Policy Lessons from India’s Total Sanitation Campaign

1. Policy Lessons from India’sTotal Sanitation Campaign 18 July 2012

2. open defecation is common.open defecation is important.

3. three starting points • open defecation harms early life health • early life health matters for life-long human capital and productivity • open defecation has negative externalities, which require government responsibility

4. 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)

5. importance of safe excreta disposal

6. similar trend among Indian states

7. lasting effects of early life health • 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

9. negative externalities of open defecation one household’s open defecation can hurt everybody else, even if everybody else disposes of their feces safely

10. negative externalities of open defecation in economic theory, negative externalities are an important indicator of government responsibility

11. sanitation and the TSC

12. 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

13. 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

14. two features may have helped: • ex post incentive for desired outcome (Holmstrom & Milgrom, 1991) • made use of existing social structure

17. two types of evidence randomized experiment 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 • 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?

18. experimental results in Nanded and Nandurbar there was no experiment mean difference between treatment and control villages, height-for-age z Source: Chaudhury, Moulik, Hammer, Pokharel, & Spears (in progress)

19. non-experimental results I

20. 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?

21. 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

22. effects of TSC on IMR, DLHS-3

23. 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”

24. non-experimental results II census organization’s Annual Health Survey census TSC latrines built 2001 2010-2011

25. did districts in which more TSC latrines were built between 2001 and 2010 see a greater decline in rural IMRthan other comparable districts?

26. 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

27. effects of early life health on human capital

28. 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?

29. 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

30. are children who live in districts that had more TSC latrines in their first year of life better able to recognize letters and numberswhen they are six years old, relative to other children born in different years or different districts? Source: Spears and S. Lamba (2012)

31. TSC  ASER tests Source: Spears and S. Lamba (2012)

32. NGP the clean village prize

33. clean village prize • a reward for open defecation free villages • village chairman receives prize and monetary incentive at a prestigious ceremony • interesting to economists: • incentivizing the output, ex post • discontinuity in incentive • “once the award was started, the numbers increased like anything”

34. an incentive with discontinuities a step function of village population • a lot of money for rural India • … but not enough to move IMR just by making people richer

35. village chairmen’s motivation incentive(population) > cost(population) • 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

36. 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

37. 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

38. so, should the prize be increased? only with an investment in better monitoring and prize evaluation • 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 Source: R. Lamba and Spears (2012)

39. TSC to NBA policy opportunities and risks

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

41. which level of decision-making? Source: Kishore and Spears (in progress), NFHS-3

42. village-level information is necessary accessed 2/2012

43. 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.

44. 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.

45. 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.

46. 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.

47. financing ex post incentives subsidy ? policy emphasis latrineconstruction latrineuse ? a fewpradhans captured whose Interest? ? contractors