A Weakest Link Theory of Decentralized Government Investment

Deb S., Joseph G., Andrés L.A., Zabludovsky J.G.

This paper reports the findings of a cluster-randomized control study to assess the impact of India's flagship sanitation program, as implemented in Punjab, that aimed to eliminate the practice of open defecation and improve the awareness and practice of good hygiene across rural Punjab. The study finds that the program interventions specific to the Gram Panchayats (villages) had a modest effect on improving access to toilets and reducing open defecation among households with children in rural Punjab. However, awareness of the importance of handwashing before eating and after defecation among school-going children improved by 8–14 percentage points in treatment arms relative to control, though no significant impact on handwashing practices was observed. Consistent with the problem of implementation failure, the findings indicate the inherent difficulties of implementing bottom-up interventions through a large-scale government program.

Czura K., Menzel A., Miotto M.

Menstrual hygiene practices in low-income countries are often limited by lack of finances and information, with potentially adverse consequences for women's well-being and workplace outcomes. In a randomized controlled trial with around 1,900 female workers from four Bangladeshi garment factories, we relax both constraints individually and jointly by providing free sanitary pads and information on hygienic menstrual practices. Both access to sanitary pads and information improve menstrual practices, either by the adoption of new products, or by knowledge gains and improved use of traditional materials, and both interventions improve health outcomes. However, these positive effects do not translate to better labor outcomes, such as earnings and work attendance.

Gautam S.

This paper analyzes the impact of externalities on household demand for sanitation and the subsequent welfare effects generated from policy interventions. A critical feature of household sanitation (e.g., toilets) is that the take-up generates externalities where the privately chosen level is less than the socially optimal. To analyze the impact of policy interventions, I explicitly model household choice, taking into account the interdependence of household decision-making within the village. I identify and estimate the model using micro-survey data from India. Using the estimated model, I show how untargeted price subsidies, although cost effective at increasing sanitation coverage, have a regressive effect. I contrast this policy response with a targeted cash transfer to households with children, which ameliorates the regressive impact at the expense of a lower take-up.

Augsburg B., Baquero J.P., Gautam S., Rodriguez-Lesmes P.

This paper measures the additional value of sanitation within the marriage arrangement. We use data from the Indian human development household survey (IHDS) to model the marital decisions of men and women in rural India and to estimate the marital surplus (the gains from being married). We use the model to demonstrate that the government's Total Sanitation Campaign (TSC) increased marital surplus and changed marriage market outcomes for men and women. Decomposition reveals (i) that sanitation makes it more attractive to be in a marriage for both gender, and (ii) that TSC exposure led to a decrease in the wife's surplus share, implying a redistribution of gains within the marriage.

Allakulov U., Cocciolo S., Das B., Habib M.A., Rambjer L., Tompsett A.

Can transparency interventions improve WASH service provision? We use a randomized experiment to evaluate the impacts of a transparency intervention, a deliberative multi-stakeholder workshop initiated with a community scorecard exercise, in schools in rural Bangladesh. To measure impacts, we combine survey data, direct observations, and administrative data. The intervention leads to moderate but consistent improvements in knowledge of WASH standards and practices, and institutions for WASH service management, but does not improve school WASH service provision or change WASH facility use patterns. Drawing on rich descriptive data, we suggest several reasons why the intervention we evaluate did not improve WASH service outcomes and propose ways to improve the design of future interventions.

Bakhtiar M.M., Guiteras R.P., Levinsohn J., Mobarak A.M.

Addressing public health externalities often requires community-level collective action. Due to social norms, each person’s sanitation investment decisions may depend on the decisions of neighbors. We report on a cluster randomized controlled trial conducted with 19,000 households in rural Bangladesh where we grouped neighboring households and introduced (either financial or social recognition) rewards with a joint liability component for the group, or asked each group member to make a private or public pledge to maintain a hygienic latrine. The group financial reward has the strongest impact in the short term (3 months), inducing a 7.5–12.5 percentage point increase in hygienic latrine ownership, but this effect dissipates in the medium term (15 months). In contrast, the public commitment induced a 4.2–6.3 percentage point increase in hygienic latrine ownership in the short term, but this effect persists in the medium term. Non-financial social recognition or a private pledge has no detectable effect on sanitation investments.

Augsburg B., Malde B., Olorenshaw H., Wahhaj Z.

We exploit novel data collected within a randomized controlled trial of a sanitation microcredit intervention to study how intra-household gender differences in perceptions of costs and benefits of sanitation impact investment decisions. We show that – as long as the wife is involved in household decision-making – the intra-household differences in perceptions we document influence borrowing and investments: uptake of the sanitation loan is higher among households where the wife has higher benefit perception, whereas successful conversion to a toilet depends on differences in monetary cost perceptions. The estimated effects are consistent with the predictions of a model of intra-household decision-making.

Augsburg B., Caeyers B., Giunti S., Malde B., Smets S.

Imperfect capital markets and commitment problems impede lumpy human capital investments. Labeled loans have been postulated as a potential solution to both constraints, but little is known about the role of the label in influencing investment choices in practice. We draw on a cluster randomized controlled trial in rural India to test predictions from a theoretical model, providing novel evidence that labeled microcredit is effective in influencing household borrowing and investment decisions and increasing take-up of a lumpy human capital investment, a toilet.

Deutschmann J.W., Gars J., Houde J., Lipscomb M., Schechter L.

Privatization of a public good (the management of sewage treatment centers in Dakar, Senegal) leads to an increase in the productivity of downstream sewage dumping companies and a decrease in downstream prices of the services they provide to households. We use the universe of legal dumping of sanitation waste from May 2009 to May 2018 to show that legal dumping increased substantially following privatization-on average an increase of 74%, or an increase of about 1640 trips to treatment centers each month. This is due to increased productivity of all trucks, not just those associated with the company managing the privatized treatment centers. Household-level survey data shows that downstream prices of legal sanitary dumping decreased by 5% following privatization, and DHS data shows that diarrhea rates among children under five decreased in Dakar relative to secondary cities in Senegal following privatization with no similar effect on respiratory illness as a placebo.

Kresch E.P., Walker M., Best M.C., Gerard F., Naritomi J.

This paper investigates the role that sanitation plays in upholding the social contract, whereby citizens pay taxes in exchange for governments providing goods and services. We study the case of Manaus, Brazil, where sewer connections vary considerably across the city and property taxes are calculated in a presumptive manner that does not account for a household’s access to sanitation. We find that households with access to the city sewer system are significantly more likely to pay their property tax, relative to households that only have access to latrines or lack access to improved sanitation entirely. Our evidence is consistent with a role for the social contract in this decision, as households with sewer systems are more likely to have positive attitudes towards the municipal government. • We study the relationship between sanitation and property tax compliance in Manaus, Brazil. • Property tax is calculated by the municipal government using a presumptive formula based on observable physical characteristics of the property. • Tax calculation does not include sanitation type, so households with similar tax bills can vary in having a sewer, latrine, or no sanitation. • Households with sewers are more likely to be compliant with property taxes and have a favorable view of municipal government.

Cameron L., Gertler P., Shah M., Alzua M.L., Martinez S., Patil S.

We examine the impacts of a sanitation program designed to eliminate open defecation in at-scale randomized field experiments in four countries: India, Indonesia, Mali, and Tanzania. The programs – all variants of the widely-used Community-Led Total Sanitation (CLTS) approach - increase village private sanitation coverage in all four locations by 7–39 percentage points. We use the experimentally-induced variation in access to sanitation to identify the causal relationship between village sanitation coverage and child height. We find evidence of threshold effects where increases in child health of 0.3 standard deviations are realized once village sanitation coverage reaches 50–75%. There do not appear to be further gains beyond this threshold. These results suggest that there are large health benefits to achieving coverage levels well below the 100% coverage pushed by the CLTS movement. Open defecation decreased in all countries through improved access to private sanitation facilities, and additionally through increased use of sanitation facilities in Mali who implemented the most intensive behavior change intervention. • Examine impact of sanitation program in India, Indonesia, Mali, and Tanzania. • Treatment increases village private sanitation coverage by 7–39 percentage points. • Identify causal relationship between village sanitation coverage and child height. • Child health gains realized once village sanitation coverage reaches 50 percent. • Suggests large health benefits achieving coverage levels well below 100% coverage.

Augsburg B., Bancalari A., Durrani Z., Vaidyanathan M., White Z.

We implement a randomized controlled trial and a qualitative study to assess whether, and if so how, behavioral change can be sustained. We do so in the context of Pakistan’s national sanitation strategy to combat open defecation, Community-Led Total Sanitation. Our findings demonstrate that continued follow-up activities that build on the original intervention lead to only modest reductions in reversal to unsafe sanitation on average, but gain in importance where initial conditions are unfavorable, i.e. poor public infrastructure and sanitation facilities. Promotion efforts are hence best targeted towards those who face larger difficulties in constructing and maintaining high-quality sanitation. The effects were sustained at least one year after the implementation of activities. • We study the effectiveness of follow-up activities in sustaining behavior change. • Without follow-up activities, the likelihood of reverting to open defecation doubled in a 2-year period. • Continued follow-up activities lead to only modest reductions in reversal to unsafe sanitation, on average. • The effectiveness of follow-up activities are however significant where initial conditions are unfavorable. • The effects were sustained at least one year after the implementation of activities.

Cumming O., Arnold B.F., Ban R., Clasen T., Esteves Mills J., Freeman M.C., Gordon B., Guiteras R., Howard G., Hunter P.R., Johnston R.B., Pickering A.J., Prendergast A.J., Prüss-Ustün A., Rosenboom J.W., et. al.

Three large new trials of unprecedented scale and cost, which included novel factorial designs, have found no effect of basic water, sanitation and hygiene (WASH) interventions on childhood stunting, and only mixed effects on childhood diarrhea. Arriving at the inception of the United Nations’ Sustainable Development Goals, and the bold new target of safely managed water, sanitation and hygiene for all by 2030, these results warrant the attention of researchers, policy-makers and practitioners. Here we report the conclusions of an expert meeting convened by the World Health Organization and the Bill and Melinda Gates Foundation to discuss these findings, and present five key consensus messages as a basis for wider discussion and debate in the WASH and nutrition sectors. We judge these trials to have high internal validity, constituting good evidence that these specific interventions had no effect on childhood linear growth, and mixed effects on childhood diarrhea. These results suggest that, in settings such as these, more comprehensive or ambitious WASH interventions may be needed to achieve a major impact on child health. These results are important because such basic interventions are often deployed in low-income rural settings with the expectation of improving child health, although this is rarely the sole justification. Our view is that these three new trials do not show that WASH in general cannot influence child linear growth, but they do demonstrate that these specific interventions had no influence in settings where stunting remains an important public health challenge. We support a call for transformative WASH, in so much as it encapsulates the guiding principle that – in any context – a comprehensive package of WASH interventions is needed that is tailored to address the local exposure landscape and enteric disease burden.

Humphrey J.H., Mbuya M.N., Ntozini R., Moulton L.H., Stoltzfus R.J., Tavengwa N.V., Mutasa K., Majo F., Mutasa B., Mangwadu G., Chasokela C.M., Chigumira A., Chasekwa B., Smith L.E., Tielsch J.M., et. al.

Child stunting reduces survival and impairs neurodevelopment. We tested the independent and combined effects of improved water, sanitation, and hygiene (WASH), and improved infant and young child feeding (IYCF) on stunting and anaemia in in Zimbabwe.We did a cluster-randomised, community-based, 2 × 2 factorial trial in two rural districts in Zimbabwe. Clusters were defined as the catchment area of between one and four village health workers employed by the Zimbabwe Ministry of Health and Child Care. Women were eligible for inclusion if they permanently lived in clusters and were confirmed pregnant. Clusters were randomly assigned (1:1:1:1) to standard of care (52 clusters), IYCF (20 g of a small-quantity lipid-based nutrient supplement per day from age 6 to 18 months plus complementary feeding counselling; 53 clusters), WASH (construction of a ventilated improved pit latrine, provision of two handwashing stations, liquid soap, chlorine, and play space plus hygiene counselling; 53 clusters), or IYCF plus WASH (53 clusters). A constrained randomisation technique was used to achieve balance across the groups for 14 variables related to geography, demography, water access, and community-level sanitation coverage. Masking of participants and fieldworkers was not possible. The primary outcomes were infant length-for-age Z score and haemoglobin concentrations at 18 months of age among children born to mothers who were HIV negative during pregnancy. These outcomes were analysed in the intention-to-treat population. We estimated the effects of the interventions by comparing the two IYCF groups with the two non-IYCF groups and the two WASH groups with the two non-WASH groups, except for outcomes that had an important statistical interaction between the interventions. This trial is registered with ClinicalTrials.gov, number NCT01824940.Between Nov 22, 2012, and March 27, 2015, 5280 pregnant women were enrolled from 211 clusters. 3686 children born to HIV-negative mothers were assessed at age 18 months (884 in the standard of care group from 52 clusters, 893 in the IYCF group from 53 clusters, 918 in the WASH group from 53 clusters, and 991 in the IYCF plus WASH group from 51 clusters). In the IYCF intervention groups, the mean length-for-age Z score was 0·16 (95% CI 0·08-0·23) higher and the mean haemoglobin concentration was 2·03 g/L (1·28-2·79) higher than those in the non-IYCF intervention groups. The IYCF intervention reduced the number of stunted children from 620 (35%) of 1792 to 514 (27%) of 1879, and the number of children with anaemia from 245 (13·9%) of 1759 to 193 (10·5%) of 1845. The WASH intervention had no effect on either primary outcome. Neither intervention reduced the prevalence of diarrhoea at 12 or 18 months. No trial-related serious adverse events, and only three trial-related adverse events, were reported.Household-level elementary WASH interventions implemented in rural areas in low-income countries are unlikely to reduce stunting or anaemia and might not reduce diarrhoea. Implementation of these WASH interventions in combination with IYCF interventions is unlikely to reduce stunting or anaemia more than implementation of IYCF alone.Bill & Melinda Gates Foundation, UK Department for International Development, Wellcome Trust, Swiss Development Cooperation, UNICEF, and US National Institutes of Health.

Luby S.P., Rahman M., Arnold B.F., Unicomb L., Ashraf S., Winch P.J., Stewart C.P., Begum F., Hussain F., Benjamin-Chung J., Leontsini E., Naser A.M., Parvez S.M., Hubbard A.E., Lin A., et. al.

Summary Background Diarrhoea and growth faltering in early childhood are associated with subsequent adverse outcomes. We aimed to assess whether water quality, sanitation, and handwashing interventions alone or combined with nutrition interventions reduced diarrhoea or growth faltering. Methods The WASH Benefits Bangladesh cluster-randomised trial enrolled pregnant women from villages in rural Bangladesh and evaluated outcomes at 1-year and 2-years' follow-up. Pregnant women in geographically adjacent clusters were block-randomised to one of seven clusters: chlorinated drinking water (water); upgraded sanitation (sanitation); promotion of handwashing with soap (handwashing); combined water, sanitation, and handwashing; counselling on appropriate child nutrition plus lipid-based nutrient supplements (nutrition); combined water, sanitation, handwashing, and nutrition; and control (data collection only). Primary outcomes were caregiver-reported diarrhoea in the past 7 days among children who were in utero or younger than 3 years at enrolment and length-for-age Z score among children born to enrolled pregnant women. Masking was not possible for data collection, but analyses were masked. Analysis was by intention to treat. This trial is registered at ClinicalTrials.gov, number NCC01590095. Findings Between May 31, 2012, and July 7, 2013, 5551 pregnant women in 720 clusters were randomly allocated to one of seven groups. 1382 women were assigned to the control group; 698 to water; 696 to sanitation; 688 to handwashing; 702 to water, sanitation, and handwashing; 699 to nutrition; and 686 to water, sanitation, handwashing, and nutrition. 331 (6%) women were lost to follow-up. Data on diarrhoea at year 1 or year 2 (combined) were available for 14 425 children (7331 in year 1, 7094 in year 2) and data on length-for-age Z score in year 2 were available for 4584 children (92% of living children were measured at year 2). All interventions had high adherence. Compared with a prevalence of 5·7% (200 of 3517 child weeks) in the control group, 7-day diarrhoea prevalence was lower among index children and children under 3 years at enrolment who received sanitation (61 [3·5%] of 1760; prevalence ratio 0·61, 95% CI 0·46–0·81), handwashing (62 [3·5%] of 1795; 0·60, 0·45–0·80), combined water, sanitation, and handwashing (74 [3·9%] of 1902; 0·69, 0·53–0·90), nutrition (62 [3·5%] of 1766; 0·64, 0·49–0·85), and combined water, sanitation, handwashing, and nutrition (66 [3·5%] of 1861; 0·62, 0·47–0·81); diarrhoea prevalence was not significantly lower in children receiving water treatment (90 [4·9%] of 1824; 0·89, 0·70–1·13). Compared with control (mean length-for-age Z score −1·79), children were taller by year 2 in the nutrition group (mean difference 0·25 [95% CI 0·15–0·36]) and in the combined water, sanitation, handwashing, and nutrition group (0·13 [0·02–0·24]). The individual water, sanitation, and handwashing groups, and combined water, sanitation, and handwashing group had no effect on linear growth. Interpretation Nutrient supplementation and counselling modestly improved linear growth, but there was no benefit to the integration of water, sanitation, and handwashing with nutrition. Adherence was high in all groups and diarrhoea prevalence was reduced in all intervention groups except water treatment. Combined water, sanitation, and handwashing interventions provided no additive benefit over single interventions. Funding Bill & Melinda Gates Foundation.

Deutschmann J.W.