Duke 2008 | ASHE | Equity and Efficiency in Health and Healthcare

Inadequate access to sanitation infrastructure among one third of the world's population contributes to persistent global health challenges, helping to perpetuate inequalities in health, social, and economic outcomes. Diarrhea is the most significant cause of child mortality worldwide. Moreover, women and marginalized sub-populations typically bear the brunt of the burden related to inadequate sanitation, but often (like the children who suffer from diarrhea) lack the political voice and financial capital to invest in sanitation goods and services. Serious intergenerational and intra-generational inequities, along with pervasive externalities in prevention of and infection through diarrheal diseases, provide a strong rationale for public policy interventions. Despite these concerns, policymakers and economists have paid relatively little attention to the drivers of households' sanitation choices. Rigorous empirical work examining households' decisions to abandon the long-standing practice of open defecation and adopt new behaviors is crucial for public policies aimed at improving sanitation and solving efficiency and equity problems surrounding this major global health challenge.

In this paper, we describe a randomized community-led total sanitation intervention in rural Orissa, India, and examine how social interactions influence key sanitation behaviors. Fieldwork in Orissa indicated strong preferences for 'Open Sky Latrines' and a marked reluctance to adopt the new practice of using toilets. We develop a theory of households' sanitation decisions that highlights a range of private and collective costs and benefits of building and using latrines. For both epidemiological and social reasons, an individual household's payoff to latrine use will depend in part on the sanitation decisions of other households in the village. This creates a coordination problem in the supply of an environment that is free of microbial contamination. Thus, we study an intensive social mobilization campaign that targets whole villages rather than individuals and attempts to shift social norms underlying the practice of open defecation. The campaign relied on a series of participatory community activities intended to create a sense of shame about open defecation and enable community-wide collective action to end this practice through universal latrine use. In addition, some households received subsidies for latrine construction.

Difference in difference estimates indicate that the social mobilization campaign had a large and unambiguous impact on adoption of latrines. We estimate the size and nature of the influence of social interactions in driving this increase in latrine use. To identify these social interactions, we employ three alternative econometric strategies. The first uses functional form assumptions, the second employs a set of exclusion restrictions, and the third approach examines a sub-population that was not eligible for subsidies under the campaign. Across these different models, we find consistent evidence that latrine adoption among other households in the village had a positive and significant effect on a household's own adoption decision. The robustness of our results across different methods indicates that the models' different identifying assumptions are not driving our results. Our findings indicate that social pressure to adopt latrines can be a powerful motivator. Sanitation policies that target social drivers of behavior change may be more effective than those that focus only on private incentives.