This paper presents country-level projections for WASH-related mortality and the unrealized gains from lack of coverage with improved WASH services in Sub-Saharan Africa from 1950–2050.  We estimate these foregone gains from improved water and sanitation services as the sum of health burden avoided and reduced time spent collecting water.  We use a simulation model to calculate the morbidity and mortality burden, and the time spent collecting water, associated with lack of coverage with water and sanitation services from 1950 to 2008.  Then, projections of future GDP and population growth are used to estimate foregone gains from lack of full coverage from 2008 to 2050 for countries in SSA. The simulation model is calibrated based on regression analyses of cross-country data.  The willingness to pay for avoided mortality risk is expressed in monetary terms by multiplying the WASH-mortality rate for the population by the value of a statistical life (VSL). The VSL increases with income, as the willingness to pay for mortality risk reductions increases with income.

In a previous study we found that much of the world will probably achieve rapid declines in WASH mortality and associated foregone gains from expanding coverage with water and sanitation, but that Sub-Saharan Africa is a notable exception (Jeuland et al. 2012). In order to more fully explore the projected results for Sub-Saharan Africa, we grouped countries according to broad economic classifications proposed by Radlet 2010: emerging economies (high GDP growth), threshold economies, oil-exporting, and all others.  All of these country classifications have increasing trends in total population without piped water and sanitation and therefore deaths due to WASH-related diseases, although magnitudes differ.  Oil-exporting countries have lower water and sanitation coverage rates compared to emerging economies.  This difference exists despite considerably higher urbanization in oil-exporting countries. We find that total WASH deaths and associated gains foregone are predicted to be similar in emerging economies and oil-exporting countries.  This similarity is partially due to slightly greater population among the emerging economies.  Thus, despite lower WASH mortality rates in emerging economies, total WASH health losses are comparable.

 A crucial question is what can be done to accelerate a downturn in the ‘peak’ of unrealized economic gains related to WASH, i.e. how can some of these gains be captured before 2050?  Expected economic growth alone does not appear to be sufficient to correct the problem of rising future WASH mortality in SSA. In this paper we use the simulation model to identify combinations of model parameters that would be associated with an earlier downturn in  ‘peak’ gains foregone in SSA.