Shame or Subsidy: What explains the impact of TSC_Sumeet Patil_ 2013

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A study on what works more for TSC- shame or subsidy.

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Shame or Subsidy: What explains the impact of TSC_Sumeet Patil_ 2013

  1. 1. 3ie Delhi Seminar Series Shame or Subsidy What explains the impact of Total Sanitation Campaign Sumeet Patil 1 S. K. Pattanayak 2, K Dickinson 3, J-C Yang 3, C. Poulos 31 NEERMAN, Mumbai (formerly RTI International)2 Duke University, USA (formerly RTI International)3 RTI International, USA
  2. 2. Study Team Partners  Rajiv Gandhi Drinking Water Mission, Govt of India  Orissa State Water and Sanitation Mission and Department of Rural Development –  World Bank – Funders  WHO, USAID, UNICEF, ICMR - Multidisciplinary technical advisory group  RTI International – Principal investigating agency  Duke University – Analysis and publication phase  NEERMAN – Analysis and publication phase  TNS Mode – Survey agency2
  3. 3. Overview of Presentation  Policy Context for Study (4 slides)  Study Objectives (1 slide)  Intervention (3 slides)  Methodology and Implementation (9 slides)  Results (12 slides) Approximately, 45 minutes3
  4. 4. Race against TimeSource: WSP 2009 calendar 4
  5. 5. Policy Context for Study Child Diarrhea - key underlying link for India’s MDG targets Sanitation is expected to break fecal-oral transmission and thus improve health Universal access to toilets (no open defecation) by 2022 is a goal of Nirmal Bharat Abiyaan (NBA) Heated comparison between supply “pushed” subsidy based TSC and CLTS based demand driven “no subsidy” based approaches Limited evidence to guide implementers and policy makers5
  6. 6. Govt M&E/MIS data highly unreliable Source: Chambers and Von Medeazza (2013): working paper6
  7. 7. Policy Context for Study Evidence to make determination is very thin  Impact evaluation in sanitation sectors (are (were) few  Cross-sectional assessments (lacking baseline, control, statistical power) Need for rigorous impact evaluation  2005 RCT. Hammer and Spear (2013). Working Paper  2006 RCT. Pattanayak et al. (2009). This paper  2011 RCT. Patil et al. (2013). Working Paper  2011 4-arm QE. We hope that endline happens7
  8. 8. Overview of Presentation  Policy Context for Study Study Objectives  Intervention  Methodology and Implementation  Results8
  9. 9. Study Objectives Whether CLTS based behavior change coupled with subsidy based intervention (TSC) impacts latrine use and child health?  Track the logic chain from inputs to intermediate outputs to outcomes to health impacts  Generate operational knowledge to guide policy Ability to study the effect of Shame only and shame + subsidy because of the TSC program design feature9
  10. 10. Overview of Presentation  Policy Context for Study  Study Objectives Intervention  Methodology and Implementation  Results10
  11. 11. Community-Led Total Sanitation in Bhadrak Knowledge Links11
  12. 12. Intervention: Community-Led Total Sanitation (Kar, IDS)  Knowledge alone does not change behavior; need to create “triggering events” and intensive Behavior Change campaign  “walk of shame”  “defecation mapping”  “fecal calculation”  TSC related Incentives for BPL for latrine construction (Rs 1500)  Supply side: masons, rural sanitation mart, know how, motivation, monitoring  Immediate outputs: Out of 20 villages, 9 resolved to end OD, 2 agreed in principle, 5 decided to meet, and 4 were unable to reach a consensus12
  13. 13. CLTS Program – Logic Model13
  14. 14. Overview of Presentation  Policy Context for Study  Study Objectives  Intervention Methodology and Implementation  Results14
  15. 15. Study Design Randomized Control Experiment  Well controlled. Random and blind assignment of treatment Sample Size: 20 CLTS villages + 20 control villages and 25 HHs per village (with u5 children) Baseline (2005) and Endline (2006) Panel Surveys 2 rounds, same season, same households Difference in Difference (DID) estimation of impacts  Difference: Before and After and With and Without15
  16. 16. Sample Selection Selected a district (Bhadrak) with adequate water Selected blocks (Tihidi & Chandbali) without prior TSC Restricted villages to have >70 HHs and < 500 HHs Restricted to 1 village per GP to reduce spill over Selected 40 villages & randomly assigned 20 to treatment Listed and mapped all households in 40 villages Randomly selected and surveyed 25 households with child < 5 yrs in each village16
  17. 17. Study Villages 20.- Controlled Villages of Nayananda RTI - WB Study 10 0 10 Km. Birabarpur N Aigiria Budhapur Mangrajpur Haripur W E Tentulida Barikpur Arjunbindha S TIHIDI Sasankhas BLOCK Nuasahi Badapimpali Amarpur Padisahi Sansamukabedhi Balipada Satuti Bhimpur Rajnagar Orali Baincha Hengupati Hatapur Madhupur Talabandha Gouriprasad Jashipur Taladumka Sanasingpur Baliarpur Bahu CHANDBALI BLOCK Guanal Begunia Balisahi Jaladharpur Ambolo Bhuinbruti Deuligaan Tentulida Jaydurgapatna Dhurbapahalipur LEGEND: Control village Villages17
  18. 18. Data: Measurements  Outputs, Outcomes, Impacts:  Household pit latrines (IHL): constructed, operational and in-use  Diarrhea frequency & severity (> 3 episodes in 24-hr, 2-week recall)  Child growth (anthropometrics – MUAC, weight, height)  Additional parameters:  Individual - sex, age, class, caste, religion  Household - family size and composition, education, housing conditions, asset holdings, occupation and expenditures, services  Community – roads, electricity, environmental sanitation, employment, clinics, schools, credits, markets  Institutional - main governmental and NGO programs, local government size and composition18  Water quality (E. coli & total coliform) – community sources (all),
  19. 19. Data: Household Survey  Respondent - Primary Care Giver  Water samples collected from approx 50% of surveyed households  Modular questionnaire  Knowledge, Attitudes  Household SEC  Sanitation Behaviors – outputs and outcomes  Hygiene Behaviors  Water Sources and their use  Water Treatment/safety behaviors  Food safety behaviors  Environmental conditions – HH and community  Budget constraints  Community Participation19
  20. 20. Data: Community Survey  Respondent – sarpanch, GP member, Informal leader, Doctor, etc  Water samples collected from up to 10 in-use drinking water sources  Modular questionnaire design  Background: population, households, area, arable land, major crop grown  Public infrastructure: roads, water supply, sanitation, hygiene, electricity, clinics, schools, STD booths, telegraph offices, post offices, credits and markets  Environmental sanitation: general cleanliness, drainage, animal and household waste, use of water sources, open defecation practices  WSS scheme: Swajaldhara, piped water, hand pumps, etc  Development Programs: Health, education, women support etc  Economy: employment opportunities, major governmental and NGO programs, prices  Local government: structure, composition, activities20
  21. 21. Survey Implementation - I  Schedule & Resources 1 month of data collection to catch the monsoons!!  Field Teams – RTI (3 + 1 consultant) and TNS (30 field people + 2 researchers)  Focus groups  Pre-testing (2 rounds of 50 household surveys)  Training (8 days. Mix of in-class and field practice) (manuals prepared)  Supervision: Supervisors  executives  Managers  Researchers. Back checks, spot checks.21
  22. 22. Fieldwork22
  23. 23. Survey Implementation - II  Data Processing  On field editing, 100% scrutiny before data entry  CSPro based data entry  Cross-tabulation based cleaning  WQ Samples  50% HHs and up to 10 in use sources.  Sterilized bottles  Cold chain transport to lab within 24 hours23
  24. 24. Overview of Presentation  Policy Context for Study  Study Objectives  Intervention  Methodology and Implementation Results24
  25. 25. Baseline Balance - I T C p-valueSEC From scheduled caste 28 26 0.858 From other backward classes 29 24 0.449 Below poverty line 60 61 0.91WASH Used improved water sourced 37 42 0.602 Boiled or treated drinking water 9 13 0.192 Adults washed hands at 5 critical instances 11 9 0.564 Dumped garbage outside of house 68 69 0.794 Threw wastewater in the backyard 46 48 0.705 With individual household latrine 6 12.7 0.0325
  26. 26. Baseline Balance - II T C P-valueAttitudes Completely dissatisfied with current sanitation 72 61 0.011 Water supply is most important improvement 7 12 0.149 Sanitation is most important improvement 5 8 0.264 Women lack privacy during defecation 32 30 0.82 Women are not safe defecating in the open 29 29 0.463 Government should bear the cost of sanitation 53 50 0.561Health U5 diarrhea in past 2 weeks 28 23 0.218 (MUAC)-for-age z-score for U5 -1.3 -1.3 0.677 height-for-age z-score for U5 -2 -1.9 0.687 weight-for-age z-score for U5 -2.2 -2.3 0.341 26
  27. 27. Estimation27
  28. 28. % Households owning & using Toilets (by intervention and year) DID= 26%-0%= 26%***40% 32%30%20% 26% 13% 0% 13% 6%10% 0% 2005 2006 2005 2006 CLTS Villages Control Villages I indicates the 95% confidence interval.28
  29. 29. E Coli Levels in HH Drinking Water 25 20 15 10 5 0 2005 2006 2005 2006 CLTS Control29
  30. 30. Elusive Health Impacts BL/EL T C T-C DID 0 27% 23% 4.30% U5 diarrhea Prevalence -4.90% 1 14% 15% -0.60% 0 -1.34 -1.33 -0.011 MUAC-for-age z-score 0.133 1 -1.2 -1.32 0.123 0 -1.95 -1.94 -0.007 Height-for-age z-score 0.281 1 -2.01 -2.29 .273* 0 -2.16 -2.25 0.088 Weight-for-age z-score -0.192 1 -2.22 -2.3 0.06930
  31. 31. Shame or Subsidy? Full sample BPL APL Impact (mean test with EL) 19 23.7 12 Impact DID 28.7 34.2 20.7  Triple Difference to get the relative effect of shame and subsidy  BPL = Subsidy + Shame and APL = Shame alone  DID for BPL – DID for APL = 34.2 – 20.7 = 13.5%31  13 % effect (about 1/3rd) by the “subsidies”
  32. 32. Is this result replicable elsewhere?  Another RCT in Madhya Pradesh  A scaled up and more “realistic” program  50% to shame + “less subsidy” and 50% to shame and “more subsidy (by Rs 2700) Control Treatment N Mean N Difference Overall 1514 0.22 1525 0.19 (0.035) *** Poor 375 0.17 300 0.32 (0.046) *** Non-poor 1139 0.24 1225 0.15 (0.037) ***32
  33. 33. 33 A 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 0% Ba mb da ol pi a m pa Ba la lia rp Ba ur lip ad Ba a rik pu Be r gu n Bh ia i Bi mp ra u ba r ra D Bo pur hr ub dha ap pu ah r G Treatment Villages al ou ip ra ur pr as ad H at a M pur ad Percent of Households Owning a Latrine, hu pu N ua r s Pa ahi dh is Sa R ahi na ajn sa ag m ar uk av Are effects sustainable? Sa ed sa i nk Ta ha la ba s Ta nd la h 2007 GoO Data 2004 GoO Data 2006 HH Survey 2005 HH Survey du a m uk a 2006 Community Survey
  34. 34. Findings from Mixed Methods - I  Some factors indicate “possibility of sustainability”  Increased satisfaction with sanitation situation  Increased belief that improving sanitation is the family’s responsibility  Lack of knowledge of the “germ theory” is not the most important BUT privacy and dignity are key  Households prioritize. Toilets may be “our” priority, not theirs: 80% want health dispensary, 59% roads. Compare to 7-9% for water supply and sanitation34
  35. 35. Findings from Mixed Methods - II  Support structure – NGOs, district officials, involvement of triggering team, village institutional capacity are important success factors  Subsidies are tricky business  may have created an incentive for NGOs to “cut corners” and produce lower quality latrines  Concern that subsidies in general defeat the sense of self-reliance  Will subsidy be counteractive in long term?  How and when you give subsidies will matter  Community based incentives (e.g. NGP) instead of individuals?  Is “post” incentives practical for poor population?35
  36. 36. 7 years later…  Credible evidence that “shaming” works  BUT, so do subsidies  BUT, does the relative contributions depend on “intensity” of CLTS or amount of subsidy?  Seems to be continued increase in toilet coverage  BUT, what about use? And toilet maintenance?  BUT, will we reach 100% open defecation free status?  BUT, what about health impacts?  7 year later, we still stare at above critical36 questions without credible answers
  37. 37. Thank You  Sumeet Patil: srpatil@neerman.org  Other papers  Pattanayak et al. (2010), “ “How valuable are environmental health interventions?...” Bull WHO, 88:535-542.  Pattanayaket al. (2009), “Shame or subsidy revisited: …” Bull WHO, 87:1-19.  Pattanayak et al. (2009), “Of taps and toilets….”, J of Water and Health, 7(3): 434–451.  World Bank (2011). “Of Taps an Toilets”. WB report on Evaluation of CDD program in RWSS.37

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