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Kigali, Rwanda lacks a centralized sewer system, which leaves residents to choose between on-site options; the majority of residents in informal settlements use pit latrines as their primary form of sanitation. When their pits fill, the pits are either sealed, or emptied; emptying is often done by hand and then dumped in the environment, putting the residents and the broader population at risk of infectious disease outbreaks. In this paper, we used revealed and stated preference models to: (1) estimate the demand curve for improved emptying services; and, (2) evaluate household preferences and the willingness to pay (WTP) for different attributes of improved emptying services. We also quantify the costs of improved service delivery at different scales of production. The study included 1167 households from Kigali, Rwanda across 30 geographic clusters. Our results show that, at a price of US $79 per pit, 15% of all the pits would be emptied by improved emptying services, roughly the current rate of manual emptying. Grouping empties by neighborhood and ensuring that each truck services an average of four households per day could reduce the production costs to US$ 44 per empty, ensuring full cost coverage at that price. At a lower price of US $24, we estimate that the sealing of pits might be fully eliminated, with full coverage of improved emptying services for all pits; this would require a relatively small subsidy of US$ 20 per empty. Our results show that households had strong preferences for fecal sludge (FS) treatment, formalized services (which include worker protections), and distant disposal. The results from the study indicate a few key policies and operational strategies that can be used for maximizing the inclusion of low-income households in safely managed sanitation services, while also incorporating household preferences and participation.

Intermittent delivery of piped water can lead to waterborne illness through contamination in the pipelines or during household storage, use of unsafe water sources during intermittencies, and limited water availability for hygiene. We assessed the association between continuous versus intermittent water supply and waterborne diseases, child mortality, and weight for age in Hubli-Dharwad, India. We conducted a matched cohort study with multivariate matching to identify intermittent and continuous supply areas with comparable characteristics in Hubli-Dharwad. We followed 3,922 households in 16 neighborhoods with children <5 y old, with four longitudinal visits over 15 mo (Nov 2010-Feb 2012) to record caregiver-reported health outcomes (diarrhea, highly credible gastrointestinal illness, bloody diarrhea, typhoid fever, cholera, hepatitis, and deaths of children <2 y old) and, at the final visit, to measure weight for age for children <5 y old. We also collected caregiver-reported data on negative control outcomes (cough/cold and scrapes/bruises) to assess potential bias from residual confounding or differential measurement error. Continuous supply had no significant overall association with diarrhea (prevalence ratio [PR] = 0.93, 95% confidence interval [CI]: 0.83-1.04, p = 0.19), bloody diarrhea (PR = 0.78, 95% CI: 0.60-1.01, p = 0.06), or weight-for-age z-scores (Δz = 0.01, 95% CI: -0.07-0.09, p = 0.79) in children <5 y old. In prespecified subgroup analyses by socioeconomic status, children <5 y old in lower-income continuous supply households had 37% lower prevalence of bloody diarrhea (PR = 0.63, 95% CI: 0.46-0.87, p-value for interaction = 0.03) than lower-income intermittent supply households; in higher-income households, there was no significant association between continuous versus intermittent supply and child diarrheal illnesses. Continuous supply areas also had 42% fewer households with ≥1 reported case of typhoid fever (cumulative incidence ratio [CIR] = 0.58, 95% CI: 0.41-0.78, p = 0.001) than intermittent supply areas. There was no significant association with hepatitis, cholera, or mortality of children <2 y old; however, our results were indicative of lower mortality of children <2 y old (CIR = 0.51, 95% CI: 0.22-1.07, p = 0.10) in continuous supply areas. The major limitations of our study were the potential for unmeasured confounding given the observational design and measurement bias from differential reporting of health symptoms given the nonblinded treatment. However, there was no significant difference in the prevalence of the negative control outcomes between study groups that would suggest undetected confounding or measurement bias. Continuous water supply had no significant overall association with diarrheal disease or ponderal growth in children <5 y old in Hubli-Dharwad; this might be due to point-of-use water contamination from continuing household storage and exposure to diarrheagenic pathogens through nonwaterborne routes. Continuous supply was associated with lower prevalence of dysentery in children in low-income households and lower typhoid fever incidence, suggesting that intermittently operated piped water systems are a significant transmission mechanism for Salmonella typhi and dysentery-causing pathogens in this urban population, despite centralized water treatment. Continuous supply was associated with reduced transmission, especially in the poorer higher-risk segments of the population.

Urban water systems in Asia and Africa mostly provide intermittent rather than continuous water supplies; such systems compromise water quality and inconvenience the user. Starting in 2008, an upgrade to continuous (24/7) water services was provided for 10% of the twin cities of Hubli-Dharwad, India, through a process of privatisation and formalisation. The goals were to improve water quality, free consumers from collecting and storing water, and reduce non-revenue (i.e. unpaid for) water. Drawing on household surveys (n = 1986) conducted in 2010-2011 in the 24/7 zones, as well as on a range of interviews, we find that, even with 'formal' 24/7 water service, most consumers continue the supposedly 'informal' practices of in-home storage and water use without payment of bills. We argue that multiple unaccounted-for factors - including a history of distrust between the consumer and the utility, seemingly small infrastructural details, resistance to higher tariffs, and valuing convenience above water quality - have kept these informal practices embedded within the formalised delivery system. Our research contributes to understanding why formalisation may only partially supplant informal practices even when the formal system is functional and reliable.

In a 500-household pilot, we tested an innovative approach to water demand management, implemented in collaboration with a water utility in a large city in the Middle East and North Africa (MENA) region. We provided a novel intervention, called a Water Savings Credit (WSC), which granted participants volumetric rebates on their water bills for their reductions in water consumption. WSCs were effective at encouraging conservation in our pilot in Marrakech. Our approach has the benefits of a price incentive, without the political risk of a tariff increase. For urban water utilities that provide highly subsidized services, this approach could ultimately pay for itself, or potentially result in net financial savings. Our approach may be especially effective in the countries of the MENA region, as the region has a high rate of subsidization for water services, and because it is facing increasing water scarcity from economic growth, urbanization, and climate change.

Safely managed waste reuse may be a sustainable way to protect human health and livelihoods in agrarian-based countries without adequate sewerage. The safe recovery and reuse of fecal sludge-derived fertilizer (FSF) has become an important policy discussion in low-income economies as a way to manage urban sanitation to benefit peri-urban agriculture. But what drives the user acceptance of composted fecal sludge? We develop a preference-ranking model to understand the attributes of FSF that contribute to its acceptance in Karnataka, India. We use this traditionally economic modeling method to uncover cultural practices and power disparities underlying the waste economy. We model farmowners and farmworkers separately, as the choice to use FSF as an employer versus as an employee is fundamentally different. We find that farmers who are willing to use FSF prefer to conceal its origins from their workers and from their own caste group. This is particularly the case for caste-adhering, vegetarian farmowners. We find that workers are open to using FSF if its attributes resemble cow manure, which they are comfortable handling. The waste economy in rural India remains shaped by caste hierarchies and practices, but these remain unacknowledged in policies promoting sustainable ‘business’ models for safe reuse. Current efforts under consideration toward formalizing the reuse sector should explicitly acknowledge caste practices in the waste economy, or they may perpetuate the size and scope of the caste-based informal sector.

This study explores the legal barriers created by state governments for justice-impacted individuals. The more work barriers the state creates for someone with a criminal record, the more attractive illegal activities become. We examine differences across states in the data set provided by the National Inventory of Collateral Consequences of Conviction. We compare incarceration rates, unemployment rates, and labor force participation rates to the number of rules that affect someone with a criminal background. Our results predict that states with more collateral consequences will have higher per-capita imprisonment, higher unemployment, and lower labor force participation rates.

Background Intermittent delivery of piped water can lead to waterborne illness through contamination in the pipelines or during household storage, use of unsafe water sources during intermittencies, and limited water availability for hygiene. We assessed the association between continuous versus intermittent water supply and waterborne diseases, child mortality, and weight for age in Hubli-Dharwad, India. Methods and Findings We conducted a matched cohort study with multivariate matching to identify intermittent and continuous supply areas with comparable characteristics in Hubli-Dharwad. We followed 3,922 households in 16 neighborhoods with children <5 y old, with four longitudinal visits over 15 mo (Nov 2010-Feb 2012) to record caregiver-reported health outcomes (diarrhea, highly credible gastrointestinal illness, bloody diarrhea, typhoid fever, cholera, hepatitis, and deaths of children <2 y old) and, at the final visit, to measure weight for age for children <5 y old. We also collected caregiver-reported data on negative control outcomes (cough/cold and scrapes/bruises) to assess potential bias from residual confounding or differential measurement error. Continuous supply had no significant overall association with diarrhea (prevalence ratio [PR] = 0.93, 95% confidence interval [CI]: 0.83-1.04, p = 0.19), bloody diarrhea (PR = 0.78, 95% CI: 0.60-1.01, p = 0.06), or weight-for-age z-scores ([delta]z = 0.01, 95% CI: -0.07-0.09, p = 0.79) in children <5 y old. In prespecified subgroup analyses by socioeconomic status, children <5 y old in lower-income continuous supply households had 37% lower prevalence of bloody diarrhea (PR = 0.63, 95% CI: 0.46-0.87, p-value for interaction = 0.03) than lower-income intermittent supply households; in higher-income households, there was no significant association between continuous versus intermittent supply and child diarrheal illnesses. Continuous supply areas also had 42% fewer households with ≥1 reported case of typhoid fever (cumulative incidence ratio [CIR] = 0.58, 95% CI: 0.41-0.78, p = 0.001) than intermittent supply areas. There was no significant association with hepatitis, cholera, or mortality of children <2 y old; however, our results were indicative of lower mortality of children <2 y old (CIR = 0.51, 95% CI: 0.22-1.07, p = 0.10) in continuous supply areas. The major limitations of our study were the potential for unmeasured confounding given the observational design and measurement bias from differential reporting of health symptoms given the nonblinded treatment. However, there was no significant difference in the prevalence of the negative control outcomes between study groups that would suggest undetected confounding or measurement bias. Conclusions Continuous water supply had no significant overall association with diarrheal disease or ponderal growth in children <5 y old in Hubli-Dharwad; this might be due to point-of-use water contamination from continuing household storage and exposure to diarrheagenic pathogens through nonwaterborne routes. Continuous supply was associated with lower prevalence of dysentery in children in low-income households and lower typhoid fever incidence, suggesting that intermittently operated piped water systems are a significant transmission mechanism for Salmonella typhi and dysentery-causing pathogens in this urban population, despite centralized water treatment. Continuous supply was associated with reduced transmission, especially in the poorer higher-risk segments of the population.

Employing a matched cohort research design, eight wards with intermittent water supply are compared to eight wards upgraded to continuous (24 × 7) supply in a demonstration project in Hubli–Dharwad, Karnataka, with respect to tap water quality, child health, water storage practices, and coping costs across socio-economic strata. Water consumption and waste in the intermittent zones, and the potential for scale-up of continuous supply to the entire city, are estimated. It was found that the 24 × 7 project improved water quality, did not improve overall child health, but did reduce serious waterborne illnesses in the lowest-income strata, reduced the costs of waiting, increased monthly water bills, and potentially reduced water security for some of the poorest households.

In the year 2008, the Karnataka Urban Water Sector (KUWS) Improvement Project brought continuous water service (CWS) to a demonstration zone in the twin cities of Hubli-Dharwad, India. Scale-up of CWS for the rest of the city has been authorized and the initial stages of construction are currently in progress. We compared the historical consumption pattern in the CWS demonstration zone of Hubli with system capacity. We found that demand in the demonstration zone has stayed within system capacity and below the national standards for adequate supply. We developed two forecast models of bulk water demand under CWS and compared forecasts with planned future system capacity. In the case of full scale-up of CWS to the rest of Hubli-Dharwad, our forecasts indicate that planned system capacity may be insufficient to meet bulk demand. These forecast models can be adopted by similar mid-sized cities in India.

Well into the 21st century, safe and affordable drinking water remains an unmet human need. Globally, at least 1.8 billion people are potentially exposed to microbial contamination in their drinking water on a regular basis (Onda, LoBuglio, and Bartram 2012). These people are found disproportionately in low-income households located in developing countries; nearly half of all people without access to an improved water source live in Sub-Saharan Africa, while one fifth live in Southern Asia (WHO/UNICEF 2015). Attempts at increasing access to safe water include a wide range of scales, from urban piped water networks providing services to millions of people, to Household Water Treatment and safe storage Systems (HWTS) which allow individuals to provide safe drinking water to their family. Encouraging uptake across a population and ensuring consistent and correct usage are vital for the creation of improved health outcomes from HWTS interventions. For urban water utilities and community systems, assessing and addressing health risks, planning successful upgrades and forecasting revenue streams requires an understanding of how people access, collect and store water, as well as their willingness to pay (WTP) for water services. In the cases of both HWTS interventions and piped water systems, addressing this public health issue requires an understanding of the perspectives, preferences, access points and financial means of end-users, especially those at the lowest income levels and in the most inaccessible locales. This dissertation has focused on two different case studies: one in rural Tanzania and the other in urban India. In both locations our teams collected observations regarding preferences and current practices of water access and usage. We measured WTP across a variety of potential options for drinking water treatment and access in both locations. In the city of Hubli-Dharwad, India, I evaluated a pilot project, measuring stated WTP for both end-users experiencing continuous water service (CWS) and those experiencing intermittent water service (IWS). In four rural villages of Tanzania we asked local residents to evaluate six HWTS, and then collected information on user preferences and WTP. For both locations I analyzed our observations with current policy debates in mind, and gave recommendations for both future research as well as the local management of domestic water systems. These two very different locations have little in common except for a need to improve access to safe drinking water; my research provides vital information on how to create interventions that people want and need. The results from Tanzania are relevant for other countries in Sub-Saharan Africa, as well as other developing regions with limited access to improved water sources and high rates of turbidity. The results from Hubli-Dharwad are relevant to other urban areas in South Asia, and IWS piped water networks in other developing regions as well. The knowledge generated in both locations also contributes to the literature on user preferences and WTP for water services. For the HWTS literature, my research addresses questions about why some HWTS interventions may have failed to scale up to a larger population or to sustain usage among participating households over time; namely that taste, smell, aesthetics, familiarity and ease of use are all vital components of an individual’s decision as whether or not they will treat their drinking water. For this reason, boiling deserves reconsideration as a potentially important option for future HWTS interventions. WTP for retail HWTS is non-zero for the majority of households even in a highly impoverished location such as rural Tanzania, but it is still far below retail prices. The user preferences and WTP analysis for in Hubli-Dharwad sheds light on what piped water services are valued by end-users, and gives some indications on whether and when they should be pursued, adding to the research literature concerning urban utility management and informal urban services. In particular, three key findings emerge from my work there. The first is that CWS may not always be the best upgrade option, and may not provide all of the benefits that it usually is assumed to provide, depending on the experiences, preferences and beliefs of the local end-users. Second, a subset of low-income households depends on free supplemental water sources and therefore service upgrade projects should not include their removal. And finally, water quality is important, but taste and smell can confound households’ perceptions of water quality, and therefore water aesthetics are a salient issue that may deserve greater attention in the future.