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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
2
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
113
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?
19
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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
Chris Nicoletti
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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
