Policy Lessons from India’sTotal Sanitation Campaign

18 July 2012

open defecation is common.

open defecation is important.

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

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)

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

-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

• 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

negative externalities of open defecation

one household’s open defecation can hurt everybody else, even if

everybody else disposes of their feces safely

negative externalities of open defecation

in economic theory, negative externalities are an important

indicator of government responsibility

sanitation and the TSC

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

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

two features may have helped:

1. ex post incentive for desired outcome (Holmstrom & Milgrom, 1991)

2. made use of existing social structure

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

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

non-experimental results I

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?

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

effects of TSC on IMR, DLHS-3

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”

TSC latrines built2001 2010-2011

censuscensus organization’sAnnual Health Survey

non-experimental results II

did districts in which more TSC latrines were built between 2001 and 2010 see a greater decline in rural IMR than other

comparable districts?

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

effects of early life health on human capital

lower IMR

children’s height

cognitive achievement

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?

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

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)

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)

the clean village prizeNGP

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”

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

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)

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

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

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)

policy opportunities and risksTSC to NBA

cost per average infant death averted2010 U.S. dollars; J-PAL method (Dhaliwal, et al.)

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?

village-level information is necessary

2008

2009

20102011

2012

year in which TSC data was last updated, by village

accessed 2/2012

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.

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.

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.

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.

CSRSP TSC NBAfin

anci

ngpo

licy

emph

asis

capt

ured

who

seIn

tere

st?

subsidy

latrineconstruction

contractors

ex postincentives

latrineuse

a fewpradhans

?

?

?