2 shah dse2
TRANSCRIPT
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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
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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
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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
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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
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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
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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
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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….
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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:
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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
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Indonesia and East Java
http://education.yahoo.com/reference/factbook/id/map.html
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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
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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
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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
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(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
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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
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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
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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
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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).
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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
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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
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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
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Households (IE)
Villages (IE)
Villages (Admin)
0% 10% 20% 30% 40% 50% 60% 70% 80% 90%
Implementation: % Triggered
Control Treatment
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What If All Villages Were Triggered?
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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%
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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
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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
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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.