Scaling up Sanitation Marketing to Reach SDGs 3 and 6: Evidence from a Research Study in Rural Cambodia

Cassandra Ake, Georgetown

Chris Nicoletti, iDE

October 30, 2018

The Rest of the Research Team

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Mutiara Alam

Addini

Anna

Konstantinova

Akaravuit

Pancharoen

Dr.

Jacobus

Cilliers

Rachel

Rose (iDE)

Presentation Outline

● Preview of results

● Background and motivation

● Methodology

● Results

○ Did iDE’s intervention lead to increases in latrine coverage?

○ Did iDE’s intervention lead to improvements in health?

● Policy implications

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Preview of Results

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What we found

• iDE’s intervention has led to increases in latrine coverage compared to other regions of the country.

• iDE’s intervention has led to decreases in diarrhea prevalence, but no other health effects, compared to other regions of the country.

• This shows promise for market based sanitation interventions over CLTS, etc.

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Background

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Why latrines?

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In the literature

Historical epidemiological studies show that having a latrine is associated with improvements in health for children under-5. Average decrease found is 36%

But, recent experimental studies attempting to verify these findings have returned no evidence that health improves after a latrine is installed.

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What is the state of sanitation in Cambodia?

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● 18% of under 5 childhood mortality in Cambodia was directly caused by poor sanitation in 2008. Behind

the rest of SE Asia in terms of latrine coverage.

● Cambodia has a national strategy to increase latrine ownership, but no clear implementation plan or

funds. Universal access would cost 1.2 billion USD.

Who is iDE?

• Started in 1982, IDE now works in 11 countries

worldwide on a variety of issues, including

WASH (6)

• Markets are the most powerful force for

significant, widespread and lasting impact on

rural prosperity. The rural poor are customers,

producers, and entrepreneurs.

• When people invest their own money, they’re

more likely to embrace the change necessary

to improve their lives

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What is iDE’s role?

● Through Sanitation Marketing Scale-Up (SMSU), iDE develops affordable,

aspirational WASH products; trains local entrepreneurs to manufacture

and install them; and recruits and trains independent sales agents to create

consumer demand for improved WASH products and services.

● Since 2012, SMSU has aimed to scale Sanitation Marketing in Cambodia

across seven provinces, distilling principles, methods, and tools to support

the replication of Sanitation Marketing nationally.

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Theory of Change

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Methodology

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Methodology

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Objective

Estimating the extent to which iDE sanitation marketing intervention has increased latrine

coverage rates and reduced diarrheal prevalence rates for children under five in Cambodia.

Data

●Primary data collected by iDE

●Secondary data from Cambodia Socio-Economic Survey (CSES) (2004, 2009, 2014) and

Demographic Health Survey (DHS) (2000, 2005, 2010, 2014)

Method

A quasi-experimental research study of primary and secondary data sources used difference-in-

difference models to measure iDE’s causal impacts on changes in latrine coverage at the

commune and district-levels and health outcomes at the district level.

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Results: Did iDE’s intervention lead to increases in latrine coverage?

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Latrine coverage results:

Parallel trends testing using CSES data

Latrine coverage increases over time. Treatment and control provinces are relatively parallel in latrine coverage prior to the intervention.

Note: Control provinces include those that were not exposed to iDE’s intervention or to WaterSHED’s intervention.

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Latrine coverage results:

Impact of iDE’s intervention

Difference-in-difference analysis shows latrine coverage increases by 19.9 percentage points, or a 105% increase, in iDE provinces compared to control provinces after iDE’s intervention.

Endline

Results: Did iDE’s intervention lead to improvements in health outcomes?

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Diarrhea prevalence results:

Parallel trends testing using DHS data

Control and treatment provinces show parallel trends from 2005-2010, but those trends do not extend to 2000.

Note: Control provinces include those that were not exposed to iDE’s intervention or to WaterSHED’s intervention.

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Diarrhea prevalence results:

Impact of iDE’s intervention

Difference-in-difference analysis shows diarrhea prevalence decreases by 6.53 percentage points, or a 61% decrease, in iDE provinces compared to control provinces after iDE’s intervention.

Endline

Policy implications

● Market-based WASH programs that drive behavior change toward

consistent latrine use can positively impact diarrhea prevalence.

● Additional health benefits may accrue from addressing the water and

hygiene barriers to disease transmission

● Significant reduction of diarrhea prevalence can be achieved at lower

coverage thresholds.

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Questions?

Thank you!

Cassandra Ake

ca323@georgetown.edu

Chris Nicoletti

cnicoletti@ideglobal.org

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Appendix

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Estimating equations

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Outcome at the commune or district level

Whether iDE’s intervention took place in the province

Whether the observation is after the intervention

Whether WaterSHED’s intervention took place in province

Covariates at the commune or district levels

Estimating equation

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Outcome at the district level

Whether iDE’s intervention took place in the province

Whether the observation is after the intervention

Whether WaterSHED’s intervention took place in province

Covariates at the district level

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Latrine coverage Diarrhea prevalence

(1) (2) (3) (4) (5) (6)

Sanitation marketing target area 0.0338 -0.0410 0.0780 0.0540 0.0339 0.0266

(0.074) (0.055) (0.059) (0.036) (0.023) (0.018)

After 2012 0.119*** -0.00848 0.118*** 0.142*** -0.0139 -0.0103

(0.029) (0.032) (0.024) (0.027) (0.037) (0.031)

Sanitation marketing target area X after 2012 0.140** 0.199*** 0.0786 0.0322 -0.0735* -0.0653*

(0.051) (0.042) (0.049) (0.042) (0.043) (0.035)

Data source CSES CSES DHS DHS DHS DHS

Covariates includeda No Yes No Yes No Yes

Control meanc 0.189 0.189 0.214 0.214 0.169 0.169

Observations 1120 1100 335 321 335 321