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Policy Lessons from India’sTotal Sanitation Campaign
18 July 2012
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open defecation is common.
open defecation is important.
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1. open defecation harms early life health
2. early life health matters for life-long human capital and productivity
3. open defecation has negative externalities, which require government responsibility
three starting points
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importance of safe excreta disposal
why are children in India shorter, on average, than children in African countries
that are poorer, on average?(Deaton, PNAS 2007)
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importance of safe excreta disposal-3
-2-1
01
mea
n he
ight
-for-a
ge z
of c
hild
ren
unde
r 3
0 20 40 60 80percent of households without toilet or latrine
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-2.5
-2-1
.5-1
heig
ht f
or a
ge z
sco
re (
WH
O 2
006)
0 .2 .4 .6 .8 1fraction of population openly defecating
95% CI linear best fit
similar trend among Indian states
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• disease in early life has enduring consequences for human capital (Almond and Currie, 2011)
• poor health and inadequate nutrition in early life cause persistent deficits in cognitive development and ability (e.g. Case and Paxson 2010).
• health promotes growing tall, smart, and productive
lasting effects of early life health
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negative externalities of open defecation
one household’s open defecation can hurt everybody else, even if
everybody else disposes of their feces safely
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negative externalities of open defecation
in economic theory, negative externalities are an important
indicator of government responsibility
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sanitation and the TSC
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evidence from India’s Total Sanitation Campaign
• partially subsidized pit latrine construction, with an incentive to local leaders to socially motivate use– over 10 years from 2001 to 2011, about one household
latrine per 10 people in rural India• real, full-scale implementation by the Indian
government– external validity (Ravallion 2012, and others)– estimates average over administrative losses– large scale detect effects on mortality
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India’s Total Sanitation Campaign
• announced in 1999, began spending money to build latrines in 2001 $1.5 billion over 10 years
• focused on low-cost pit latrines; incomplete subsidy
• emphasis on outcome: becoming open defecation free
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two features may have helped:
1. ex post incentive for desired outcome (Holmstrom & Milgrom, 1991)
2. made use of existing social structure
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two types of evidence
randomized experiment• three districts in
Maharashtra– … but in fact in only one was
the experiment actually implemented
• villages randomly selected for TSC-type intervention in February 2004
• are children taller in August of 2005?
non-experimental• three identification
strategies IMR & height– year-to-year variation in
latrine construction by district– long difference in IMR from
2001 to 2011 census data– discontinuity in the incentive
to local leaders
• can study actual, large-scale implementation
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experimental results
Source: Chaudhury, Moulik, Hammer, Pokharel, & Spears (in progress)
in Nanded and Nandurbar there was no experiment
Ahmadnagar Nanded & Nandurbar-0.1
-0.050
0.050.1
0.150.2
0.250.3
0.350.4
beforeafter
mean difference between
treatment and control villages, height-for-age z
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non-experimental results I
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are infants born in districts and years in which many TSC latrines have been constructed more likely to survive their first year of life, relative to
other infants born in different years in that district or in different districts?
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data: district level household survey 3
• conducted mainly in 2008, birth history since January 1st, 2004
• from this, construct repeated cross section of 198,287 infants born alive
• dependent variable: survived: 0; died: 1,000• independent variable: TSC latrines built by
first year of life from administrative records
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effects of TSC on IMR, DLHS-3
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evidence of a causal effect• similar with district-specific linear trends• no pre-program correlation (“parallel trends”)• effect on post-neonatal mortality, not on
neonatal mortality• interactions indicate plausible mechanisms
– bigger effect on children given non-breastmilk food earlier in first year
– larger effect where population density is greater• Granger causality: no effect “back in time”
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TSC latrines built2001 2010-2011
censuscensus organization’sAnnual Health Survey
non-experimental results II
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did districts in which more TSC latrines were built between 2001 and 2010 see a greater decline in rural IMR than other
comparable districts?
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long difference in differences
• similar result: decline in IMR of about 4 deaths per 1,000 babies born alive– able to control for other district-level factors
• no evidence against parallel trends– no “effect” on change in IMR in 1990s or 1980s
• falsification tests– no “effect” on urban IMR– no “effect” of institutional delivery program– no “effect” of public works program with similar data
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effects of early life health on human capital
lower IMR
children’s height
cognitive achievement
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do children who live in districts that had more TSC latrines in their first year of life subsequently grow taller, relative to other children
born in different years or different districts?
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TSC taller children
• IHDS 2005 data: individual-level identification strategy identical to DLHS infant mortality
• at mean TSC intensity, children are 0.2 height-for-age standard deviations taller
• robust to controls, including for height of older sibling (who was not exposed to program)
• effect only seen on rural children, not urban
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are children who live in districts that had more TSC latrines in their first year of life better able to recognize letters and numbers when they are six years old,
relative to other children born in different years or different districts?
Source: Spears and S. Lamba (2012)
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2001 2002 20030.69
0.7
0.71
0.72
0.73
0.74
0.75
0.76
0.77
0
0.002
0.004
0.006
0.008
0.01
0.012
0.014
never TSC some TSC latrines per capita
frac
tion
reco
gniz
ing
num
bers
TSC
latr
ines
per
rura
l cap
ita
TSC ASER tests
Source: Spears and S. Lamba (2012)
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the clean village prizeNGP
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clean village prize• a reward for open defecation free villages• village chairman receives prize and monetary
incentive at a prestigious ceremony• interesting to economists:
1. incentivizing the output, ex post2. discontinuity in incentive
• “once the award was started, the numbers increased like anything”
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an incentive with discontinuities
• a lot of money for rural India• … but not enough to move IMR just by
making people richer
a step function of village population
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village chairmen’s motivation
• incentive largely to village chairman
• in otherwise similar villages, the chairman will implement the TSC with more intensity in villages with populations just above cut-point
incentive(population) > cost(population)
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discontinuity-based causal identification
• IMR after the program should be lower in villages with populations just above the cut-points than in villages just below them
• … and similarly for districts with many villages just above the cut-points
• discontinuity only for this program• 2001 population set before program• none of this uses official TSC data
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effects of the NGP• districts with a greater average prize per
capita among villages:– built more latrines per capita– experienced lower 2010-2011 infant mortality
• districts with more villages just above the discontinuity experienced lower IMR; districts with more just below had greater IMR
• instrumenting for 2011 census latrine coverage replicates individual level IMR: -89
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so, should the prize be increased?
• increasing the prize amount would increase the incentive for undeserving applications
• this would further burden evaluation resources• a resulting drop in the quality of monitoring
could further encourage bogus applications• … and the NGP incentive unravels
only with an investment in better monitoring and prize evaluation
Source: R. Lamba and Spears (2012)
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policy opportunities and risksTSC to NBA
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cost per average infant death averted2010 U.S. dollars; J-PAL method (Dhaliwal, et al.)
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02
46
810
de
nsi
ty
0 .2 .4 .6 .8 1
fraction of village openly defecating
Source: Kishore and Spears (in progress), NFHS-3
which level of decision-making?
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village-level information is necessary
2008
2009
20102011
2012
year in which TSC data was last updated, by village
accessed 2/2012
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policy lessons from the TSC
Improving sanitation – meaning safe excreta disposal – must be a top priority
for India.
Because open defecation has negative externalities, it is everybody’s problem,
and requires government action.
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policy lessons from the TSC
By promoting and incentivizing latrine use, the TSC has had positive initial
impacts on children’s health, human capital, and cognitive achievement.
The TSC and clean village prize together are a comparatively very inexpensive
way to save babies’ lives.
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policy lessons from the TSC
Villages are a critical level of governance for promoting sanitation and latrine use.
Incentives to local leaders for outcomes are useful and should be strengthened by both
increasing the monetary incentive and devoting resources to ensure accurate
evaluation and adjudication.
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policy lessons from the TSC
Achieving total sanitation coverage will require safeguarding the quality of
administrative data, by providing resources for data sources that bypass political, bureaucratic, and financial interests.
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