Social_Management

Explore the Issue of assertiveness and the importance of this for midwives. The Oxford Dictionary defines assertiveness as: Asserting oneself, being forthright and positive. Hermes states that assertive behaviour Involves standing up for personal rights and expressing thoughts, feelings and beliefs in direct, honest, and appropriate ways which do not violate another person’s rights. The purpose of assertive behaviour is to communicate ideas, feelings and needs clearly without being aggressive and in the appropriate way not to humiliate or degrade the other person. It is an area that has a long history of study, dating back to Salter (1949) and Wolpe (1958) who studied a great deal in the field of behaviour. There has also been great volumes of research conducted into assertion training. Rakos (1997) pointed out that “ assertion is a learned skill, not a “trait” Historically Midwifery has seen many changes, in 1902 the Midwives Act became law and Midwifery became an established profession in Britain. Midwives underwent supervised training and registration. However, it was not until the 1970’s that the chairmanship of the statutory body, the Central Midwives Board, passed to a midwife. (Murphy-Black 1995) Poroch & McIntosh (1995) suggested that in the past midwives and nurses were submissive helpers of doctors. The Changing Childbirth Act (DOH 1993) challenged the government to address the access to maternity services to give women the power to make real and informed choices about their maternity care. Over the years the changing social status of women has been reflected in the many changes within the profession. Assertive behaviour has been an essential communication tool for women in pursuing equality. The reason I have chosen this subject is my unfamiliarity with assertiveness and therefore need to explore the subject to enhance my clinical care through the use of assertive skills. As midwives working within a professional team, using assertiveness skills is essential to working in a professional manner. There are different principles that identify behaviour, attitudes and feelings that influence how we interact with other people. Being assertive is standing up for others, this means that you are deciding for yourself and allowing and enabling other people to decide for themselves (Sully & Dallas 2005). In a study by Farrell (2001) it was concluded that midwives and nurses sometimes did not display a nurturing and caring approach, suggesting that there is a fine line between aggression and assertive behaviour. This could also be because midwives and nurses are themselves not nurtured' Aggression occurs when people are lacking in confidence and insecure. Barnard (1992) suggests that the structure of the health care system is such that nurses and midwives are not encouraged enough to be assertive. There is little evidence to show the assertiveness ability of midwives and the benefits of assertive practice. However, the effects of oppression described by Farrell (2001) as abuse, low esteem and aggression are unhealthy for midwives and the clients in their care. Delivering quality care is a central function of midwifery, fear of negative response from others prevents midwives from behaving as they should. Being assertive also means to allow your colleagues to express an opinion, you should also be supportive, complimentary and know when to say “No” where appropriate. An assertiveness workshop in Chichester identified the following statements as “Being assertive as a midwife” • Use your own knowledge • The fear of litigation can work both ways; remind people of the adverse consequences of their refusal to acquiesce. • Refuse to administer a treatment you see no need for, ask a consultant to institute it. • Question the reasons for the proposed intervention (or non-intervention) ask the doctor/midwife to explain the need for it to you so that you can explain it to the woman. • You have the right to question treatment. You also are educated and experienced. Along with these statements it is important to remember that we have the right to be treated with respect, express our feelings, to make mistakes, to change our minds, to ask for what we want, to say “I don’t understand” and to deal with others without being dependant on them for approval. According to Watson (1998) assertiveness is necessary in both verbal and non-verbal communication. It is apparent in our body language and the tone of our voices, therefore as midwives when we talk to clients in an assertive way it should be in a clear and positive way. As a student it is sometimes difficult to be assertive surrounded by the great realms of power in which we train. However, as a professional we must possess the ability to be assertive. This assertiveness is often shown in the lecture halls of university’s when student midwives are referred to as “nurses” this non use of our proper title makes us assertive in ensuring that our separate identity is acknowledged by both tutors and student nurses alike. Our roles after all are that of “with woman” serving the needs of healthy, child bearing women, not the sick and dying. As midwives we have a duty of care to the women we look after therefore the care that we give should be supportive, spiritual, and assertive. Not in an aggressive or controlling way but as an advocate of her wishes. As an advocate the midwife can help her clients to persist assertively their attempts to gain the appropriate care and information, and when necessary to act on their behalf. (Bond:1986) There is a need as a student midwife to develop communication and assertiveness skills. According to Watson (1998), a midwife uses an assertive approach to take full responsibility for her actions. In the labour room an assertive midwife can make a huge difference during labour. At this time many women are exhausted and in pain. The midwife will encourage the woman to change positions enabling her to move to a more physiological position, enabling a more effective delivery. On placement in a local birth centre I have witnessed first hand how the midwives encourage women through labour. Allowing these women to be assertive themselves by giving them the freedom to walk about freely, eating and drinking at will and actively supported at every angle. The women in their care are respected as individuals and can communicate with all the professionals. In the birth centre these women also enjoy informed choice, as everything is explained to them throughout each pregnancy. However, occasionally midwives can show an aggressive communication style when promoting the “Baby friendly Initiative” Women who have not expressed a preference to their feeding technique can be manipulated into breastfeeding her baby without really wanting to. This seems to be more apparent in young mothers who are not assertive enough in their wishes and will often go home early just to feel at ease with bottle feeding their baby. This means that as midwives we must be careful not to “over exert” our own preferences, leaving our clients to make informed choices of their own. However, many women have decided how they wish to feed their infant as soon as they know that they are pregnant, even before the first ante-natal visit. As midwives we should support them in these women in whatever method they choose. Emmons (2001:6) stated that assertive behaviour promotes equality in human relationships, enabling us to act in our own best interests, to stand up for ourselves without undue anxiety, to express honest feelings comfortably, to exercise personal rights without denying the rights of others. This enables us to respect the rights of others, something as midwives we should do with all the women we look after. The growth of organisations such as the National Childbirth Trust (NCT) and the Association of Radical Midwives (AIMS) is evidence that child bearing women need midwives to have a voice and to be advocates for women within the maternity services. Bond (1992). For many years pressure groups such as ARM (Association of Radical Midwives) have been active in bringing women’s needs and choices of care to the forefront of our minds. Their objectives are: To share ideas, skills and information with colleagues and clients. To help midwives develop their role as advocates for women's active participation in maternity care. To support midwives in their efforts to provide continuity of care. To explore alternative patterns of care. To encourage the evaluation of developments within the sphere of midwifery practice. (ARM 2006) As midwives we have a duty of care to these women. Legally and ethically midwives are responsible for their actions, The NMC (2004a) Code of Professional Conduct 1.3 states “You are personally accountable for your practice”. This means that you are answerable for your actions and omissions, regardless of advice or directions from another professional.” Therefore a professional must possess the ability to be assertive, for some women pregnancy can be a fulfilling experience. However, this “wonderful” experience can be shattered in a moment and leave lifelong consequences when things do not go according to plan. We must therefore remember that as part of our everyday practice the midwives’ Code of Conduct states that, ‘in all circumstances the safety and welfare of the mother and her baby must be of primary importance’. There have unfortunately been cases where the midwife in charge has not shown these important qualities when looking after women. In many cases now within district hospitals midwives are not “standing up” for the women they are looking after. This has been documented in many ways by Kitzinger, S. (2006) who writes; midwives like epidurals, because they keep women quiet, immobile and safely tucked up in bed. When a woman presents with a birth plan it has been greeted with “you can swing from the chandeliers as far as I am concerned. A midwife stood over a pregnant woman who was in immense pain and laughed saying ‘ it’s a bit different from what you were doing nine months ago’ These comments are unacceptable and thankfully, only used by a minority of professionals. However, what is said to these women can have lasting effects on her emotionally and can even stop her from having another child. Many women feel vulnerable in pregnancy, labour and the postnatal period. Therefore a midwife must be prepared to challenge care that she feels inappropriate on the woman’s behalf to give her the confidence to ask the appropriate questions. A midwife must also act as the woman’s advocate when she is unable to stand up for herself. It is important however to remember different cultures when asserting oneself. In Asian culture a person prefers not to say no, therefore yes may mean ‘no’ or perhaps. Therefore it is essential to establish whilst in conversation that instructions and implications have been understood. (Sully & Dallas: 2005) Midwives therefore must recognise and support the spiritual needs of women. LeMon (1990) stated that assertive communication is the key to managing conflict. Regardless of its nature, assertiveness is the only response that gives someone the opportunity to resolve conflict appropriately. Midwives are in an ideal position to have face to face communication with child bearing women. This enables both the mother and the midwife to find out the information they both want. Midwives require effective communication skills as good communication can make a person feel valued and listened to. This improves understanding, reduces anxiety and improves understanding, which in turn helps clients to make their own choices. (RCM 2001) As we move away from the high induction rates of the 1970’s more women are choosing to give birth at home and in local birth centres. Women want continuity of care, choice in the care they are provided with and control over the process of childbirth. All over the world midwives have made changes to the way they work by their assertive behaviour. Across the world unlicensed midwives have achieved licensure. Midwives have the right to practice in New Zealand equal to their medical colleagues. Lay midwives in Ontario, Canada fought to make midwifery legally recognised and licensed. In Germany midwives fought obstetricians who wanted births to be performed by them with the midwife as an assistant. German midwives organised opposition to this and won. In Romania around 1978 midwifery was abolished by the Ceaucescu regime midwives lost their jobs and their training was withdrawn (Murphy-Black). It was from this point on that women were to enter into maternity units with very limited education and hygiene awareness. The introduction of a workshop for these women in 1992, the first time that they had met, was held under the direction of the World Health Organisation and UNICEF. The women were asked for their initial assessment on how and what could be done to once again make midwifery a strong and recognised profession. Their priority was to form an association of which meeting could be held to discuss the ways in which pressure could be brought upon the authorities so that midwifery could once again be recognised. They saw clearly a need to exercise the collective will to achieve their goals.(Jenkins : 1992) This shows that as midwives there are many ways in which we need to be assertive. Campaigning for better jobs, rates of pay, new facilities and for us to be heard as a profession. What will happen if we just sit back and do nothing' What we campaign for reflects on the care provided to our clients and the care that we can provide. Using political channels to our advantage has seen rewards. After receiving evidence from women and the RCM the Select Committee on Health recommended a complete reappraisal of the maternity services. The Select Committee (1992) recommended : That the status of midwives as professionals is acknowledged in their terms and conditions of employment which should be based on the presumption that they have a right to develop and audit their professional standards. That we should move as rapidly towards a situation in which midwives have their own caseload, and take full responsibility for the women who are under their care. That all midwives should be given the opportunity to establish and run midwife managed maternity units within and outside hospitals. That the right of midwives to admit women to the NHS hospitals should be made explicit. (Murphy-Black : 1995) Although a Select Committee does not have the force of government, their recommendations were heard and some implemented. Thus another way in which midwives assertiveness can change things. However, assertiveness can be used in an aggressive way, this is noticeable at all levels. LeMon wrote that “in each one of us is the animal instinct called “fight or flight”. This means that when we are frightened or threatened we have instinctive responses. An aggressive person is one that fights and shows aggressive behaviour that may include physically invading someone’s space or by bullying them. (LeMon: 1995) Bullying is something that midwives have to deal with on a daily basis. According to Keeling (2006) the number of reported incidents in the workplace appears to be increasing. A survey by the Royal College of Midwives discovered that 51% of respondents had been bullied by a more senior colleague, 41% by a midwifery manager and 21% by a supervisor of midwives. (RCM, 1996) In normal circumstances the first point of contact for a victim would be the supervisor of midwives. However the bully is frequently the victim’s manager or supervisor. Clients can be bullied in the same way by professionals. The midwife that does not listen to a woman when she is telling her that she is the victim of domestic violence is as guilty as the person inflicting that violence. In the same way as the woman who wants a natural birth with little or no intervention, where will she be if as midwives we do not speak for her' The ideal is that every women’s birth experience is a positive one, regardless of whether it all goes the way she envisaged. Midwives that take the time to work with women to achieve their goal are the assertive midwives that we need to be. Being a midwife means “with woman” this role needs assertive advocates of women who will stand up for their rights and challenge professionals when they feel that things are not as they should be. There are also spiritual and ethical issues of assertiveness. In the context of midwifery we should acknowledge the relationship of the mind, body and spirit to the changes that take place within the woman during pregnancy. (Hall : 2005) The Changing Childbirth Report (1993) states that we should provide translation, interpreting and advocacy services based on an assessment of the needs of the local population. So, if we are a little more assertive in a situation where we would have previously been submissive, aggressive or manipulative, then we as midwives will make a difference. If we can communicate our client’s views and wishes in an assertive not aggressive way then we as midwives can make a difference. And finally if we can achieve what women want, if it is important enough to us then all the hard work will be worth it. . References Barnard, P. (1992) “Developing Confidence”. Nursing Times 47 (4) 9-10 Bond, M. (1992) Assertiveness and the Midwife. London: Southbank Polytechnic. Department of Health (1993) Changing Childbirth report. Part 1 report of the Expert Maternity Group. HMSO : London Farrell, G.A. (2001) “From tall poppies to squashed weeds: why don’t nurses pull together more'” The Journal of Advanced Nursing 35 (1) 26-33 Hall, J. (2005) Midwifery, Mind & Spirit emerging issues of care Elsevier Ltd Oxford. Jenkins, E R (1992) Report of a visit to Romania, prepared for the World health Organisation. Unpublished. Keeling, J. (2006) “Bullying in the workplace, what it is and how to deal with it” The British Journal of Midwifery 14 (10) 616-621 Kitzinger, S. (2006) Birth Crisis London: Routledge 26-27 LeMon, J. (1995) Assertiveness: “Get what you want without being pushy” p36-37 National press publications: USA Murphy-Black, T. (1995) Issues in Midwifery p 6-7 Churchill Livingstone : London NMC (2004a) the NMC code of professional conduct, standards for conduct, performance and ethics. NMC, London. Poroch, D. & McIntosh, W. (1995) “Barriers to assertive skills in nurses” Australian and New Zealand Journal of Mental Health Nursing. 4 113-123 Rakos, R. (1991) Assertive behaviour: Theory, Research and Training. London: Routledge Royal College of Midwives (2001) The midwife’s role in public health. Position paper 24. London RCM (1996) “In place of fear: Recognising and confronting the problem of bullying in Midwifery” British Journal of Midwifery 14 (10) 620-621 Sully P, & Dallas J. (2005) Essential Communication Skills for Nursing. London : Elsevier Watson, M. (1998) “Assertiveness: an essential tool for the midwife” The Practising Midwife 1 (3) 30-32 Econ 417 | Water and Sanitation | Copenhagen Consensus | Irene Segurado4/10/2010 | “Water is the basis of life on earth. The quality of life directly depends on water quality. Good water quality sustains healthy ecosystems and hence leads to improved human well-being. However, poor water quality affects the environment and human well-being. For example waterborne diseases cause the death of more than 1.5 million children each year. The quality of water resources is increasingly threatened by pollution. Human activity over the past 50 years is responsible for unprecedented pollution of water resources in history. It is estimated that over 2.5 billion people globally live without adequate sanitation. Every day, 2 million tons of sewage and other effluents drain into the world’s waters. The problem is worse in developing countries where over 90% of raw sewage and 70% of untreated industrial wastes are dumped into surface waters”. The Copenhagen consensus was design to evaluate economic solution to the current global issues we are currently facing and rate which projects were the ones that have more economic sense to invest in, that is which projects lay the most benefits. However, the challenge paper on Water and Sanitation does not meet the requirements to sustain its conclusions in a reliable way. In this article we will find how many of the conclusions made in the challenge paper were based on incomplete information and how many economic aspects were simply ignored due to difficulty to calculate their impact. The Copenhagen challenge paper for water and Sanitation in 2008 was written by Dale Whittington, W. Michael Hanemann, Claudia Sadoff and Marc Jeuland. The authors divided the paper in two main sections, the first part of the challenge paper focuses on assessing the costs and benefits of investing on water and sanitation infrastructure. The second Part of the project discuses cost and benefits of specific Water and Sanitation investments. There have been various disagreements to the work done by the main authors; Jenna Davis Frank R. Rijsberman and Alix Peterson Zwane are the main discussant of the challenge paper, and their work criticizes those points that were ignored by the challenge paper main authors.  In this part article, I will first summarize and discuss the main points discussed in the challenge paper on assessing the cost and benefits of investing in water and Sanitation infrastructure and then focus on the investments presented as best solutions. Before introducing any cost analysis on water and sanitation, Whittington et al. set up the background conditions that have made water investment quite challenging, they mention 6 main observation:    1. Water and Sanitation are a huge social enterprise and conform one of the largest sectors in most developed countries.   2. Water distribution and Access to Sanitation are goals that require high long-lasting capital expenditure due to the required infrastructure; the initial costs are very high so decisions should be done thoughtfully.   3. Demand for water is extremely inelastic; therefore, there is high incentive and opportunities for monopolistic activities when governance is weak.   4. Water is easy to store but transportation cost are very high when facing long distances.   5. Even though there is a positive correlation between water and sanitation infrastructure and income, many households choose to have electricity before network water and sanitation in many developing countries.   6. There are many people that believe that water should not be regard as a commodity but as a human right. Whittington et Al. Initiate the Cost analysis by describing the Cost of Municipal Water and Sanitation Networked Infrastructure. They estimate the average unit cost of providing modern services to an urban household. Under these costs their study includes, opportunity cost for water, raw water storage, transmission and treatment, local distribution network, collection and conveyance of sewage to the treatment plant, secondary wastewater treatment and damage from the discharge of treated water and overall overhead. With a 6% discount rate and assuming a lifespan of 20 years for capital, total economic costs for networked infrastructure is calculated to be about $2/m³. However, this price could double or triple in arid and less accessible areas. A lower bound is set to be $0.8/m³ for a more simple system that would have minimum storage and minimum water treatment. This means, that monthly cost of water would be about $8 per household if we assume that higher cost of water would reduce consumption compared to in developed countries. No major criticism was done on the way the authors calculated the cost for W&S infrastructure, however, Rijsberman et al. did mention that “the ‘gold-standard’ opportunities chosen by Whittington et al. are not the most appropriate for the target group of beneficiaries; we believe that less costly (non-networked) options are available that would demonstrate significantly improved cost-benefit ratios” (p. 2). The current group that urges for access to clean water and sanitation is found in rural areas and it is the population with income below $1 and $2. Whether the cost benefit ratio is high for networked infrastructure or not, it would not solve the quest to halve the percentage of people without access to improved W&S. This does not mean that inversions in W&S infrastructure are wasteful just not appropriate for the problem targeted.  When discussing the Economic benefits of Improved Water and Sanitation services, Whittington et Al. only take account of the benefits accrued by households since those are the greatest ones. Under those benefits the authors consider the benefits that some households obtain from getting access to cheaper water than the one they purchase from the water vendors. Secondly, Whittington et Al. include the benefits that households inquire by saving money they spend for temporal storage, decontamination or time and expense in finding supplies. The last source of benefit analyzed by the authors is the avoided cost of illness; they use a lower bound estimate to calculate the benefits of avoiding illness where reduction of mortality, pain, suffering and other health benefits are not taking into account. Consequently, the authors conclude that avoiding cost of illness alone is not enough to provide economic justification for Water and Sanitation improvement.  The analysis of benefits for networked water and sanitation has been one of the most argued; both of the discussants have found the benefits to be understated in the challenge paper. First of all, the fact that the main ignored mortality when analysing estimating the benefits of networked W&S has been hardly criticized. According to Davis, “Recent work suggests that mortality reductions resulting from the extension of piped water networks in urban areas can be substantial. Cutler and Miller (1), for example, find that the provision of treated, piped water supply was responsible for nearly half the total mortality reduction in major US cities between 1900 and 1940. The authors estimate a benefit‐cost ratio of more than 23 (95% confidence interval of 7 to 40) for these investments”. In addition to this evidence, Rijsberman and Zwane present other studies that show the considerable benefits in reducing mortality that piped water and sanitation networks have had when introduced in less dense population like the Native American Communities and when introduced in middle income countries like Argentina. It is clear that the benefits of W&S networks are clearly understated by not taking in account reduction in mortality. When assessing the willingness to pay households put on improved water access and sanitation Whittington et Al. conclude, “The contingent valuation surveys of household demand for improved water and sanitation services did not suggest that households’ perceived economic benefits from improved water and sanitation services would commonly exceed the full economic costs of providing water and sanitation services (pp 37)”. As an example of the low willingness to pay observed for W&S, the authors mention how households would pay for access to electricity before access to piped water and sewerage. On the other hand, Davis explains this occurrence might be explained by the lack on the supply side. Furthermore, the challenge paper mentions some arguments indicate that the low willingness to pay for W&S networks might be due to households not being able to recognize the overall benefits. “[Proponents] argue that households’ perceived economic benefits are not accurate reflections of the actual benefits people will receive from improved services. Many health professionals do not believe that people in areas that need such services (i.e. where health benefits would potentially be high) have an adequate understanding of the link between improved services and improved health (p. 41).” For example, There are many current circumstances in which willingness to pay for certain commodities would be low due to ignorance or to higher value set on short term benefits, for instance in the case of girls education. Whittington et Al. does not address clearly this argument. The lack of improved sanitation produces negative externalities that have to be beard by the whole community and therefore, individuals might not value the benefits of accessing to improved sanitation as much as the community would value them. Finally, after analysis made on cost and benefits for investing in modern networked Water access and Sanitation, Whittington et Al. got to concluded that the benefits of W&S infrastructure would not exceed the Costs for some households. However after analysing information given by the discussants, we can tell that benefits of investing in W&S in urban households can far exceed the costs, if we properly include morality and other externalities like progress in achieving environmental sustainability, development and overall health that W&S infrastructures bring. The fact that those externalities are difficult to measure does not give excuse to ignore them when facing investing decisions. As I mention before, even W&S networks could give higher returns than estimated in the challenge paper, they are not the best solution to attack the global problem we currently face were billions of people lack access to clean water and sanitation. W&S infrastructures do provide many benefits and are projects that promote sustainably and development. However, they are better suited for cities with rapid economic growth and they do require high initial costs that would not be possible to be made in a massive way to alleviate all the current needs. In addition, “Among the 1.2 and 2.6 billion persons lacking access to water supply and sanitation services, respectively, roughly 80% live in low‐density (“rural”) areas. The non‐network interventions evaluated by the Challenge Paper authors appear particularly well suited for these types of communities (p.9).” (Also refer to figure 2) There are three main solutions studies on the challenge paper that focus on low cost non-networked interventions and multi-purpose investments in major water resources. The first intervention consists in a rural water supply program providing poor rural communities in Africa with deep boreholes and public hand pumps. The second intervention is a Total Sanitation Campaigns to achieve open defecation-free communities in South Asia. The third intervention consists in the use of Biosand Filters for “Point-of-use” Household Water Treatment. Finally, the last intervention describes project construction of large multipurpose dams in Africa.   However, as   Rijsberman et al. observe, “The [challenge] paper does not consider in detail either how improved service may realistically be provided to the urban or peri-urban poor or key management and information barriers to implementation of either networked or non-networked solutions (p. 7).” Water and Sanitation Intervention No. 1 – A rural water supply program providing poor rural communities in Africa with deep boreholes and public hand pumps. Boreholes and communal hand pump are considered best and cheapest technology options for places where deep groundwater is the best available water source. As many projects of this nature had failed in the past, the authors of the challenge paper proposed a “demand-driven” community management where households pay some of the costs of maintenance and distribution of the services and are also involved in the decision making. This type of projects, emerged in the 90s has proven to be quite effective in keeping the usage of the system consistent overtime. Under the cost of the project the authors include, Drilling, transportation of materials, other capital costs, overhead, and other maintenance cost. Assuming a 15 years life spine for the project and a 6% discount rate, overall monthly cost of a borehole per household would be $2.65 per household, each borehole is assume to provide for 300 people. The benefit analysis of this project consist of, time saved that could be used for working, cooking, leisure, child caring. Woman are the main group that benefits by the time saved provided by boreholes, since 64% of those in charge of finding and collecting water supplies are woman. Other benefits included in the analysis are improved lifestyle and aesthetics and health benefits, which in this case include for diminish rate of mortality. Overall, Whittington et Al. estimates benefits to be $7.19 per month which implies a cost benefit ratio of 3.2. According to Davis, benefits might also be understated in this analysis. “Setting aside possible moral objections regarding the calibration of the VSL [value of statistical life] for lower‐income populations and using regional median values for per capita income, the implied values of a statistical life for sub‐Saharan Africa and South Asia range between 4and 16 times higher than those used in the Challenge Paper’s analyses. Modest adjustments of the VSL would improve the (already attractive) interventions considered by the authors (p. 6). Water and Sanitation Intervention No. 2 – Total Sanitation Campaigns to achieve open defecation-free communities in South Asia It is important to notice that behavioural changes are to be done in order for any sanitation project to be cost-effective. For example, “In South Asia, a Community-Led Total Sanitation (CLTS) approach has been successful in many areas. Raising awareness of the health and social benefits of sanitation creates a demand which can then be fulfilled by choosing from a menu of low-cost options (p. 6).”   In many cases, projects that are accompanied by a hygienic campaign are to be more successful in reducing diseases. Davis also mentions “A meta‐analysis by Curtis and Cairncross (32), [...] found that handwashing with soap reduces the risk of diarrhea by 42‐47%. A randomized controlled trial in Pakistan found outcomes of this magnitude for both diarrhea and pneumonia incidence among children (p. 9).”  The main cost of the project consists on latrine building, cleaning and maintenance and commitment to campaign exposure. Assuming a 6 year life for the latrine and a 6% discount rate, the total monthly cost per household using the latrines would be $0.43 per month. The main benefits included in this analysis are reduction of diseases and mortality and time saving and they amount to $1.14, therefore, cost-benefit ratio is 2.7. However these estimates might vary from area to area. Davis adds to the argument, “Impacts are mediated by users’ behaviour to a greater extent than the other interventions considered, and will also vary with population density, topography, and source of water supply. Such uncertainties should be better reflected in the authors’ model, e.g., by expanding the range of the diarrheal incidence reduction parameter and/or increasing its standard deviation (p. 8)”. Water and Sanitation Intervention No. 3 – Biosand Filters for “Point-of-use” Household Water Treatment Biosand filters are a Point of use (POU) technologie can be used to remove contaminants in raw water supplies, it is more effective than boiling which is the most prevalent method used to treat water by households. Biosand filters are made by common materials, they are cheap and easy to install. There are now close to 100,000 biosand filters in use by households in developing countries. “Sand and gravel is packed into a concrete or plastic chamber, and a length of PVC pipe allows collection of the filtered water. Pathogens are removed by physical filtration and a biologically active slime layer ("schmutzdecke") which forms at the top of the sand column, while suspended and some dissolved solids are removed by physical processes in the filter. A filter can easily produce hundreds of litters of clean water a day” (p. 7). This type of technology is best suited for places where sources of water are available at short distances. Cost for this project includes, materials, training, and transportation cost. Assuming a life of 8 years per filter and a 6% discount rate, total monthly cost of the project would be $1.4. While benefits consist on a higher prevention of illness and mortality then with the other methods and it assumes usage declines 2% per year, no time saving is derived from using the filters. Total Benefits are estimated to be $3.86 which leaves a benefit cost ratio of 2.7.  The main criticism of this project is done by Davis stating that, “The Challenge Paper authors’ assumption of a 2% decline annually in use of the household filter thus seems optimistic. For example, researchers from Cranfield University (27) found that 21% of a sample of Ethiopian households had ceased use of their Biosand filters after five years. Brown and Sobsey (28) found regular use of a ceramic filter [...] fell by 2% per month among a sample of Cambodian households.” More research needs to be done in this aspect in order to estimate a more accurate cost benefit ratio for the project. Water and Sanitation Intervention No. 4 – Large multipurpose dams in Africa Description of the intervention Whittington et al. describes 2 main reasons to suggest dam constructions in Africa. First, many African are extremely short of water storage capacity and second there some places in Africa where good sites for dams are not being used. Estimating cost and benefits for this kind of projects is more complicated since they are very capital intensive and produces very long term benefits. Whittington et al. uses a 6% discount rate and they let us know that using that discount rate might overstate future benefits.  When estimating the cost of the project, Whittington et al. include, construction costs, power and transmission lines, annual operation and maintenance, compensation for displaces families and an allowance for the costs of possible failure (at a probability of 0.01% annually). Under the benefits the authors mention power generation increase in real value at a rate of 5% per annum, increase irrigation. Total cost benefit ratio is 1.8 for this type of projects. Conclusion: Overall it is difficult to assess the benefits and the cost of that access to clean Water and improved Sanitation can bring to a community, however the authors in the challenge paper ignored many aspects in the analysis made strong statements based on incomplete information. They tend to have a bias towards the lower bound of the benefits since all externalities were ignored. There is also no focus on sustainability and development. Most of the solution proposed on the paper had no implementation plan and lacked real basis on how resources would be managed, especially since many of the countries lacking services also suffer from overall corruption. Water and Sanitation are very important features to promote sustainability, and our focus should be to create project at low cost that are sustainable so that less developed countries can eventually sustain those projects by themselves.    Bibliografy: Davis,J., Copenhagen Consensus 2008 Perspective Paper Sanitation and Water, http://www.copenhagenconsensus.com/The%2010%20challenges/Sanitation%20and%20Water-1.aspx  Rijsberman et al.,Copenhagen Consensus 2008 Perspective Paper Sanitation and Water, http://www.copenhagenconsensus.com/The%2010%20challenges/Sanitation%20and%20Water-1.aspx Whittington et Al., Copenhagen Consensus 2008 Challenge Paper Sanitation and Water, http://www.copenhagenconsensus.com/The%2010%20challenges/Sanitation%20and%20Water-1.aspx Whittington et Al., Copenhagen consensus 2008 water and sanitation executive summary http://www.copenhagenconsensus.com/The%2010%20challenges/Sanitation%20and%20Water-1.aspx WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation 2010, http://whqlibdoc.who.int/publications/2010/9789241563956_eng_full_text.pdf World water Day website  http://www.unwater.org/worldwaterday/downloads/WWD2010_LOWRES_BROCHURE_EN.pdf -------------------------------------------- [ 1 ]. 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