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  • Context: The greatest disease burden falls on infants and children under five years old (Murray & Lopez 1997). By reducing normal food consumption and nutrient adsorption, diarrhoeal diseases are also a significant cause of malnutrition, leading to impaired physical growth and cognitive development (Guerrant et al. 1999), reduced resistance to infection (Baqui et al. 1993), and, potentially, long-term gastrointestinal disorders (Schneider et al. 1978). Economic impacts of poor sanitation and hygiene fall into two broad categories: (i) costs associated with treatment of illness; and (ii) the productivity losses from missed work or school days, and time spent travelling to and waiting at public latrines (Hutton et al. 2007).Good evidence that sanitation decreases diarrhea but the current evidence of health impacts of sanitation and hygiene interventions comes from studies that impose controlled conditions in small populations over short time periods. These trialsare akin to “efficacy” trials in drug development: an evaluation of the interventions’ impact under ideal conditions.

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  • 1. 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
  • 2. 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
  • 3. 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
  • 4.  Social Marketing Events +  Communication Campaign Demand side Social 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
  • 5. Basic IE Questions What is the overall Impact of TSSM on • Sanitation improvement and construction • Open Defecation • Health – Diarrhea – Parasites – Anemia – Height and weight – Cognitive development
  • 6. 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
  • 7. I. Theory of Change II. IE Design III. Results I. Sanitation II. Open Defecation III. Health Outcomes IV. Implementation issues V. India results VI. Policy Messages Today…. 7
  • 8. Conceptual Framework: Theory of Change D = DTT + DNT 1-T( ) 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:
  • 9. TSSM Pathways To Reduce OD TD TD DDT NT T NTT 1=sanitationhavenotdowhothoseofusein.3 =sanitationhavewhothoseofusein.2 =onconstructiSanitation.1
  • 10. Indonesia and East Java http://education.yahoo.com/reference/factbook/id/map.html
  • 11. Randomly Sampled 160 communities („dusun‟ or hamlet) Randomly Assigned to 8 districts participated in study Treatment 80 dusuns Random Sample 1046 HHs East Java: 29 districts total 10 districts in TSSM Phase 2 Control 80 dusuns Random Sample 1041 HHs Sampling & Experimental Design
  • 12. 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
  • 13. 0 0.02 0.04 0.06 0.08 0.1 0.12 0.14 0.16 0.18 0.2 All Sanitation at Baseline No Sanitation at Baseline Sanitation Improvement/Construction Between Baseline & Endline Treatment Control
  • 14. (1) (2) (3) (4) (5) (6) (7) No Sanitation at BL No Sanitation at BL Full Sample - No controls Full Sample - controls Panel No sanitation at Baseline Sanitation at Baseline Non-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 1,908 939 969 596 333 R-squared 0.11 0.11 0.12 0.21 0.16 0.22 0.43 Means 0.128 0.128 0.128 0.081 0.171 0.105 0.042 Toilet Construction ITT Estimates
  • 15. 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
  • 16. 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
  • 17. 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
  • 18. 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).
  • 19. 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
  • 20. Messages • TSSM reduced mostly through behavioral change  Explained ≈70% of the reduction in OD • Less successful through sanitation construction • Big potential gains from sanitation construction TSSM in Indonesia only increased sanitation by 3.7%  At baseline only ≈ 45% had sanitation
  • 21. 0 10 20 30 40 50 60 70 80 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 Obstacles to Building Sanitation
  • 22. 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% Households (IE) Villages (IE) Villages (Admin) Implementation: % Triggered Control Treatment
  • 23. What If All Villages Were Triggered?
  • 24. 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%
  • 25. 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
  • 26. 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
  • 27. 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.