Family and social effects on adoption of preventative health measures

Sanitation - broadly defined as hygienic means of promoting health through prevention of human contact with the hazards of waste and in particular human waste - has long been acknowledged as an indispensable element of disease prevention and primary health care programmes (Declaration of Alma-Ata, 1978). An estimated 2.3 billion people do not have access to basic sanitation services, and 4.5 billion people do not have access to safely managed sanitation. Hence the scale of the problem is urgent, and improving sanitation is included in both the Millennium and Sustainable Development Goals (MDGs and SDGs). It is estimated that better sanitation could prevent the majority of diarrheal-related deaths of 361,000 children aged less than 5 years each year. Improved sanitation would also have substantial impacts on developing countries' economic growth: the Water and Sanitation Program of the World Bank estimates that India, the context of the proposed research, loses more than 6% of its annual GDP due to inadequate sanitation.

Strategies to improve sanitation coverage across the developing world have focused predominantly on providing information and credit or subsidies to encourage the construction of private household toilets. However, a large number of recent impact evaluation studies on sanitation interventions in low-income countries find only modest impacts on toilet uptake and usage.
It is crucial for the design and targeting of policies aimed at improving sanitation, and consequently health and productivity, to gain a deeper understanding of what imperfections and constraints are driving this observed failure of sanitation interventions to achieve their full potential.

The proposed research aims to inform the design of effective sanitation interventions and policies by identifying the importance of social factors in explaining sanitation adoption decisions. In particular, our research will focus on understanding the role of dynamics within the household, such as between husband and wife who may value sanitation differently, and within peer groups, which are particularly important in interventions such as micro-credit which are delivered through groups within the community.

We focus on the context of India, which contributes almost 60% of the close to one billion people who defecate in the open globally (WHO/UNICEF JMP, 2017). The Government of India is committed to achieving SDG 6 of clean water and sanitation for all by 2030, including via its ambitious Clean India Movement which aims to make India open-defecation-free by 2019. At the same time, India remains a patriarchal society, where women are often seen as subordinate to men, and a society with very strict norms governing social interactions within the community. Social factors, and in particular those related to gender and community, are therefore likely to pose particularly strong constraints on sanitation investments in India.

We will seek to answer a number of important and related questions. First, we will ask whether women indeed bear higher costs of open defecation and place a higher valuation of toilets relative to men. Yet second, since women often have lower bargaining power within poor Indian households, we will investigate to what extent bargaining within the household over budget and mobility constrains their ability to invest in sanitation via building private latrines or using community toilets. Third, the effectiveness of encouraging individuals to invest in private latrines via microfinance lending is also likely to depend on the preferences and behaviour of key individuals within joint-liability microfinance groups. We will explore such intra-group dynamics and how leaders influence sanitation investment decisions. Finally, we will model and test whether investing in toilets allows grooms on the marriage market a better chance of attracting higher-quality brides (or any bride at all).

First and foremost, we will strive for our proposed research project to have a direct impact on the institutions, policy makers and funders involved in the specific interventions subject to this study, including the Municipal Corporations of the Indian cities Lucknow and Kanpur, the microfinance institution Grameen Kota and its NGO arm, Navya Disha, the umbrella organisation FINISH Society, which works with more than 60 partners in more than 50 districts in 10 states of India, including Micro Finance Institutions (MFIs), NGOs and Cooperatives, and Sulabh International Social Service Organisation, which has community toilet complexes in 25 states and 4 union territories of India. All four studies further have the potential to directly speak to the design of India's flagship sanitation program, the Swachh Bharat Abhiyan or "Clean India" - the primary driving force behind the Government of India's sanitation coverage goal, estimated to cost 9.2 Billion USD.

Results of this research will continue to support implementing institutions to gain a better understanding of the underlying mechanisms of outcomes achieved through their interventions. This knowledge will enable evidence-based decisions to be made about the design and delivery of their interventions and form the foundation of advocacy initiatives. Also funders directly involved in the projects will be able to feed our research outputs into general awareness-creation and policymaking with the aim of enhancing productivity in developing countries. Funders include the Strategic Impact Evaluation Fund (SIEF) (funds from the Department for International Development (DfID), managed by the World Bank (WB)), and the International Initiative for Impact Evaluation (3ie). We will also engage partners in our other ongoing research work related to sanitation, which is conducted with organisations including WaterAid UK and Nigeria as well as PLAN International, through projects funded by the Bill and Melinda Gates Foundation and DfID.

To achieve our ultimate goal of supporting sector decision-making through the provision of rigorous academic evidence, we will work with our partners from these impact evaluation studies to help ensure that our analysis responds to sector-relevant questions, placing emphasis on engaging key sector actors and translating the evidence into digestible outputs. Details on planned activities are provided in the Pathways to Impact section, and include presenting findings at important sector convenings (UNC Health and Water conference, iHEA Congress); engaging in one-to-one meetings with staff of institutions such as UNICEF who provide technical support to governments on sanitation interventions; active participation in donor meetings (organised by for example the Gates Foundation and DfID); and writing of policy brief and blogs, organisation of e-discussions, making use of tweets and publication of outputs on the IFS website (which currently enjoys >750k sessions and over 500k unique visitors a year from UK and abroad). We will benefit from the support of an experienced and successful communications team at the Institute for Fiscal Studies: including the Head of Public Relations, who has a strong track record of communicating with UK stakeholders in government, third sector, academia and media; and a media and writing consultant, who has wide networks in the international development community.

In all activities, we will be building on long-standing relationships. We expect the project design to continue to strengthen these relationships for future collaborations.