Measuring and valuing broader impacts in public health: Development of a sanitation-related quality of life instrument in Maputo, Mozambique

Two billion people globally lack access to a basic toilet. While improving sanitation reduces infectious disease, toilet users often identify privacy, safety and dignity as more important. However, these outcomes have not been incorporated in sanitation-related economic evaluations. This illustrates the general challenge of outcome measurement and valuation in the economic evaluation of public health interventions, and risks misallocating the US$ 20 billion invested in sanitation in low- and middle-income countries every year. In this study in urban Mozambique, we develop an instrument to measure sanitation-related quality of life (SanQoL). Applying methods from health economics and the capability approach, we develop a descriptive system to measure five attributes identified in prior qualitative research: disgust, health, shame, safety and privacy. Sampling individuals from the intervention and control groups of a sanitation intervention trial, we elicit attribute ranks to value a SanQoL index and assess its validity and reliability. In combination with a measure of time using a sanitation service, SanQoL can quantify incremental benefits in a sanitation-focused cost-effectiveness analysis. After monetary valuation based on willingness to pay, QoL benefits could be summed with health gains in cost-benefit analysis, the most common method in sanitation economic evaluations.