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How Does Health Promotion Work? Evidence From The Dirty Business of Eliminating Open Defecation

Author

Listed:
  • Paul Gertler
  • Manisha Shah
  • Maria Laura Alzua
  • Lisa Cameron
  • Sebastian Martinez
  • Sumeet Patil

Abstract

We investigate the mechanisms underlying health promotion campaigns designed to eliminate open defecation in at-scale randomized field experiments in four countries: India, Indonesia, Mali, and Tanzania. Health promotion works through a number of mechanisms, including: providing information on the return to better behavior, nudging better behavior that one already knows is in her self-interest, and encouraging households to invest in health products that lower the marginal cost of good behavior. We find that health promotion generally worked through both convincing households to invest in in-home sanitation facilities and nudging increased use of those facilities. We also estimate the causal relationship between village open defecation rates and child height using experimentally induced variation in open defecation for identification. Surprisingly we find a fairly linear relationship between village open defecation rates and the height of children less than 5 years old. Fully eliminating open defecation from a village where everyone defecates in the open would increase child height by 0.44 standard deviations. Hence modest to small reductions in open defecation are unlikely to have a detectable effect on child height and explain why many health promotion interventions designed to reduce open defecation fail to improve child height. Our results suggest that stronger interventions that combine intensive health promotional nudges with subsidies for sanitation construction may be needed to reduce open defecation enough to generate meaningful improvements in child health.

Suggested Citation

  • Paul Gertler & Manisha Shah & Maria Laura Alzua & Lisa Cameron & Sebastian Martinez & Sumeet Patil, 2015. "How Does Health Promotion Work? Evidence From The Dirty Business of Eliminating Open Defecation," NBER Working Papers 20997, National Bureau of Economic Research, Inc.
  • Handle: RePEc:nbr:nberwo:20997
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    Cited by:

    1. 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.
    2. 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.
    3. Andrew Dustan & Juan Manuel Hernandez-Agramonte & Stanislao Maldonado, 2018. "Motivating bureaucrats with non-monetary incentives when state capacity is weak: Evidence from large-scale," Natural Field Experiments 00664, The Field Experiments Website.
    4. Adukia,Anjali & Alsan,Marcella & Babiarz,Kim & Goldhaber-Fiebert,Jeremy D. & Prince,Lea, 2020. "Religion and Sanitation Practices," Policy Research Working Paper Series 9131, The World Bank.
    5. Cameron, Lisa A. & Olivia, Susan & Shah, Manisha, 2015. "Initial Conditions Matter: Social Capital and Participatory Development," IZA Discussion Papers 9563, Institute of Labor Economics (IZA).
    6. Deepak Saraswat, 2018. "Gender Composition of Children and Sanitation Behavior In India," Working papers 2018-12, University of Connecticut, Department of Economics.
    7. Dustan, Andrew & Maldonado, Stanislao & Hernandez-Agramonte, Juan Manuel, 2018. "Motivating bureaucrats with non-monetary incentives when state capacity is weak: Evidence from large-scale field experiments in Peru," MPRA Paper 90952, University Library of Munich, Germany.
    8. María Laura Alzúa & Habiba Djebbari & Amy J. Pickering, 2020. "A community based program promotes sanitation," AMSE Working Papers 1857, Aix-Marseille School of Economics, France.
    9. María Laura Alzúa & Habiba Djebbari & Amy J. Pickering, 2018. "A community based program promotes sanitation," CEDLAS, Working Papers 0228, CEDLAS, Universidad Nacional de La Plata.
    10. Ray, Rita & Datta, Rajlakshmi, 2017. "Do separate female toilets in primary and upper primary schools improve female enrollment? A case study from India," Children and Youth Services Review, Elsevier, vol. 79(C), pages 263-273.
    11. Maria Laura Alzua & Habiba Djebbari & Amy J. Pickering, 2018. "A community based program promotes sanitation," Working Papers halshs-02462885, HAL.
    12. 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.
    13. Rosangela Bando & Sebastian Galiani & Paul Gertler, 2016. "The Effects of Non-Contributory Pensions on Material and Subjective Well Being," NBER Working Papers 22995, National Bureau of Economic Research, Inc.
    14. Guiteras, Raymond & Levinsohn, James A & Mobarak, Ahmed Mushfiq, 2019. "Demand Estimation with Strategic Complementarities: Sanitation in Bangladesh," CEPR Discussion Papers 13498, C.E.P.R. Discussion Papers.

    More about this item

    JEL classification:

    • I12 - Health, Education, and Welfare - - Health - - - Health Behavior
    • I15 - Health, Education, and Welfare - - Health - - - Health and Economic Development
    • O15 - Economic Development, Innovation, Technological Change, and Growth - - Economic Development - - - Economic Development: Human Resources; Human Development; Income Distribution; Migration

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