IDEAS home Printed from
   My bibliography  Save this paper

Water, sanitation and child health: Evidence from subnational panel data in 59 countries


  • Headey, Derek D.
  • Palloni, Giordano


Water, sanitation and hygiene (WASH) investments are widely seen as essential for improving health in early childhood. However, the experimental literature on WASH interventions identifies inconsistent impacts on child health outcomes, with relatively robust impacts on diarrhea and other symptoms of infection, but weak and varying impacts on child nutrition. In contrast, observational research exploiting cross-sectional variation in water and sanitation access is much more sanguine, finding strong associations with diarrhea prevalence, mortality and stunting. In practice, both literatures suffer from significant methodological limitations. Experimental WASH evaluations are often subject to poor compliance, rural bias, and short duration of exposure, while cross-sectional observational evidence may be highly vulnerable to omitted variables bias. To overcome some of the limitations of both literatures, we construct a panel of 442 subnational regions in 59 countries with multiple Demographic Health Surveys. This large subnational panel is used to implement difference-in-difference regressions that allow us to examine whether longer term changes in water and sanitation at the subnational level predict improvements in child morbidity, mortality and nutrition. We find results that are partially consistent with both literatures. Improved water access is statistically insignificantly associated with most outcomes, although water piped into the dwelling predicts reductions in child stunting. Improvements in sanitation predict large reductions in diarrhea prevalence and child mortality, but are not associated with changes in stunting or wasting. We estimate that sanitation improvements can account for just under 10% of the decline in child mortality from 1990-2015.

Suggested Citation

  • Headey, Derek D. & Palloni, Giordano, 2018. "Water, sanitation and child health: Evidence from subnational panel data in 59 countries," IFPRI discussion papers 1753, International Food Policy Research Institute (IFPRI).
  • Handle: RePEc:fpr:ifprid:1753

    Download full text from publisher

    File URL:
    Download Restriction: no

    Other versions of this item:

    References listed on IDEAS

    1. Jens Kovsted & Claus C. Pörtner & Finn Tarp, 2002. "Child Health and Mortality: Does Health Knowledge Matter?," Journal of African Economies, Centre for the Study of African Economies (CSAE), vol. 11(4), pages 542-560.
    2. Payal Hathi & Sabrina Haque & Lovey Pant & Diane Coffey & Dean Spears, 2017. "Place and Child Health: The Interaction of Population Density and Sanitation in Developing Countries," Demography, Springer;Population Association of America (PAA), vol. 54(1), pages 337-360, February.
    3. Stephan Klasen & Tobias Lechtenfeld & Kristina Meier & Johannes Rieckmann, 2012. "Benefits trickling away: the health impact of extending access to piped water and sanitation in urban Yemen," Journal of Development Effectiveness, Taylor & Francis Journals, vol. 4(4), pages 537-565, December.
    4. Elena Gross & Isabel Günther & Youdi Schipper, 2018. "Women Are Walking and Waiting for Water: The Time Value of Public Water Supply," Economic Development and Cultural Change, University of Chicago Press, vol. 66(3), pages 489-517.
    5. Michael Geruso & Dean Spears, 2018. "Neighborhood Sanitation and Infant Mortality," American Economic Journal: Applied Economics, American Economic Association, vol. 10(2), pages 125-162, April.
    6. World Bank, 2017. "World Development Indicators 2017," World Bank Publications, The World Bank, number 26447.
    7. Dean Spears, 2012. "How much international variation in child height can sanitation explain?," Working Papers 1438, Princeton University, Woodrow Wilson School of Public and International Affairs, Center for Health and Wellbeing..
    8. Florencia Devoto & Esther Duflo & Pascaline Dupas & William Parienté & Vincent Pons, 2012. "Happiness on Tap: Piped Water Adoption in Urban Morocco," American Economic Journal: Economic Policy, American Economic Association, vol. 4(4), pages 68-99, November.
    9. Diane Coffey & Michael Geruso & Dean Spears, 2018. "Sanitation, Disease Externalities and Anaemia: Evidence From Nepal," Economic Journal, Royal Economic Society, vol. 128(611), pages 1395-1432, June.
    10. Coffey, Diane & Spears, Dean & Vyas, Sangita, 2017. "Switching to sanitation: Understanding latrine adoption in a representative panel of rural Indian households," Social Science & Medicine, Elsevier, vol. 188(C), pages 41-50.
    11. Huda, Tarique Md. Nurul & Unicomb, Leanne & Johnston, Richard B. & Halder, Amal K. & Yushuf Sharker, Md. Abu & Luby, Stephen P., 2012. "Interim evaluation of a large scale sanitation, hygiene and water improvement programme on childhood diarrhea and respiratory disease in rural Bangladesh," Social Science & Medicine, Elsevier, vol. 75(4), pages 604-611.
    12. Davis, Jennifer, 2004. "Corruption in Public Service Delivery: Experience from South Asia's Water and Sanitation Sector," World Development, Elsevier, vol. 32(1), pages 53-71, January.
    13. Spears, Dean, 2013. "Policy Lessons from the Implementation of India’s Total Sanitation Campaign," India Policy Forum, National Council of Applied Economic Research, vol. 9(1), pages 63-104.
    14. Amy J. Pickering & Habiba Djebbari & Carolina Lopez & Massa Coulibaly & Maria Laura Alzua, 2015. "Effect of a community-led sanitation intervention on child diarrhoea and child growth in rural Mali: a cluster-randomised controlled trial," Post-Print hal-01456117, HAL.
    15. Niels-Hugo Blunch, 2017. "Adult literacy programs in developing countries," IZA World of Labor, Institute of Labor Economics (IZA), pages 374-374, July.
    16. Paul Goldsmith-Pinkham & Isaac Sorkin & Henry Swift, 2020. "Bartik Instruments: What, When, Why, and How," American Economic Review, American Economic Association, vol. 110(8), pages 2586-2624, August.
    17. Gunther, Isabel & Fink, Gunther, 2010. "Water, sanitation and children's health : evidence from 172 DHS surveys," Policy Research Working Paper Series 5275, The World Bank.
    18. David Cutler & Grant Miller, 2005. "The role of public health improvements in health advances: The twentieth-century United States," Demography, Springer;Population Association of America (PAA), vol. 42(1), pages 1-22, February.
    19. Spielman, David J. & Pandya-Lorch, Rajul, 2009. "Millions fed: Proven successes in agricultural development," IFPRI books, International Food Policy Research Institute (IFPRI), number Millions Fed Book: 2009, Winter.
    20. Blunch, Niels-Hugo, 2013. "Staying Alive: Adult Literacy Programs and Child Mortality in Rural Ghana," World Development, Elsevier, vol. 42(C), pages 114-126.
    21. Headey, Derek & Hoddinott, John & Ali, Disha & Tesfaye, Roman & Dereje, Mekdim, 2015. "The Other Asian Enigma: Explaining the Rapid Reduction of Undernutrition in Bangladesh," World Development, Elsevier, vol. 66(C), pages 749-761.
    22. Imbens,Guido W. & Rubin,Donald B., 2015. "Causal Inference for Statistics, Social, and Biomedical Sciences," Cambridge Books, Cambridge University Press, number 9780521885881, February.
    23. Paul Glewwe, 1999. "Why Does Mother's Schooling Raise Child Health in Developing Countries? Evidence from Morocco," Journal of Human Resources, University of Wisconsin Press, vol. 34(1), pages 124-159.
    24. Andres, Luis A. & Briceno, Bertha & Chase, Claire & Echenique, Juan A., 2014. "Sanitation and externalities : evidence from early childhood health in rural India," Policy Research Working Paper Series 6737, The World Bank.
    Full references (including those not matched with items on IDEAS)


    Citations are extracted by the CitEc Project, subscribe to its RSS feed for this item.

    Cited by:

    1. Amanda Beatty & Evan Borkum & William Leith & Marisa Henry & Margo Berends & Clair Null & Nicholas Ingwersen, "undated". "MCC Indonesia Nutrition Project Impact Evaluation Final Report," Mathematica Policy Research Reports 177dad81487243d59a9fefbcf, Mathematica Policy Research.
    2. Tadadjeu, Sosson & Njangang, Henri & Ningaye, Paul & Nourou, Mohammadou, 2020. "Linking natural resource dependence and access to water and sanitation in African countries," Resources Policy, Elsevier, vol. 69(C).

    Most related items

    These are the items that most often cite the same works as this one and are cited by the same works as this one.
    1. Spears, Dean, 2020. "Exposure to open defecation can account for the Indian enigma of child height," Journal of Development Economics, Elsevier, vol. 146(C).
    2. Evan Plous Kresch & Molly Lipscomb & Laura Schechter, 2020. "Externalities and Spillovers from Sanitation and Waste Management in Urban and Rural Neighborhoods," Applied Economic Perspectives and Policy, John Wiley & Sons, vol. 42(3), pages 395-420, September.
    3. Indunil De Silva & Sudarno Sumarto, 2018. "Child Malnutrition in Indonesia: Can Education, Sanitation and Healthcare Augment the Role of Income?," Journal of International Development, John Wiley & Sons, Ltd., vol. 30(5), pages 837-864, July.
    4. Vyas, Sangita & Kov, Phyrum & Smets, Susanna & Spears, Dean, 2016. "Disease externalities and net nutrition: Evidence from changes in sanitation and child height in Cambodia, 2005–2010," Economics & Human Biology, Elsevier, vol. 23(C), pages 235-245.
    5. Hoehn-Velasco, Lauren, 2018. "Explaining declines in US rural mortality, 1910–1933: The role of county health departments," Explorations in Economic History, Elsevier, vol. 70(C), pages 42-72.
    6. Hammer, Jeffrey & Spears, Dean, 2016. "Village sanitation and child health: Effects and external validity in a randomized field experiment in rural India," Journal of Health Economics, Elsevier, vol. 48(C), pages 135-148.
    7. Ervin, Paul A. & Bubak, Vit, 2019. "Closing the rural-urban gap in child malnutrition: Evidence from Paraguay, 1997–2012," Economics & Human Biology, Elsevier, vol. 32(C), pages 1-10.
    8. Vangani, Ruchi & Gerber, Nicolas & Saxena, Deepak & Mavalankar, Dileep & von Braun, Joachim, 2016. "Impact of different irrigation systems on water quality in peri-urban areas of Gujarat, India," Discussion Papers 243145, University of Bonn, Center for Development Research (ZEF).
    9. Patricia Augier & Marion Dovis & Charles Lai-Tong, 2016. "Better Access to Water, Better Children's Health: A Mirage?," Oxford Development Studies, Taylor & Francis Journals, vol. 44(1), pages 70-92, January.
    10. Makate, Marshall & Makate, Clifton, 2016. "Is poor sanitation killing more children in rural Zimbabwe? Results of propensity score matching method," MPRA Paper 72831, University Library of Munich, Germany, revised 02 Aug 2016.
    11. Coffey, Diane & Spears, Dean & Vyas, Sangita, 2017. "Switching to sanitation: Understanding latrine adoption in a representative panel of rural Indian households," Social Science & Medicine, Elsevier, vol. 188(C), pages 41-50.
    12. Hugh Sharma Waddington & Sandy Cairncross, 2021. "PROTOCOL: Water, sanitation and hygiene for reducing childhood mortality in low‐ and middle‐income countries," Campbell Systematic Reviews, John Wiley & Sons, vol. 17(1), March.
    13. Kanika Mahajan & Sheetal Sekhri, 2020. "Access to Toilets and Violence Against Women," Working Papers 44, Ashoka University, Department of Economics.
    14. Diane Coffey & Ashwini Deshpande & Jeffrey Hammer & Dean Spears, 2019. "Local Social Inequality, Economic Inequality, and Disparities in Child Height in India," Demography, Springer;Population Association of America (PAA), vol. 56(4), pages 1427-1452, August.
    15. Derek Headey & David Stifel & Liangzhi You & Zhe Guo, 2018. "Remoteness, urbanization, and child nutrition in sub‐Saharan Africa," Agricultural Economics, International Association of Agricultural Economists, vol. 49(6), pages 765-775, November.
    16. Ahsan, Md Nazmul & Maharaj, Riddhi, 2018. "Parental human capital and child health at birth in India," Economics & Human Biology, Elsevier, vol. 30(C), pages 130-149.
    17. Augsburg, Britta & Rodríguez-Lesmes, Paul Andrés, 2018. "Sanitation and child health in India," World Development, Elsevier, vol. 107(C), pages 22-39.
    18. Kristensen, Frederikke Frehr & Sharp, Paul, 2021. "Disease Surveillance, Mortality and Race: The Case of HIV/AIDS in the United States," CAGE Online Working Paper Series 553, Competitive Advantage in the Global Economy (CAGE).
    19. Lionel Kesztenbaum & Jean-Laurent Rosenthal, 2014. "Income versus Sanitation; Mortality Decline in Paris, 1880-1914," PSE Working Papers halshs-01018594, HAL.
    20. Daniel Gallardo‐Albarrán, 2020. "Sanitary infrastructures and the decline of mortality in Germany, 1877–1913," Economic History Review, Economic History Society, vol. 73(3), pages 730-757, August.

    More about this item


    public health; hygiene; children; mortality; water; child nutrition; improved water; sanitation and hygiene (WASH);
    All these keywords.

    NEP fields

    This paper has been announced in the following NEP Reports:


    Access and download statistics


    All material on this site has been provided by the respective publishers and authors. You can help correct errors and omissions. When requesting a correction, please mention this item's handle: RePEc:fpr:ifprid:1753. See general information about how to correct material in RePEc.

    For technical questions regarding this item, or to correct its authors, title, abstract, bibliographic or download information, contact: . General contact details of provider: .

    If you have authored this item and are not yet registered with RePEc, we encourage you to do it here. This allows to link your profile to this item. It also allows you to accept potential citations to this item that we are uncertain about.

    If CitEc recognized a bibliographic reference but did not link an item in RePEc to it, you can help with this form .

    If you know of missing items citing this one, you can help us creating those links by adding the relevant references in the same way as above, for each refering item. If you are a registered author of this item, you may also want to check the "citations" tab in your RePEc Author Service profile, as there may be some citations waiting for confirmation.

    For technical questions regarding this item, or to correct its authors, title, abstract, bibliographic or download information, contact: (email available below). General contact details of provider: .

    Please note that corrections may take a couple of weeks to filter through the various RePEc services.

    IDEAS is a RePEc service hosted by the Research Division of the Federal Reserve Bank of St. Louis . RePEc uses bibliographic data supplied by the respective publishers.