Water supply and health in developing countries: selective primary health care revisited

The inclusion of water supply and sanitation programs as a component of primary health care (PHC) has been questioned on the basis of calculations of the costs of these programs per infant death averted. In this paper the procedures used in these cost-effectiveness calculations are examined and found to be wanting. The calculations are misleading since gross rather than net costs have been used, and the health impact of these programs underestimated. It is also shown that the methodology used is biased against water supply and sanitation and other programs with multiple outputs. The time constraints facing mothers in implementing PHC programs, as well as the contribution of improved water supplies in alleviating these constraints are outlined. Data are presented to show that, if poor women in developing countries were to choose the mix of activities to be included in PHC programs, improved water supplies would frequently constitute part of that mix.