapSan Trial supported by the Bill and Melinda Gates Foundation. Ian is funded by an ESRC doctoral studentship.


1 thought on “Better lives with better toilets – SanQoL translated for public engagement”

  1. Thank you Ian for sharing this. One more thing for you to investigate is what do the urban poor do with filled up latrines.
    Please continue with the good work and keep sharing.


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