Quantifying averted disability adjusted life years as a performance indicator for water quality interventions: a review of current methodologies and challenges Open Access

Anderson, Darcy Mary (2017)

Permanent URL: https://etd.library.emory.edu/concern/etds/j098zb23s?locale=en


Access to a safe, sustainable drinking water supply protects against infectious disease and promotes overall health. While considerable progress has been made towards increasing water access, poor quality and sustainability remain a challenge. Traditional financing and delivery methods pay implementers based on activities and inputs, which offers minimal incentive for ensuring water quality monitoring and sustainable operation. Pay for performance offers an alternative financing strategy that delivers all or a portion of payment based on performance indicators of desired outputs or outcomes, increasing incentives for delivering actual improvements in health. Averted disability adjusted life years (ADALYS) have been used as a performance indicator for environmental health interventions to measure the aggregate burden of disease morbidity and mortality averted as a result of project intervention. Water-related disease burden can be measured for application as an ADALYs performance indicator following either a comparative risk assessment or quantitative microbial risk assessment approach. Comparative risk assessment models disease burden using water source type as a proxy indicator of microbial water quality, while quantitative microbial risk assessment uses contamination levels of indicator pathogens to model disease burden. This paper describes and compares the indicators and risk assessment methodologies. It also summarizes limitations of applying these approaches towards quantifying ADALYs as a performance indicator for water quality interventions.

Table of Contents

1. Background...1

1.1. Water and health...1

1.2. Challenges for ensuring safe and sustainable access...2

2. Incentivizing health gains over service delivery...3

2.1. Current delivery approaches...3

2.2. Pay for performance financing...4

3. Adapting pay for performance financing to water quality interventions...5

3.1. Designing pay for performance incentives...5

3.2. ADALYs...6

3.3. Developing pay for performance financing for water quality interventions...6

4. Indicators for monitoring drinking water quality...7

4.1. Proxy indicators under the WHO/UNICEF's Joint Monitoring Program...7

4.2. Microbial indicators in the WHO's Guidelines for Drinking-water Quality...8

5. Risk assessment approaches to quantify water-related disease burden...9

5.1. Overview of existing risk assessment methodologies...9

5.2. Comparative risk assessment methodologies...9

5.3. Limitations of comparative risk assessment...11

5.4. Quantitative microbial risk assessment methodologies...13

5.5. Limitations of quantitative microbial risk assessment...15

5.6. Challenges of exposure assessment...16

6. Quantifying the effects of water quality interventions...17

6.1. Averted disability adjusted life years as a performance indicator...17

6.2. Applying risk assessment methodologies as performance indicators for water quality interventions...18

7. Discussion...19

8. Conclusions...22


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