from EVIDENCE to POLICY THWBN S~BR IDmSS*A Learning what works for better programs and policies March 2015 INDIA: How Many Toilets Does it Take to Improve Health? Access to proper sanitation helps keep children healthy, but households need to have improved sanitation for benefits to millions of people in the developing world still practice open be seen across the whole village? And what's the impact in a defecation, putting children at risk. Diarrhea, which can re- village that goes from zero toilet use to Ul coverage? sult from the spread of fecal material into food or mouths, The World Bank is committed to helping countries de- kills around 800,000 velop the necessary infrastructure and practices to improve children under the age sanitation, reducing barriers families may face in raising of five every year and healthy children. To better understand the impact of a whole leaves millions more village using improved sanitation-such as private toilets or malnourished and pit latrines-compared with just a few people in the village stunted. What's the best having access to toilets, World Bank researchers analyze a way to do create lasting national survey database on more than 200,000 children change? Previous efforts younger than four years old in rural India. More than two- often focused on en- thirds of the people in the rural areas defecate in the open. couraging individuals to invest in toilets for their households, The study found that diarrhea prevalence halved when sani- but gains are limited if not everyone in the village does the tation coverage at community level is fully achieved. The same. One reason may be that sanitation has a communal ele- study says that these results are mostly due to the positive ment because even if only one family in a neighborhood prac- spillover effects on everyone's health that occurs when all (or tices open defecation, all families may be at risk of ingesting the overwhelming majority of) households have toilets. The fecal matter. Sanitation therefore presents a unique challenge: findings can help governments and development practi- If an individual family invests in a toilet, but their neighbors tioners understand the importance of taking a commu- doiA, are there still positive benefits? What proportion of nal approach to the problem. Globally, 2.5 billion people lack access to proper sanitation. Minister Narendra Modi identified the urgency of solving the In India, the problem is acute: Some 626 million people prac- problem shordy after taking office in 2014, when he said that tice open defecation. This poses a particular health problem he wanted to end the practice in India and gave 2019 as the for babies and children, because fecal matter is tracked into target deadline. Es government has since launched Swachh homes and into food, spreading disease. Bharat Abhiyan ("Clean India Mission") to meet this dead- There have been many development efforts to encourage line. The campaign, which is supported by the World Bank, families to build sanitation facilities, but progress has been is expected to cost nearly $10 billion and includes financial modest in countries where open defecation is widely practiced. support for poor families to build sanitation facilities and an In India, open defecation declined from around 60 percent awareness campaign to change behavior, along with building in 2001 to the estimated 50 percent currently. Indiass Prime better waste disposal in rural areas. Evaluationi Researchers sought to determine the health impact on lowed them to separate the direct benefits to a family that children in households that use either a basic pit or shared builds a toilet, and the benefits when their neighbors build latrine, also known as unimproved sanitation, or switch a toilet. to a private toilet facility, known as improved sanitation. The household survey includes questions that allowed They also hoped to measure the extent to which the better researchers to measure the health impact of using sanita- health outcomes were the result of a "direct benefit"-a tion facilities. For example, mothers were asked if their child moving to a home with a latrine-or of an "external" child had diarrhea in the previous two weeks, as well as benefit-a child moving to a village where most house- what kind of toilet facility members of their household holds had access to sanitation facilities. usually use. Researchers used this information to deter- Researchers analyzed data on 209,762 children under mine the percentage of homes in a given village that had the age of 48 months in households in rural India, using access to a toilet facility. the third round of India's District Level Household Survey Among children in the sample, just 18 percent lived in 2007-2008. DLHS-3, as it is known, collected informa- in rural homes with proper toilets, while 72 percent lived tion on maternal and child health and family planning, in homes that lacked access to any kind of sanitation fa- among other things. Though the survey is nationwide, cility and therefore defecated in the open. The remain- researchers restricted the sample to rural areas only. Re- ing 10 percent had some kind of rudimentary latrines searchers analyzed a household's access to sanitation, as that were not hygienically maintained or that were shared well as the village's overall sanitation coverage. This al- with other families. c-nM *"""""""""I Reducing exposure to fecal matter had sweeping While having a toilet is important for improving effects on a child's health, reducing their health, it's even more important that the neighbors likelihood of having diarrhea by almost half. have toilets or other sanitation facilities. A child who lived in a village where all the households had The evaluation looked at health benefits in terms of in- access to latrines, toilets, and other improved sanitation fa- cidences of diarrhea in the previous two weeks and then cilities had a 47 percent lower rate of diarrhea than a child looked at how many households in the village had access living in a village where households didn't have sanitation to sanitation facilities. Researchers wanted to measure the facilities. This lower rate reflects both the impact of sani- relationship between a child's health and the so-called pri- tation facilities in the child's household and the impact of vate benefit of one household having a toilet, and the rela- other households in the village also having sanitation facili- tionship between a child's health and what they called the ties. In terms of incidence of diarrhea, this reflects an almost external benefit of other people in the village having access six percentage point drop from 12.5 percent to 6.8 percent. to sanitation facilities. This policy note summarizes "Sanitation and Externalities: Evidence from Early Childhood Health in Rural India," Luis A. Andres, Bertha Briceno, Claire Chase and Juan A. Echenique, World Bank Policy Research Working Paper 6737, January, 2014. http://go.worldbank.org/efXoB1 R540 Only a quarter of the positive health benefit can be at- The health benefits of toilets can't be viewed as a tributed to a child's family having toilet access. More than private issue and therefore, private markets can't three quarters of the 47 percent reduction in diarrhea is at- sufficiently tackle the challenge. tributable to external factors, that is to say, the fact that the child lives in a village where other people practice safe sani- The relationship between a village's overall sanitation and tation. In other words, whether all your neighbors have a diarrhea underscores the importance of a communal ap- toilet is three times more important in determining your proach to the open defecation issue. Individuals, on their child's health than whether you yourself have one. own, can't significantly improve the health of their chil- The change is less dramatic, but nevertheless notewor- dren if their neighbors don' take similar steps to curb open thy, for individual families that improve their sanitation defecation and reduce the overall probability that a child services, even if the entire village does not. Researchers will come into contact with human feces. found a 10 percent reduction in diarrhea for a child liv- ing in a household that installs a toilet and a five percent reduction for a child in a household that installs a basic, but unsanitary, latrine. These relatively small changes ac- count for the "direct" health effects of improved access for the individual. It's likely that the impact of any one household having a toilet has been underestimated in the past. Previous studies looking at the relationship between ac- cess to sanitation and children's diarrhea may be underes- timating the health benefits when a family puts in a toilet. There's the personal gain-which is that children in that household are likely to see a drop in diarrhea-and then there's the communal gain. It's the gain to the whole com- munity that hasn't always been accounted for when look- Did You Know... ing at the impact of private toilets. 82% of the one billion people practicing open defecation in the world live in just 10 countries. But crtica mas ofpeole eedsto uildtoiets India tops the list, followed by Indonesia, Pakistan, and Nigeria. But a critical mass of people needs to buil toilets Diarrheawasresponsiblefor 13%ofchilddeathsin Indiain 2010 for theltexterfnas betnefitscatottakeiewedeas. Some 65 million kilos of human feces are said to be dumped in India every day There's limited improvement to children's overall health Statistics from UNICEF if only a few households in a given village decide to in- vest in latrines. Researchers found that at least 30 per- While governments can encourage individuals to invest cent of a village had to have access to proper sanitation in toilets, it's the community, rather than the individual for diarrhea rates to start dropping among those without household, that reaps most of the benefit. This means that toilets. When coverage reaches 75 percent of a given vil- campaigns for ending open defecation need to include a lage, half the potential gains take effect (that is to say. communal approach. Individuals may not be investing in a 25 percent reduction in diarrhea prevalence). Benefits toilets because unless everyone does the same, the direct ben- increase steeply with higher levels of village sanitation ac- efits are so small. Policies, therefore, need to reflect the reality cess, which researchers say bolsters the policy goal of total that sanitation is not a private good"-and that whole vil- village coverage. lages must have sanitation to be made truly safe for children. Conclusion Open defecation remains a challenge to policy makers in Total sanitation approaches like Community-Led India and other developing countries, and as the evidence Total Sanitation, which mobilize communities to take from this research shows, the solution needs to be com- collective action to eliminate open defecation and en- munal because the problem is a communal one. Indeed, sure everyone in the community uses a toilet, have the piecemeal solutions can only make limited impact-be- potential to radically overhaul the health of millions of cause open defecation, by its very nature, affects an entire children across India and beyond. Ultimately, ensuring village: If you want to improve children's health, provid- that kids stay healthy is critical to making sure they ing incentives to individuals for using toilets may not be stay in school and have the tools to reach their poten- enough. What's critical is ensuring that at least 30 percent tial. By tackling sanitation effectively, policy makers of households in a village-and ideally, more than 50 per- around the globe are helping to ensure a generation of cent-put in toilets. Otherwise, benefits are limited. healthier kids. The Strategic Impact Evaluation Fund, part of the World Bank Group, supports and disseminates research evaluating the impact of development projects to help alleviate poverty. The goal is to collect and build empirical evidence that can help governments and development organizations design and implement the most appropriate and effective policies for better educational, health and job opportunities for people in developing countries. For more information about who we are and what we do, go to: http://www.worldbank.org/sief. The Evidence to Policy note series is produced by SIEF with generous support from the British government's Department for International Development. THE WORLD BANK THE WORLD BANK, STRATEGIC IMPACT EVALUATION FUND 1818 H STREET, NW WASHINGTON, DC 20433 Produced by the Strategic Impact Evaluation Fund Series Editor: Aliza Marcus Writer: Daphna Berman