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The Africa Infrastructure Country Diagnostic (AICD) has produced continent-wide analysis of many aspects of Africa's infrastructure challenge. The main findings were synthesized in a flagship report titled Africa's Infrastructure: a time for transformation, published in November 2009. Meant for policy makers, that report necessarily focused on the high-level conclusions. It attracted widespread media coverage feeding directly into discussions at the 2009 African Union Commission Heads of State Summit on Infrastructure. Although the flagship report served a valuable role in highlighting the main findings of the project, it could not do full justice to the richness of the data collected and technical analysis undertaken. There was clearly a need to make this more detailed material available to a wider audience of infrastructure practitioners. Hence the idea of producing four technical monographs, such as this one, to provide detailed results on each of the major infrastructure sectors, information and communication technologies (ICT), power, transport, and water, as companions to the flagship report. These technical volumes are intended as reference books on each of the infrastructure sectors. They cover all aspects of the AICD project relevant to each sector, including sector performance, gaps in financing and efficiency, and estimates of the need for additional spending on investment, operations, and maintenance. Each volume also comes with a detailed data appendix, providing easy access to all the relevant infrastructure indicators at the country level, which is a resource in and of itself.

Safe drinking water, sanitation, and hygiene (WASH) are fundamental to an improved standard of living. Globally, 91% of households used improved drinking water sources in 2015, while for improved sanitation it is 68%. Wealth disparities are stark, with rural populations, slum dwellers and marginalized groups lagging significantly behind. Service coverage is significantly lower when considering the new water and sanitation targets under the sustainable development goals (SDGs) which aspire to a higher standard of ‘safely managed’ water and sanitation. Lack of access to WASH can have an economic impact as much as 7% of Gross Domestic Product, not including the social and environmental consequences. Research points to significant health and socio-economic consequences of poor nutritional status, child growth and school performance caused by inadequate WASH. Groundwater over-extraction and pollution of surface water bodies have serious impacts on water resource availability and biodiversity, while climate change exacerbates the health risks of water insecurity. A significant literature documents the beneficial impacts of WASH interventions, and a growing number of impact evaluation studies assess how interventions are optimally financed, implemented and sustained. Many innovations in behavior change and service delivery offer potential for scaling up services to meet the SDGs.

This paper presents country-level estimates of water, sanitation and hygiene (WASH)-related mortality and the economic losses associated with poor access to water and sanitation infrastructure in sub-Saharan Africa (SSA) from 1990 to 2050. We examine the extent to which the changes that accompany economic growth will \"solve\" water and sanitation problems in SSA and, if so, how long it will take. Our simulations suggest that WASH-related mortality will continue to differ markedly across countries in sub-Saharan Africa. In many countries, expected economic growth alone will not be sufficient to eliminate WASH-related mortality or eliminate the economic losses associated with poor access to water and sanitation infrastructure by 2050. In other countries, WASH-related mortality will sharply decline, although the economic losses associated with the time spent collecting water are forecast to persist. Overall, our findings suggest that in a subset of countries in sub-Saharan Africa (e.g., Angola, Niger, Sierra Leone, Chad and several others), WASH-related investments will remain a priority for decades and require a long-term, sustained effort from both the international community and national governments.

Globally, and in Ghana, a lot of people do practice open defecation as well as share toilet facilities with other households. Meanwhile, open defecation in particular, is associated with numerous negative health and economic effects. To this end, a number of empirical studies have been conducted on the determinants of access to sanitation facilities among households in Ghana. Nonetheless, while financial inclusion (sustainable ways of ensuring easier accessibility to cheap and useful financial products and services among individuals/firms) can enhance the ability of households or individuals to afford toilet facilities, hence, could help in curbing open defecation and sharing of toilet facilities among households, the previous studies on Ghana did not pay attention to it. This study therefore uses data from the 7 th round of the Ghana Living Standards Survey (GLSS7) to examine the association of financial inclusion with open defecation and sharing of toilet facilities among households in Ghana. The binary logit regression is used as the empirical estimation technique. The results show that, financial inclusion in general is associated with lesser likelihood of open defecation and sharing of toilet facilities among households in Ghana after controlling for welfare quintile, urban or rural residence and other covariates. Moreover, while informal financial inclusion is statistically insignificant, formal financial inclusion is found to be associated with reduced open defecation and sharing of toilet facilities among households. Thus, in the attempt to eliminate open defecation as well as reduce the sharing of toilet facilities among households in Ghana, conscious efforts should be devoted towards enhancing formal financial inclusion.

Pit latrines are the most common household sanitation system in East African cities. Urbanisation reduces the space available for new latrines to be constructed when pits fill and they increasingly require emptying. But formal services that empty and transport sludge to safe disposal or treatment are often unaffordable to low-income households. Cross-subsidies have been suggested to fund services for low-income households but there are no academic studies assessing this funding mechanism. This study analyses empirical financial and operational data shared by a formal service provider in Kigali, Rwanda who is establishing a cross-subsidy model between corporate and high-income households, and low-income households in informal settlements. A semi-mechanical method is used to serve households which cannot be accessed from the road by an exhauster truck. We find that mechanical emptying is gross profitable when exhauster trucks are fully used, particularly large volume and corporate customers. Transferring sludge between vehicles for efficient transport reduces average cost. Cross-subsidies are found to be a viable funding method and a ten-fold increase in mechanical emptying by the service provider would generate 466,876 Int$ (2022 international dollars) gross profit to fund a cross-subsidy for all low-income households in Kigali which require semi-mechanical emptying. This study highlights the opportunities that city authorities have to organise funding to cross-subsidise emptying for low-income households. In addition, by using data from operational records rather than self-reported estimates the reliability of cost estimates is in improved. Further research is required to understand customer group size, demand and emptying frequencies to determine the structure of a citywide cross-subsidy.

In Mumbai, most all residents are delivered their daily supply of water for a few hours every day, on a water supply schedule. Subject to a more precarious supply than the city's upper-class residents, the city's settlers have to consistently demand that their water come on \"time\" and with \"pressure.\" Taking pressure seriously as both a social and natural force, in this article I focus on the ways in which settlers mobilize the pressures of politics, pumps, and pipes to get water. I show how these practices not only allow settlers to live in the city, but also produce what I call hydraulic citizenship—a form of belonging to the city made by effective political and technical connections to the city's infrastructure. Yet, not all settlers are able to get water from the city water department. The outcomes of settlers' efforts to access water depend on a complex matrix of socionatural relations that settlers make with city engineers and their hydraulic infrastructure. I show how these arrangements describe and produce the cultural politics of water in Mumbai. By focusing on the ways in which residents in a predominantly Muslim settlement draw water despite the state's neglect, I conclude by pointing to the indeterminacy of water, and the ways in which its seepage and leakage make different kinds of politics and publics possible in the city.

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.

Parental education is located at the center of global efforts to improve child health. In a developing-country context, the International Monetary Fund (IMF) plays a crucial role in determining how governments allocate scarce resources to education and public health interventions. Under reforms mandated by IMF structural adjustment programs, it may become harder for parents to reap the benefits of their education due to wage contraction, welfare retrenchment, and generalized social insecurity. This study assesses how the protective effect of education changes under IMF programs, and thus how parents’ ability to guard their children’s health is affected by structural adjustment. We combine cross-sectional stratified data (countries, 67; children, 1,941,734) from the Demographic and Health Surveys and the Multiple Indicator Cluster Surveys. The sample represents ∼2.8 billion (about 50%) of the world’s population in year 2000. Based on multilevel models, our findings reveal that programs reduce the protective effect of parental education on child health, especially in rural areas. For instance, in the absence of IMF programs, living in an household with educated parents reduces the odds of child malnourishment by 38% [odds ratio (OR), 0.62; 95% CI, 0.66–0.58]; in the presence of programs, this drops to 21% (OR, 0.79; 95% CI, 0.86–0.74). In other words, the presence of IMF conditionality decreases the protective effect of parents’ education on child malnourishment by no less than 17%. We observe similar adverse effects in sanitation, shelter, and health care access (including immunization), but a beneficial effect in countering water deprivation.

The investments needed to deliver sustainable water and sanitation services, including the funds that are needed to operate and maintain the infrastructure, expand their coverage and upgrade service delivery to meet current social and environmental expectations, are huge. Yet, most systems are underfunded with dire consequences for water and sanitation users, especially the poorest. Providing sustainable drinking water supply and sanitation services requires sound financial basis and strategic financial planning to ensure that existing and future financial resources are commensurate with investment needs as well as the costs of operating and maintaining services. Some of the key messages of the report are: - WSS generate substantial benefits for the economy - Investment needs to generate these benefits are large in both OECD and developing countries - Tariffs are a preferred funding source, but public budgets and ODA will have a role to play, too - Markets-based repayable finance is needed to cover high up-front capital investment costs - Strategic financial planning and other OECD tools can help Governments move forward

Severe acute malnutrition (SAM) affects 12.2 million children globally. Integrating a water, sanitation and hygiene (WASH) kit in outpatient SAM treatment can improve recovery rates by preventing WASH‐related diseases and complications, but its cost at scale remains unknown. This study estimates the cost of integrating a WASH kit, composed of chlorine‐based water treatment, safe water storage with a lid, soap, and a hygiene promotion component into Senegal's national protocol for treating uncomplicated SAM. This costing study was nested within the TISA randomised controlled trial, which evaluated the addition of a WASH component to standard SAM treatment for children aged 6–59 months. Cost data were collected from 660 participants enroled between December 2020 and December 2021. We took a societal perspective and used a micro‐costing approach to estimate direct medical, non‐medical and indirect costs. The WASH component led to a 2021 international $105.32 additional cost per child treated, with the WASH kit, transportation and management representing $33.03. Sensitisation to hygiene and water treatment cost $13.46 at health posts and $29.63 for two at‐home visits. No additional out‐of‐pocket expenses were incurred by households, but $1.58 in opportunity costs (income loss) was observed. Human resources were the main cost driver for the WASH component, exceeding the human resources for standard SAM treatment. The total societal cost per child treated was $338.77, ranging from $238.09 to $517.29 in sensitivity analysis, with the SAM treatment representing 69% ($233.40) of this total cost. The main expense for this component was Ready‐to‐Use‐Therapeutic Food (RUTF) ($154.39). The absence of additional costs for households induced by the WASH component is encouraging, as it suggests that it would not represent an obstacle to integration into the national protocol. We produced a robust and comprehensive cost estimate for integrating a WASH kit and hygiene promotion into Senegal's SAM treatment protocol. This increased the treatment cost by 45% which was lower than estimates from a previous study. Results inform budget planning and support future cost‐effectiveness analyses of integrating WASH interventions into SAM protocols. Integrating a WASH component increased treatment costs by $105.32 per child treated, representing a 45% rise in total costs. The WASH component did not result in additional households out‐of‐pocket expenses, making it a viable option for scale‐up in similar low of middle income settings. The main expenses of the WASH component were the HR related to the training sessions and the at‐home sensitisations, as well as the purchase cost of the kit. These findings are useful for implementers, policymakers and donors aiming to improve SAM treatment outcomes while ensuring efficient resource allocation.