Climate projections indicate the incidence of droughts and floods will progressively increase in many world regions during the next century. As the impact is increasingly felt by urban populations, national and municipal authorities must plan to ensure the resilience of water and wastewater infrastructure. This requires information on how much it costs to close service gaps, and the additional costs of assuring resilient services. This paper estimates the costs of extending water and wastewater coverage to urban populations in 131 low- and middle-income countries (LMICs), and the costs of protecting populations from flood and drought risks under different climate scenarios and target years. The estimates draw on service coverage data from the United Nations and cost data from published studies and data sets. Annual costs of achieving universal access to safely managed water supply in urban areas in 131 LMICs by 2040 are US$21.78 billion (US$8.6 billion capital and US$13.1 billion operation and maintenance – O&M), equivalent to US$5.5 annually per capita. Under Shared Socioeconomic Pathway 3 (SSP3), annual cost of achieving greater resilience is US$2.46 billion (droughts) and US$99 million (floods), with a total of US$2.55 billion representing an increase of 12% over the baseline costs. The cost of increasing wastewater treatment to 100% coverage for those connected is $46.4 billion per year, while the cost of extending wastewater services to the unserved and making wastewater services climate resilient is $44.6 billion per year, representing a 96% increase. This study concludes that the greatest financial challenge remains achieving universal coverage of safely managed water and wastewater services. However, budgeted plans should incorporate climate resilience to improve service continuity and prevent costly repairs and retrofitting infrastructure in the event of climate events.

Background: Healthcare-associated infections (HAIs) remain a global health challenge, and have elevated rates in Sub-Saharan Africa. HAIs impact patients and their families by causing illness, prolonged hospital stay, potential disability, excess costs and, sometimes, death. The costs of HAIs are increasing due to spreading antimicrobial resistance. A major risk factor for HAIs is lack of water, sanitation and hygiene (WASH); environmental cleaning and healthcare waste management. In Sub-Saharan Africa, these services are lacking in at least 50% of healthcare facilities. Aim: To estimate the costs associated with HAIs at national level in 14 countries in SubSaharan Africa. Methods: Economic methodologies were employed to estimate the medical costs, productivity losses and value of premature death from HAIs, drawing on national statistics and published studies to populate the economic model. Results: In 2022, the number of HAIs was estimated at 4.8 million, resulting in 500,000 deaths. Health-related economic losses amounted to US$13 billion per year, equivalent to 1.14% of combined gross domestic product and US$15.7 per capita. Healthcare costs were US$500 per HAI, and represented 5.6% of total health expenditure. The costs of providing basic WASH were US$0.91 per capita, which, if they reduced HAIs by 50%, would result in benefit-cost ratios of 1.6 (financial healthcare savings alone) and 8.6 (all economic benefits). Conclusion: HAIs have a major health and economic burden on African societies, and a significant proportion can be prevented. It is critical that health policy makers and practitioners dedicate policy space, resources and training to address HAIs. on behalf of The Healthcare Infection Society. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

This chapter provides a review of spending needs to achieve sustainable development goal (SDG) 6 targets based on five recent global cost studies. The focus of these costing exercises has been on water, sanitation, and hygiene (SDG targets 6.1 and 6.2), while fewer studies cover water pollution reduction, water efficiency measures, water management, water for ecosystems, irrigation, and flood protection. Global costs of achieving SDG 6 exceed US$ 1 trillion annually, while only a fraction of this amount is currently being spent to close the service gap. Future cost studies need to be accompanied by strategies to close the financing gap, and greater focus is needed at national and subnational levels to enable important specificities in programming and technology needs. Studies need to quantify the impact of emerging challenges, such as climate change, and to identify the full range of potential financing sources.

Background An alarming number of public health-care facilities in low-income and middle-income countries lack basic water, sanitation, hygiene (WASH), and waste management services. This study estimates the costs of achieving full coverage of basic WASH and waste services in existing public health facilities in the 46 UN designated least-developed countries (LDCs). Methods In this modelling study, in-need facilities were quantified by combining published counts of public facilities with estimated basic WASH and waste service coverage. Country-specific per-facility capital and recurrent costs to deliver basic services were collected via survey of country WASH experts and officials between Sept 24 and Dec 24, 2020. Baseline cost estimates were modelled and discounted by 5% per year. Key assumptions were adjusted to produce lower and upper estimates, including adjusting the discount rate to 8% and 3% per year, respectively. Findings An estimated US$6.5 billion to $9.6 billion from 2021 to 2030 is needed to achieve full coverage of basic WASH and waste services in public health facilities in LDCs. Capital costs are $2.9 billion to $4.8 billion and recurrent costs are $3.6 billion to $4.8 billion over this time period. A mean of $0.24-0.40 per capita in capital investment is needed each year, and annual operations and maintenance costs are expected to increase from $0.10 in 2021 to $0.39-0.60 in 2030. Waste management accounts for the greatest share of costs, requiring $3.7 billion (46.6% of the total) in the baseline estimates, followed by $1.8 billion (23.1%) for sanitation, $1.5 billion (19.5%) for water, and $845 million (10.7%) for hygiene. Needs are greatest for non-hospital facilities ($7.4 billion [94%] of $7.9 billion) and for facilities in rural areas ($5.3 billion [68%]). Interpretation Investment will need to increase to reach full coverage of basic WASH and waste services in public health facilities. Financial needs are modest compared with current overall health and WASH spending, and better service coverage will yield substantial health benefits. To sustain services and prevent degradation and early replacement, countries will need to routinely budget for operations and maintenance of WASH and waste management assets. Copyright (C) 2022 World Health Organization; licensee Elsevier.

Background: An alarming number of health care facilities in low- and middle-income countries lack basic water, sanitation, hygiene, and waste management (WASH services). This study estimates the costs of achieving universal coverage of basic WASH services in health facilities in the 46 least developed countries (LDCs).Methods: In-need facilities were quantified by combining published facility counts with estimated WASH service coverage. Country-specific per-facility capital and recurrent costs to deliver basic service standards were collected via survey. Baseline estimates were modelled alongside lower and upper estimates for which key assumptions were adjusted.Findings: An estimated US$6·5–9·6 billion over 10 years is needed to achieve universal coverage of basic WASH services in LDCs' health facilities. Capital and recurrent costs are 44–50% and 50–56% of the total, respectively. On average, US$0·24–40 per capita in capital investment is needed each year, while annual maintenance and operation costs are expected to increase from US$0·10 in 2021 to US$0·39–0·60 in 2030. Waste management accounts for the greatest share of costs (43–49%), followed by sanitation (21–28%), water (20%), and hygiene (10–11%). Needs are greatest for non-hospital facilities (94%) and in rural areas (68%).Interpretation: Investment will need to be scaled up to reach universal coverage of basic WASH services in health facilities. Financial needs are modest compared to overall health and WASH spending and will yield numerous health benefits. To sustain services, countries will need to routinely budget for operations and maintenance.Funding Information: World Health Organization (including underlying grants from the governments of Japan, Netherlands, and UK), World Bank, and UNICEF.Declaration of Interests: MC reports personal fees from the World Health Organization during the conduct of the study and from Results for Development, ThinkWell, and the World Bank outside the submitted work. SM reports personal fees from the World Health Organization during the conduct of the study and from Vysnova Partners outside the submitted work. RJ reports grants from Agence française de développement, Bill and Melinda Gates Foundation, Government of the Netherlands Ministry of Foreign Affairs, UN-Water Inter-Agency Trust Fund, United Kingdom Foreign, Commonwealth & Development Office, and Swiss Agency for Development and Cooperation, both during the conduct of the study and outside the submitted work. IA, JA-ST, SG, OH, TS, CC, GH, and MM have nothing to disclose.

The COVID-19 pandemic has shone a light on handwashing as an inexpensive, widely applicable response measure. In consequence, most governments have taken action to promote access to water and sanitation services for all. This paper documents an overview of initiatives and interventions that countries have implemented during the first months of the COVID-19 response. Initiatives have been identified across 84 countries worldwide, and categorized into those that aimed at securing water, sanitation, and hygiene (WASH) for all, and those that sought to provide technical and financial support to service providers. The pandemic has not hit countries in the same way. Accordingly, results show disparities in the response between and within regions, with the level of activity found in the countries varying largely in terms of ambition and scope. Hygiene promotion and infection prevention and control (IPC) has been widely adopted - at least one response measure found in 94% of mapped countries-, although not always matched in ambition with the assured availability of soap, water, and handwashing facilities. Support to vulnerable households to promote basic access to WASH services at scale was weak (38% of countries) or implemented locally (25%), and requiring additional focus, particularly in rural areas and small towns. In addition, parallel support needs to be extended to service providers or to house-holds themselves in the form of cash transfers, in order to ensure the financial viability and the continuity of services. All lessons learned distilled from the pandemic should help strengthen the enabling environment for more resil-ient services in future emergencies. Areas for focus could include developing specific pandemic response strate-gies and plans; strengthening coordination; and establishing emergency financial support mechanisms for water operators, for example. Overall, findings presented herein contribute to enhance current and future pandemics prevention, mitigation, and recovery. (c) 2021 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY license (http:// creativecommons.org/licenses/by/4.0/).

Introduction Domestic hand hygiene could prevent over 500 000 attributable deaths per year, but 6 in 10 people in least developed countries (LDCs) do not have a handwashing facility (HWF) with soap and water available at home. We estimated the economic costs of universal access to basic hand hygiene services in household settings in 46 LDCs. Methods Our model combines quantities of households with no HWF and prices of promotion campaigns, HWFs, soap and water. For quantities, we used estimates from the WHO/UNICEF Joint Monitoring Programme. For prices, we collated data from recent impact evaluations and electronic searches. Accounting for inflation and purchasing power, we calculated costs over 2021–2030, and estimated total cost probabilistically using Monte Carlo simulation. Results An estimated US$12.2–US$15.3 billion over 10 years is needed for universal hand hygiene in household settings in 46 LDCs. The average annual cost of hand hygiene promotion is US$334 million (24% of annual total), with a further US$233 million for ‘top-up’ promotion (17%). Together, these promotion costs represent US$0.47 annually per head of LDC population. The annual cost of HWFs, a purpose-built drum with tap and stand, is US$174 million (13%). The annual cost of soap is US$497 million (36%) and water US$127 million (9%). Conclusion The annual cost of behavioural change promotion to those with no HWF represents 4.7% of median government health expenditure in LDCs, and 1% of their annual aid receipts. These costs could be covered by mobilising resources from across government and partners, and could be reduced by harnessing economies of scale and integrating hand hygiene with other behavioural change campaigns where appropriate. Innovation is required to make soap more affordable and available for the poorest households.

This editorial argues that the use of the three 'T's financing source framework (taxes, tariffs and transfers) leads us to ignore key costs to the customer, especially the poor customer, of accessing an adequate level of the water, sanitation and hygiene (WASH) service. These costs include household investment (HI) for self-supply (commonly excluded from tariffs). We propose an adaptation to the framework, which we call 'HI and the three T's'.

Background: The Swachh Bharat (Clean India) Mission (SBM) launched in October 2014 is the world's largest sanitation campaign. Our aim was to estimate and compare major economic costs and benefits associated with sanitation improvement achieved during three years of SBM from households' financial and economic perspectives and a broader societal perspective. Methods: Cost-benefit model inputs were obtained from household surveys in the twelve Indian states that once contributed to over 90 percent of open defecation in India, published literature and secondary data. Monetized costs included household financial and time investments in building and maintaining toilets, and government's investments on subsidies and campaign activities. Monetized benefits included reductions in medical costs and mortality associated with diarrheal diseases, productive time saved from fewer diarrhoea cases and accessing outside defecation options, and increase in the property value of having a toilet. Probabilistic uncertainty analysis assessed the combined effect of key modelling assumptions and sampling errors in the inputs to the cost-benefit model. Findings: Investment costs average US$ 396 per latrine and average annual operational costs are US$ 37 (financial) and US$ 94 (time costs)'. Annual benefits of US$ 727 per household are mainly from savings associated with reduced diarrhoea incidence (55%) and from sanitation access time savings (45%). The estimated Benefit-Cost Ratios (BCRs) are 1.7 (household financial perspective), 4.5 (household economic perspective) and 4.0 (societal perspective) under Open Defecation Free (ODF, corresponding to 100% toilet coverage and usage) scenario. However, under partial-ODF scenario with 85 percent toilet use rate, the BCRs are 1.1, 3.3 and 3.0, respectively. Probabilistic uncertainty analysis shows that the financial BCRs under the partial-ODF scenario can reduce to 0.7, but societal BCR will remain above 2. Interpretation: This study shows the sanitation improvements under the SBM are highly cost-beneficial, more when communities are free of open defecation with all households using private improved sanitation facilities. Future SBM investments must ensure not only sustaining the universal toilet coverage and usage, but also ensure safe faecal waste management so that households continue to enjoy full benefits of sanitation. (C) 2020 The Author(s). Published by Elsevier Ltd.

India hosts two-thirds of the global population defecating in the open and faces a worrying trend of districts declared ‘water scarce’. This paper aims to assess the costs and health benefits of sanitation interventions undertaken by the National Rural Drinking Water Security Pilot Project in India between 2012 and 2015. To achieve this goal, a pretest–posttest control group study was undertaken in two study areas located in Karnataka and Uttar Pradesh states. Full software and infrastructure costs were included as well as health endpoints, sourced from primary health centers. In Karnataka, latrine coverage of households increased from 16% to 59% in villages with high level of interventions, and from 7% to 18% in villages with lower levels of intervention. In Uttar Pradesh, coverage increased from 33% to 70% in high intervention villages and from 27% to 39% in the low intervention villages. We found health-related net benefits of USD 13 and USD 10 per person per year and benefit/cost ratios of 2.5 and 5.0 in Karnataka Uttar Pradesh, respectively. Given the positive economic returns on the intervention in culturally heterogeneous sites of southern and northern India, this intervention has potential for bringing significant benefits to the Indian population.

Dean T. Jamison, Ala Alwan, Charles N. Mock, Rachel Nugent, David A. Watkins, Olusoji Adeyi, Shuchi Anand, Rifat Atun, Stefano Bertozzi, Zulfiqar Bhutta, Agnes Binagwaho, Robert Black, Mark Blecher, Barry R. Bloom, Elizabeth Brouwer, Donald A. P. Bundy, Dan Chisholm, Alarcos Cieza, Mark Cullen, Kristen Danforth, Nilanthi de Silva, Haile T. Debas, Peter Donkor, Tarun Dua, Kenneth A. Fleming, Mark Gallivan, Patricia García, Atul Gawande, Thomas Gaziano, Hellen Gelband, Roger Glass, Amanda Glassman, Glenda Gray, Demissie Habte, King K. Holmes, Susan Horton, Guy Hutton, Prabhat Jha, Felicia Knaul, Olive Kobusingye, Eric Krakauer, Margaret E. Kruk, Peter Lachmann, Ramanan Laxminarayan, Carol Levin, Lai Meng Looi, Nita Madhav, Adel Mahmoud, Jean-Claude Mbanya, Anthony R. Measham, María Elena Medina-Mora, Carol Medlin, Anne Mills, Jody-Anne Mills, Jaime Montoya, Ole Norheim, Zachary Olson, Folashade Omokhodion, Ben Oppenheim, Toby Ord, Vikram Patel, George C. Patton, John Peabody, Dorairaj Prabhakaran, Jinyuan Qi, Teri Reynolds, Sevket Ruacan, Rengaswamy Sankaranarayanan, Jaime Sepúlveda, Richard Skolnik, Kirk R. Smith, Agnes Soucat, Marleen Temmerman, Stephen Tollman, Stéphane Verguet, Damian Walker, Neff Walker, Yangfeng Wu y Kun Zhao Volumen 9, Capítulo 1

This chapter summarizes and critically assesses the Injury Prevention and Environmental Health volume’s four key findings. First, there is a large burden of death and disability from these conditions. Worldwide, injuries result in more than 5.1 million deaths per year out of a global total of 56 million deaths. There are also large numbers of deaths attributable to risk factors related to non-injury occupational exposures (560,000); inadequate access to clean water, sanitation, and hygiene (1.4 million deaths); and air pollution (5.5 million). The vast majority of these deaths are in low- and middle-income countries. Second, risk factors for these diseases vary with stages of development in ways that can be understood and used in designing prevention strategies. Third, there are a range of interventions that can effectively address these problems, many of which are among the most cost-effective and cost-beneficial of all interventions used to prevent disease. Fourth, this review synthesizes the volume’s prevention strategies to identify an effective essential package of interventions and policies, most of which have been inadequately applied globally. Better implementation of these interventions and policies would help to bring down the high rates of death and disability from these conditions in low- and middle-income countries towards the lower rates in high-income countries. Doing so could avert over 7,500,000 deaths annually from environmental and occupational exposures, and injuries.

Conveys the main findings of Disease Control Priorities, Third Edition (DCP3), and in particular its conclusions concerning intersectoral policy priorities and essential universal health coverage (EUHC), describing the context in which DCP3's analyses have been undertaken and introducing the substantive topics addressed. DCP3 has four major objectives that go beyond previous editions: (1) to address explicitly the financial risk protection and poverty reduction objective of health systems; (2) to apply systematic attention to the intersectoral determinants of health; (3) to organize interventions into 21 essential packages (EPs); and (4) to provide estimates for low- and lower-middle-income countries of incremental and total costs in 2030 for both EUHC and highest-priority package (HPP)—and of the magnitude of their impact on mortality. In addition to these new elements, DCP3 updates the efforts of DCP1 and DCP2 to assemble and interpret the literature on economic evaluation of health interventions.