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2_Does Access to Improved Sanitation Reduce Diarrhea (S. Kumar)

2_Does Access to Improved Sanitation Reduce Diarrhea (S. Kumar)

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Conference on Impact Evaluation: Methods, Practices, and Lessons

Auditorium A, ADB Headquarters, Manila
11 July 2012
Conference on Impact Evaluation: Methods, Practices, and Lessons

Auditorium A, ADB Headquarters, Manila
11 July 2012

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Does Access to Improved Sanitation reduce Childhood Diarrhea in Rural India?

Santosh Kumar
University of Washington

July 11, 2012/ Asian Development Bank

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Evaluation Question

Evaluate the impact of access to improved sanitation on child morbidity (diarrhoea) in rural India. Quantify child-health gains from access to improved sanitation. Why focus on diarrhoea? Why India?

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MDG and Child Mortality

MDG 4: To reduce under-5 mortality by two-thirds by 2015. “Countdown to 2015” report suggests that only 19 countries can meet MDGs 4. Nearly 8 million children under five years of age died in 2010. Pneumonia is the leading killer of children under five.

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Why Diarrhoea ? ? ?

Second leading cause of under five mortality????. Nearly one in five child deaths, about 1.5 million each year, is due to diarrhoea. It kills more young children than AIDS, malaria and measles combined. Pneumonia and diarrhoea cause 40 per cent of all child death under age five. 88 per cent of diarrhoeal deaths worldwide are attributable to unsafe water, inadequate sanitation and poor hygiene.

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Global Burden of Childhood Diarrhoea

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Symptom, causes, transmission, and forms

Common symptom of gastrointestinal infections caused by a wide range of pathogens, including bacteria, viruses and protozoa. Faecal-oral transmission Three main forms of acute childhood diarrhoea
Acute watery diarrhoea Bloody diarrhoea Persistent diarrhoea

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Oral rehydration therapy (ORT). Fluid replacement (homemade fluids). Breastfeeding. Zinc supplementation.

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Water, Sanitation, and Hygiene. Adequate nutrition, Immunization, Breastfeeding. Focus of this paper: Access to Improved Sanitation.

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Water and Sanitation coverage

About 2.5 billion people were lacking improved sanitation facilities (WHO, Unicef, 2006). Nearly 1 in 4 people in developing countries were practising open defecation Almost 1 billion people lack access to improved drinking water sources. Water and poor sanitation, account for disease burden of 3.7 percent (54.2 million) of disability adjusted life years (DALYs).

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Sanitation coverage

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Mortality-Diarrhea-Sanitation link
MDG 4: Child Mortality

Diarrhea is the second leading causeevery fifth child dies due to diarrhea

88 per cent of diarrheal deaths worldwide are attributable to unsafe water, inadequate sanitation and poor hygiene.

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Total Sanitation Campaign (TSC)

TSC, demand-driven programme, was launched in 1999 in India. Spread across 590 districts in 30 states. Rural sanitation coverage trebled from 22% in 2001 to 58% in 2008. The GOI has allocated $4 bn, and $1.4 bn has been spent. Program was implemented nation-wide in one go- no counterfactual. Program provided subsidy for toilet construction.

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Total Sanitation Campaign (TSC)

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Evaluation Design

Fundamental problem is that it is impossible to observe counterfactual. Experimental design (RCT) - gold standard. RCT addresses observable and unobservable selection bias. RCT has limitations- external validity, ethical concern, expensive, hawthorne effect.

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Non-experimental method

Diff-in-Diff method- controls observable selection bias, data at two time points, controls only time invariant unobserved characteristics. Matching methods - addresses selection bias on observed characteristics. Regression Discontinuity Design (RDD). Use of Instrumental variable (IV).

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Matching: Propensity score matching

Compare outcomes of T and C individuals with similar covariates and then aggregate to get population average treatment effect.
ATT : E(Y1 |p(X ), D = 1) − E(Y0 |p(X ), D = 0) = E(Y1 − Y0 |p(X )) (1)

Use inverse of p-score to run a weighted regression
(Hirano, Imbens, and Ridder, 2003, Econometrica).

Weight: 1/pscore for Treated and 1/(1-pscore) for Untreated

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Identifying Assumptions

Conditional Independence Assumption (CIA): there is a set X of covariates, observable to the researcher, such that after controlling for these covariates, the potential outcomes are independent of the treatment status. Common support or overlap condition Limitation: Matching does not address unobserved bias.

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Steps in PSM

Estimate propensity score based on covariates. Check the common support and balance of covariates between T and C. Take the difference in mean outcomes in T and C in the matched sample.

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Reproductive and child health survey (RCH 3)/ District Level Household Survey (DLHS 3) from India RCH 3 is third wave and was conducted during 2007-2008. Surveyed 1000-1500 households in each of 611 districts. Survey asked ”diarrhoea episode in the last two weeks for children born since 2004).

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Related literature

Prevalence and duration of diarrhoea are less in piped household (Jalan and Ravallion, 2003). Clean water usage is associated with 9 percent less diarrhoea in Philippines (Bennett, 2010). No Substantial health impacts from improved communal water sources (Kremer and others 2006). Mixed evidence(Khanna, 2008; Fewtrell et al. 2005). ORs are 0.91-0.92 for improved water and 0.87-0.92 for improved sanitation (Fink, Gunther, and Hill, 2010). Diarrhoea incidence is 5% lower in the households with access to improved sanitation in Nepal (Bose, 2009)

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Variables used for Propensity score

Household variables:
Piped water, Maternal age, Maternal education, Paternal age, Paternal education. Type of house (pucca/kutcha), Fraction of young boys, Average age of young children No of males and females in the household, Land ownership, Below poverty line (BPL) status Religion, Caste, Electrification status.

Village variables:
Health and Sanitation committee in the village, Distance to district HQ, ICDS worker in the village, Whether panchayat head lives in the village.

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Descriptive statistics of covariates (pre-matching)

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Age distribution
Age distribution of children with diarrhoea DLHS-3
By age in months



Density .02



20 Child age in months



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Post matching covariate balance- t-test

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Absolute bias, pseudo-Rsquare

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Distribution of Propensity Score



.4 .6 Propensity Score Untreated Treated: Off support

.8 Treated: On support



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Impact: Nearest Neighbor (1)

LPM (1) Improved sanitation -0.008** (0.004)

PSM (NN 1) (2) -0.022*** (0.002)

WLS (3) -0.010*** (0.003)

N 206,935 109,258 206,935 R Square 0.03 0.03 Notes: Standard errors are clustered by state and are robust to heteroskedasticity. Household characteristics include mother’s age, mother’s education, father’s age, father’s education, poverty status, whether village has health worker, caste, electrification status, house type (pucca), and religion.

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Heterogeneous impacts of improved sanitation

Nearest neighbor model Panel A: Stratified by gender of children Boy Girl Panel B: Stratified by wealth index quintiles Low SES Middle SES High SES Panel C: Whether households treat water Treat water (yes) Treat water (no)

Std. error

-0.020** -0.007

0.009 0.008

0.001 -0.008 -0.025***

0.009 0.006 0.008

-0.033*** 0.0005

0.011 0.005

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Robustness Checks

II. Robustness Checks

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Robustness Checks

First alternate estimation of p-score- use probit Second alternate estimation of p-score- logit + additional covariates Third alternate estimation of p-score - probit + additional covariates

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Robustness Checks

Different implementation of P-score NN(1) (1) Base model Alternate implementation of p-score First alternate estimation of p-score Second alternate estimation of p-score Third alternate estimation of p-score 0.021*** 0.021*** 0.022*** 0.002 0.002 0.002 0.022*** Std error (2) 0.002

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Sensitivity Analysis: Rosenbaum Bounds

III. Hidden Bias and Sensitivity Analysis (Rosenbaum Bounds)

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Sensitivity Analysis: Rosenbaum Bounds

Unobserved hidden bias such as, forward-looking behaviour Employ bounding approach proposed by Rosenbaum (2002) To determine how strongly the unobservables must influence to make the estimated treatment effects null and void

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Sensitivity Analysis: Rosenbaum Bounds

Upper bounds on the p-value for the null of zero average treatment effect are obtained for different values of Rho is estimated where Rho reflects the relative odds ratio of two observationally identical children receiving the treatment. Rho =1 means data is free of ”hidden bias” from selection on unobservables; higher values of Rho imply an increasingly important role of unobservables. For example, Rho = 2 implies that observationally identical children can differ in their relative odds of treatment by a factor of two.

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Sensitivity Analysis: Rosenbaum Bounds


+ Qmh

− Qmh

+ pmh

− pmh

(1) 1 1.2 1.4 1.6 1.8 2.0 2.2 2.4 11.62 21.23 29.46 36.68 43.15 49.03 54.44 59.45

(2) 11.62 2.07 5.97 12.98 19.19 24.78 29.89 34.60

(3) 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

(4) 0.00 0.02 0.00 0.00 0.00 0.00 0.00 0.00

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Sum up results

Access to improved sanitation reduces diarrhoea by 2.2 percentage points. This means 17% reduction in the control group and 25% higher odds of contracting diarrhea. Access to improved sanitation averts 0.8 diarrhoea cases per-household per year. Evidence of heterogenous impacts. Importance of hygienic behaviour.

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