Hygiene promotion can greatly improve the benefits of water and sanitation programmes in developing countries at relatively limited costs. There are, however, few studies with hard data on the costs and effectiveness of individual programmes and even fewer have compared the cost-effectiveness of different promotional approaches. This article argues that objectively measured reductions of key sanitation and hygiene risks are better than DALYs for evaluating hygiene and sanitation promotion programmes. It presents a framework for the cost-effectiveness analysis of such programmes, which is used to analyse six field programmes. At costs ranging from US dollar 1.05 to US dollar 1.74 per person per year in 1999 US dollar values, they achieved (almost) complete abandonment of open defecation and considerable improvements in keeping toilets free from faecal soiling, safe disposal of child faeces, and/or washing hands with soap after defecation, before eating and after cleaning children's bottoms. However, only two studies used a quasi-experimental design (before and after studies in the intervention and - matched - control area) and only two measured costs and the degree to which results were sustained after the programme had ended. If the promotion of good sanitation and hygiene is to receive the political and managerial support it deserves, every water, sanitation and/or hygiene programme should give data on inputs, costs, processes and effects over time. More and better research that reflects the here-presented model is also needed to compare the cost-effectiveness of different promotional approaches.

In tbis paper tbe value of an improved domestic water supply was investigated for economic development and gender relations in rural households in a drought-prone area. A comparative study executed witb participatory rural appraisal (PRA) methods with groups of women from 11 micro-enterprises in ten villages and five control villages showed that,when an improved domestic water supply does not function, the entrepreneurs groups bave a statistically higber loss of the economic use of water and time tban the control groups. The extra income tbat women gain wben tbe supply works and is used economically belps poor families to bridge tbe dry season. It could further be quantitatively proven that male-female gender relations were significantly better in the entrepreneurs group. Tbis was not so for mother-daughter relationsbips, wbicb gave new insights into the need to address gender equality i.ssues witb the women themselves and witb SEW A, the supporting agency. These findings support ibe view that rural poverty and tbe status of women would receive a significant boost if policy makers focused on providing employment opportun i tie.s for women along witb improved water supplies.

Dr Sijbesma (aka van Wijk) is a sociologist with a specialization in health extension. She has been involved in community managed water supply, sanitation and hygiene programmes in South Asia since 1980. The workshop and its papers on which this article is based resulted from the cooperation between BRAC, WaterAid and IRC. Financial support from the Water Supply and Sanitation Collaborative Council (WSSCC) is gratefully acknowledged.

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