Sustainable access to safe drinking water protects against infectious disease and promotes overall health. Despite considerable progress toward increasing water access, safe water quality and reliable service delivery remain a challenge. Traditional financing strategies pay implementers based on inputs and activities, with minimal incentives for water quality monitoring and sustained service operation. Pay-for-performance offers an alternative financing strategy that delivers all or a portion

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... payment based on performance indicators of desired outputs or outcomes. A pay-for-performance approach in the water sector could quantify and incentivize health impact. Averted disability-adjusted life years (ADALYs) have been used as a performance indicator to measure the burden of disease averted due to environmental health interventions. Water-related disease burden can be measured for application as an ADALYs performance indicator following either comparative risk assessment or quantitative microbial risk assessment. Comparative risk assessment models disease burden using water source type as a proxy indicator of microbial water quality, while quantitative microbial risk assessment models disease burden using concentrations of indicator pathogens. This paper compares these risk assessment methodologies, and summarizes the limitations of applying these approaches toward quantifying ADALYs as a performance indicator for water quality interventions.