Toilets Can Work: Short and Medium Run Health Impacts of Addressing Complementarities and Externalities in Water and Sanitation

Abstract

Poor water quality and sanitation are leading causes of mortality and disease in developing countries. However, interventions providing toilets in rural areas have not substantially improved health, likely because of incomplete coverage and low usage. This paper estimates the impact of an integrated water and sanitation improvement program in rural India that provided household-level water connections, latrines, and bathing facilities to all households in approximately 100 villages. The estimates suggest that the intervention was effective, reducing treated diarrhea episodes by 30-50%. These results are evident in the short term and persist for 5 years or more. Poor sanitation is widely considered a major obstacle to well-being in many parts of the world.An estimated 748 million people lack access to improved sources of water, and more than 2.5 billion lack improved sanitation (WHO -UNICEF 2014). In India, open defecation is still practiced by 65% of the rural population and only 14% of the rural population have piped-in water to the household (WHO -UNICEF 2014). By some estimates, lack of safe water, inadequate sanitation, and poor hygiene practices cause 1.1 million deaths from diarrhea each year, representing 1.5% of the global burden of disease ), similar to HIV-AIDS. Open defecation in India may be responsible for approximately 9% of total infant mortality, or 6.5 deaths per 1,000 infants per year (Geruso and Spears 2015).This challenge to well-being has not gone unnoticed. Bill Gates talks of "reinventing the toilet" and has put the weight of his foundation behind this effort (Bill & Melinda Gates Foundation 2011, Gates III 2012. Building on his 2013 campaign statement "pehle shauchalaya, phir devalaya" However, the evidence that increasing sanitation coverage alone in rural areas would reduce diarrhea and save lives is surprisingly thin. Infrastructure-based (i.e. connected to sewerage) solutions have proved effective in urban environments when combined with improvements in water supply (Cutler and Miller 2006, Galiani, Gertler, andSchargrodsky 2005). However, interventions promoting on-site sanitation without sewerage, as is typically implemented in rural and other low-density settings, have not been as effective as sewerage (Wolf et al. 2014). Two recent cluster-randomized trials evaluating sanitation-only interventions in rural India, one in Orissa ) and the other in Madhya Pradesh (Patil et al. 2014) find only modest impacts of latrine construction on latrine usage, and no impacts on health.Part of the issue is that these sanitation-focused efforts have not fully taken on board two factors that play a key role in water and sanitation: complementarities and externalities. Epidemiological complementarities between water and sanitation interventions may arise because there are multiple pathways for transmission of water-borne disease (Clasen et al. 2007, Waddington andSnilstveit 2009). A behavioral complementarity can occur if providing water encourages latrine use -1 without convenient access to...

Sanitation and Religion in South Asia: What Accounts for Differences across Countries?

“…Non-Hindu households are less likely to defecate in the open, but Table 3 shows that they also have more assets, are less educated, and are less likely to have infrastructure like electricity and piped water, on average. These factors are believed to be linked to latrine adoption (Duflo et al, 2015; Jenkins & Curtis, 2005; O’Connell, 2014; O’Reilly & Louis, 2014; Routray et al, 2015), and thus should be controlled for in some way.…”

“…Research on latrine adoption in South Asia has primarily focused on economic constraints, infrastructure, and social influence (Duflo, Greenstone, Guiteras, & Clasen, 2015; Guiteras, Levinsohn, & Mobarak, 2015; O’Reilly & Louis, 2014; Pattanayak et al, 2009). While Banda et al (2007) identify the importance of socio-cultural factors for latrine adoption in rural India, only very recently have researchers begun to investigate religion in particular.…”

Sanitation and child health in India

“…In our definition of disease environment we go beyond the imminent disease environment of the household, acknowledging that toilet ownership and usage provides a direct benefit as well as an external benefit, which is believed to be substantial (Duflo et al [2015a]; Gertler et al [2014], Geruso and Spears [2014], Andres et al [2014]). Using a toilet reduces own contact with faeces in addition to other private benefits a toilet might provide (time saving, privacy, etc).…”

“…Rigorous evidence on the potential of improvements in water access and quality exists and the complementarities between water and sanitation have been recognized [WHO, 2008, Duflo et al, 2015b, Pruesss-Uestuen et al, 2008. The understanding of the role of sanitation itself is however still limited.…”

Impactos do saneamento sobre saúde e educação: uma análise espacial

“…É reconhecida e consolidada a literatura que trata dos efeitos positivos do acesso aos serviços de abastecimento de água, tratamento e coleta de esgoto tanto em relação ao impacto sobre mortalidade infantil (Cutler e Miler, 2005;Watson, 2006;Geruso e Spears, 2015) quanto no que diz respeito aos indicadores de morbidez (Bleakley, 2007;Duflo et al, 2015;Fewtrell et al 2005).…”