Open defecation causes child stunting (could cash incentives help?) Dean Spears Princeton University WSP Phnom Penh

three parts 1. “How much international variation in child height can sanitation explain?” 2. Open defecation and child height in Cambodia 3. How could a sanitation incentive be useful in Cambodia?: Speculation inspired by India’s Nimal Gram Puraskar

Part 1: “How much international variation in child height can sanitation explain?”

Height is an important marker of health, well-being, and human capital. But differences in height across developing countries today are not well explained by differences in income.

An Asian enigma? What is an important input to health and human capital on which South Asia does particularly badly? sanitation and open defecation calorie loss due to diarrhea chronic sub-clinical enteropathy

There is already causal evidence for an effect of sanitation on child height. Today we’re doing accounting, asking “How big is the effect?” “Big enough to be very important?” Randomized, controlled experiments Indonesia (Gertler, et al 2012) Maharashtra, India (Hammer & Spears 2012) Longitudinal (e.g. fixed effects over time) studies Cohorts of children in Andhra Pradesh (Skoufias, et al 2013) Infants visited every other day in Bangladesh India’s Total Sanitation Campaign Discontinuity-based identification India’s Clean Village Prize

140 collapsed DHS surveys, Demographic and Health Surveys are the best data available about health in poor countries, and are internationally comparable each observation is a whole DHS survey (country-year) mean height and open defecation

Country average open defeaction predicts child height: children under 3 India

merely wealth? controlling for GDP changes little

wealth within India

children under 3: difference from country mean

Would this work for any indicator of well-being? We’ve seen it does not for GDP

sanitation interacts with population density

An advertisement for reading the paper Change over time in Indian districts Association of sanitation and height by child age The sanitation-height is steeper in urban than in rural places Differences in open defecation can fully account for the India-Africa height gap

Part 2: Open defecation is associated with child stunting in Cambodia 2010 Demographic and Health Survey

height and sanitation in Cambodia

by province: rural and urban

by province: rural only

by province: urban only

by age in months starting similarly tall gap by age 2 years

height and local open defecation: public and private costs of open defecation negative spillovers: steep slope even for toilet users

panel data: change from 2005 to 2010 The decrease in open defecation can linearly explain 90% of the 2005 to 2010 child height increase.

(1)(2)(3)(4)(5)(6) local open-0.777***-0.585***-0.496***-0.428***-0.456*** defecation(0.0760)(0.137)(0.127) (0.118) year ** (0.0450)(0.0443)(0.0444)(0.0423) (0.0400) household open-0.139* defecation(0.0631)(0.0589)(0.0587)(0.0572) local electrification (0.0988)(0.0939)(0.137)(0.130) urban (0.0728)(0.0692)(0.0671)(0.0644) momheight0.0547***0.0538***0.0551*** ( )( )( ) mombmi0.0253***0.0224**0.0273*** ( )( )( ) household birth demography province FE n (children under 507,286 7,184 local open defecation and child height

A 20 percentage point reduction in open defecation is associated with a 0.1 standard deviation increase in child height, which is about about 0.4 of a centimeter for a healthy four-year-old.

Part 3: Could a cash incentive help? Speculations inspired by India’s Clean Village Prize

Incentives vs. Subsidies A subsidy is a reduction in the price An incentive is an offer of something you want, to get you to change your behavior Typically subsidies are a priori and incentives are ex post, depending on what you do Typically subsidies are for latrine construction, but incentives could be conditional on latrine use This is important in India, where people often do not use even free latrines

India’s Clean Village Prize… in principle Awarded to village overall, and to village leaders specifically Recognition for being open defecation free Monetarily large for rurual India, $1,000-$2,000 (worth more at purchasing power parity Step function of village size What I like: uses social forces, incentivizes what we care about, permits local solutions

On average, the monetary award was noticed

On average, the TSC did something (although this graph alone does not prove that!)

In practice, serious implementation problems Prizes given to villages that are not open defecation free Know when monitor is coming, for example Very bad government monitoring data “Collected” by the people whose job it is to achieve latrine construction Villages randomly assigned to be required to elect a low caste leader are less likely to win the prize Recently, the subsidy has been substantially increased, effectively eliminating the net incentive to win the prize

Would such a prize be a good idea here? Is the problem here latrine construction or latrine use? Can the government implement the monitoring and conditionality? Is the local state capacity sufficent for local leaders to succeed, if they attempt to win the prize? Build monitoring capicity first: it is needed for a prize, and useful even without one.