The Dirty Business of Open Defecation: Lessons from a Sanitation Intervention

Manisha Shah

UCLA & NBER

Lisa Cameron, Monash

Paul Gertler, UC Berkeley & NBER

2 August 2013

WSP Asked “What works?”

• Evaluation of “at scale” interventions in 6 countries– 3 TSSM– 3 Hand Washing

• Coordinated– Same outcomes– Rigorous causal methods

• WSP learning agenda– Large team of IE experts & operational staff– BMGF funding

Child Health in the Developing World

• One child dies every 15 seconds from diarrheal diseases (WHO, 2000)

• Diarrhea and acute lower respiratory infections (ALRI) account for more than 40% of 10 million annual deaths young children (Black et al. 2003, Bryce et al. 2005)

• WHO and Unicef estimate 60% of poor (2.6 billion) lack access to improved sanitation (JMP 2006)

• 18.6 million people in Indonesia lacked access to proper sanitation last year

• Indonesia “not on track” for sanitation MDG

Social Marketing Events +

Communication Campaign

Demand sideSocial Marketing of Sanitation:

Supply side

Popularize improved sanitation

Sanitation choice catalogue

Training masons

3

Total Sanitation and Sanitation Marketing in Indonesia (SToPs)

Behavior Change Communications :

2

Community-led Total Sanitation:

Demand side

Stop OD by raising awareness

“map” the village

“walk of shame”

Triggers community action

Action plan & monitoring

1

4

Basic IE QuestionsWhat is the overall Impact of TSSM on• Sanitation improvement

and construction• Open Defecation• Health

– Diarrhea– Parasites– Anemia– Height and weight – Cognitive development

Advanced IE Questions

2. Decomposition of overall OD effect into

– Sanitation construction– Increased use of

sanitation (behavioral)

3. Liquidity constraints

4. Effects of stronger implementation

I. Theory of Change

II. IE Design

III. ResultsI. Sanitation

II. Open Defecation

III. Health Outcomes

IV. Implementation issues

V. India results

VI. Policy Messages

Today….

7

Conceptual Framework: Theory of Change

D = Open Defecation Rate

T = Share of households that have sanitation

DT = Open Defecation Rate of HHs with Sanitation

DNT = Open Defecation Rate of HHs without Sanitation

Decompose Open Defecation Rate into:

TSSM Pathways To Reduce OD

TD

TD

DDT

NT

T

NTT

1 = sanitation havenot do who thoseof use in .3

= sanitation have who thoseof use in .2

= onconstructi Sanitation .1

Indonesia and East Java

http://education.yahoo.com/reference/factbook/id/map.html

Randomly Sampled 160 communities (‘dusun’ or hamlet)

Randomly Assigned to

8 districts participated in study

Treatment80 dusuns

Random Sample 1046 HHs

East Java: 29 districts total10 districts in TSSM Phase 2

Control80 dusuns

Random Sample1041 HHs

Sampling & Experimental Design

Collected measures/outcomes

Community (160 dusuns):• Water supply • Sanitation facilities• Sanitation behavior• Existing programs

Household (2,087 hhs):• Basic demography• Welfare & labor market• Water supply facilities• Sanitation facilities• Sanitation behavior

Children <5 (2,353 children):• Anemia & anthropometry• Diarrhea & ALRI• Child development (ASQ)• Feeding & behavior

Longitudinal (2,087 hhs):• Child health measures• T/C compliance measures

Endline (2,500 hhs):• 2638 Children <5• Fecal samples • Everything else similar

All

Sanita

tion at Base

line

No Sanita

tion at Base

line

00.020.040.060.08

0.10.120.140.160.18

0.2

Sanitation Improvement/Construction Between Baseline & Endline

TreatmentControl

  (1) (2) (3) (4) (5) (6) (7)            No Sanitation

at BLNo Sanitation

at BL  Full Sample -

No controlsFull Sample -

controlsPanel No sanitation

at BaselineSanitation at

BaselineNon-Poor Poor

               Treatment 0.37*** 0.039*** 0.032*** 0.038** 0.007 0.044** 0.032  [0.01] [0.01] [0.01] [0.02] [0.02] [0.02] [0.03]               Observations 2,500 2,500 1,908 939 969 596 333R-squared 0.11 0.11 0.12 0.21 0.16 0.22 0.43Means 0.128 0.128 0.128 0.081 0.171 0.105 0.042

Toilet Construction ITT Estimates

Open Defecation

Sanitation at

Baseline No Sanitation at Baseline

All Non-Poor Poor

Anyone

Treatment -0.06** -0.06*** -0.06** -0.06*

Control Mean 0.24 0.83 0.80 0.86

Women

Treatment -0.01 -0.06** -0.05* -0.07*

Control Mean 0.072 0.77 0.73 0.83

Men

Treatment -0.03* -0.07** -0.05* -0.08*

Control Mean 0.12 0.79 0.77 0.83

Children

Treatment -0.04** -0.07** -0.07** -0.07*

Control Mean 0.18 0.79 0.75 0.84

Observations 967 939 596 333

Open Defecation

Sanitation at

Baseline No Sanitation at Baseline

All Non-Poor Poor

Anyone

Treatment -0.06** -0.06*** -0.06** -0.06*

Control Mean 0.24 0.83 0.80 0.86

Women

Treatment -0.01 -0.06** -0.05* -0.07*

Control Mean 0.072 0.77 0.73 0.83

Men

Treatment -0.03* -0.07** -0.05* -0.08*

Control Mean 0.12 0.79 0.77 0.83

Children

Treatment -0.04** -0.07** -0.07** -0.07*

Control Mean 0.18 0.79 0.75 0.84

Observations 967 939 596 333

Open Defecation

Sanitation at

Baseline No Sanitation at Baseline

All Non-Poor Poor

Anyone

Treatment -0.06** -0.06*** -0.06** -0.06*

Control Mean 0.24 0.83 0.80 0.86

Women

Treatment -0.01 -0.06** -0.05* -0.07*

Control Mean 0.072 0.77 0.73 0.83

Men

Treatment -0.03* -0.07** -0.05* -0.08*

Control Mean 0.12 0.79 0.77 0.83

Children

Treatment -0.04** -0.07** -0.07** -0.07*

Control Mean 0.18 0.79 0.75 0.84

Observations 967 939 596 333

Estimating Model Parameters from Decomposition

(1) (2) (3) (4) Any

Householder Women Men Child

Treatment -0.06** -0.05* -0.06* -0.06** [0.03] [0.03] [0.03] [0.03] Built Toilet -0.48*** -0.59*** -0.49*** -0.51*** [0.09] [0.07] [0.08] [0.08] Treatment*Built Toilet 0.08 0.15* 0.08 0.07 [0.11] [0.09] [0.10] [0.10] Constant 0.91*** 0.85*** 0.75*** 0.84*** [0.12] [0.14] [0.13] [0.13] Observations 939 939 939 939 R-squared 0.42 0.51 0.46 0.45 Means 0.827 0.765 0.789 0.785

Sample is No Sanitation at Baseline. Robust standard errors in brackets. *** p<0.01, ** p<0.05, * p<0.1 (two-sided test).

Decomposition of Δ in OD • Total estimated effect of TSSM on OD = -.06

• Components:– Δ in sanitation construction (infrastructure)

- .48*(.032) = -0.015– Δ in use of those who have sanitation (behavioral of those who

built) 0.08*.128 = 0.010

– Δ in use of those who do not have sanitation (behavioral of those who did not build)

-0.06*(1-.28) = -.052

• Note that they add up to -0.06

Messages

• TSSM reduced mostly through behavioral change Explained ≈70% of the reduction in OD

• Less successful through sanitation construction

• Big potential gains from sanitation constructionTSSM in Indonesia only increased sanitation by 3.7% At baseline only ≈ 45% had sanitation

Tenancy Issues

Permit Issues

Too Comples

Water not available

No one to build

Soil Conditions

No materials available

Satisfied with current

No Savings

Other

Space

High Cost

0 10 20 30 40 50 60 70 80

Obstacles to Building Sanitation

Households (IE)

Villages (IE)

Villages (Admin)

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

Implementation: % Triggered

Control Treatment

What If All Villages Were Triggered?

Results Summary

• TSSM was successful at– Reducing OD– Improving health outcomes

• Mostly worked through behavioral change• Less successful at motivating sanitation construction• Big potential gains through sanitation construction

– Cost and liquidity constraints biggest obstacles

• Full implementation increases effects by 40%

India Intervention (TSC)

• 80 rural villages in Madhya Pradesh (40T/40C)• Offered subsidies to poorer households and

resulted in a much greater increase in construction (toilet coverage: 22% v 41%; OD decreased 74% v 84%)

• BUT no consistent improvements in child health outcomes– Potential reason is endline happened >6months in

only 14 of 40 Treatment villages

Policy Messages

• TSSM (CLTS) model – Improves health primarily thru behavioral change– Less successful through sanitation construction

• Need to strengthen sanitation components– Subsidized prices– Credit– Community financing

• Need to Improve implementation

Next Steps

Seeking funding to re-visit households to:

• Evaluate households’ willingness to pay for sanitation. Offer microfinance to poorer households. Does this enable communities to become open defecation free?

• Examine the sustainability of the program impacts - whether the toilets are maintained and used in the longer term, and the consequent longer term health impacts.