The Impact of Pro-Poor Sanitation Subsidies in Open Defecation-Free Communities: A Randomized, Controlled Trial in Rural Ghana.

BACKGROUND: According to the World Health Organization/United Nations International Children's Fund Joint Monitoring Program, 494 million people practice open defecation globally. After achieving open defecation-free (ODF) status through efforts such as Community-Led Total Sanitation (CLTS), communities (particularly vulnerable households) may revert to open defecation, especially when toilet collapse is common and durable toilets are unaffordable. Accordingly, there is increasing interest in pro-poor sanitation subsidies. OBJECTIVES: This study determined the impacts of a pro-poor sanitation subsidy program on sanitation conditions among the most vulnerable households and others in the community. METHODS: In 109 post-ODF communities in Northern Ghana, we conducted a cluster randomized controlled trial to evaluate a pro-poor subsidy program that identified the most vulnerable households through community consultation to receive vouchers for durable toilet substructures. We surveyed households to assess toilet coverage, quality, and use before and after the intervention and tracked program costs. RESULTS: Overall, sanitation conditions deteriorated substantially from baseline to endline (average of 21 months). In control communities (not receiving the pro-poor subsidy), open defecation increased from 25% (baseline) to 69% (endline). The subsidy intervention attenuated this deterioration (open defecation increased from 25% to only 54% in subsidy communities), with the greatest impacts among voucher-eligible households. Noneligible households in compounds with subsidized toilets also exhibited lower open defecation levels owing to in-compound sharing (common in this context). CLTS followed by the subsidy program would benefit more households than CLTS alone but would cost 21-37% more per household that no longer practiced open defecation or upgraded to a durable toilet. DISCUSSION: Sanitation declines, often due to toilet collapse, suggest a need for approaches beyond CLTS alone. This subsidy program attenuated declines, but durable toilets likely remained unaffordable for noneligible households. Targeting criteria more closely aligned with sanitation inequities, such as household heads who are female or did not complete primary education, may help to generate greater and more sustainable impacts in Northern Ghana and, potentially, other contexts facing toilet collapse and limited market access. https://doi.org/10.1289/EHP10443.

Strategic complements: Poverty-targeted subsidy programs show additive benefits on household toilet purchases in rural Cambodia when coupled with sanitation marketing.

While poverty-targeted subsidies have shown promise as a means of reducing financial constraints on low-income populations to invest in new latrines, concerns have been raised about whether they may reduce demand for new latrines among non-eligible, non-poor populations, especially in geographically limited or closed markets. Using quasi experimental methods, we investigate the interaction effects of the "CHOBA" subsidy, a partial poverty-targeted monetary incentive to build a toilet, and a sanitation marketing program (SanMark) on new latrine uptake among households from different income segments in 110 rural villages across six Cambodian provinces. These programs were implemented either jointly with or independently. Overall, we find strong complementarity of the CHOBA subsidy with SanMark where the coupled implementation of the programs increased latrine uptake across all households as compared to exclusive deployment of the programs independently. Additionally, the CHOBA subsidy alone resulted in higher gains among the poor compared to SanMark suggesting that financial constraint is indeed a significant demand barrier for new latrines. The presence of the poverty-targeted subsidies did not reduce demand for new latrine purchases among ineligible households. Instead, we find some evidence for a positive spillover effect of subsidies on uptake of latrines among ineligible households in villages where both programs were implemented indicating that the presence of sanitation subsidies and the decision to purchase latrines among non-beneficiaries can be viewed as complements. We employ multivariate logistic regressions as well as further robustness checks to estimate the effects of the different interventions, with qualitatively consistent results.

Sanitation, financial incentives and health spillovers: A cluster randomised trial.

Poor sanitation and its consequent negative health outcomes continue to plague the developing world. Drawing on the finding that financial subsidies have changed behaviour in other health contexts, we conducted a clustered randomised trial in 160 villages in Lao PDR to evaluate the effectiveness of combining financial incentives with Community-Led Total Sanitation (CLTS), a widely-conducted behaviour change program. Villages were randomly allocated to four groups, all of which received CLTS but differed in the type of subsidy offered (none, household, village or both). Using data from a random sample of households with young children and village administrative data, we show that household incentives increased sanitation take-up among the poor, whereas a village incentive increased take-up primarily among the non-poor. Improved sanitation produced positive health spillovers - a 10 percentage point increase in village sanitation coverage decreased the probability of childhood stunting by 3 percentage points.

Where Does CLTS Work Best? Quantifying Predictors of CLTS Performance in Four Countries.

Improving the effectiveness of rural sanitation interventions is critical for meeting the United Nations' Sustainable Development Goals and improving public health. Community-led total sanitation (CLTS) is the most widely used rural sanitation intervention globally; however, evidence shows that CLTS does not work equally well everywhere. Contextual factors outside the control of implementers may partially determine CLTS outcomes, although the extent of these influences is poorly understood. In this study, we investigate the extent to which 18 contextual factors from readily available datasets can help predict the achievement and sustainability of open-defecation-free (ODF) status in Cambodia, Ghana, Liberia, and Zambia. Using multilevel logistic regressions, we found that the predictors of CLTS performance varied between countries, with the exception of small community size. Accessibility and literacy levels were correlated with CLTS outcomes, but the direction of correlation differed between countries. To translate findings into practical guidance for CLTS implementers, we used classification and regression trees to identify a "split point" for each contextual factor significantly associated with ODF achievement. We also identified the combinations of factors conducive to a minimum of 50% ODF achievement. This study demonstrates that publicly available, high-resolution datasets on accessibility, socioeconomic, and environmental factors can be leveraged to target CLTS activities to the most favorable contexts.

Exploring the Use and Appeal of Playpens to Protect Infants from Exposure to Animals, Animal Feces, and Dirt in Rural Ethiopia.

The persistence and pervasiveness of growth stunting in low- and middle-income countries spur reexamination of disease transmission pathways related to water, sanitation, and hygiene. Animal feces constitute a more important reservoir of enteric pathogens in homes in low-income countries than previously recognized, and exploratory object mouthing and direct ingestion of soil and animal feces represent underexplored exposure pathways. The effectiveness, adoption, constraints, and scale-up potential of measures for reducing infant and young children's exposure to fecal pathogens are recently beginning to be systematically explored. This mixed methods study tested the feasibility and appeal of using playpens to establish a hygienic "safe zone" for infants in rural Ethiopia. We conducted home trials of three playpen designs, including two models made from locally available materials through user-centered design. After using playpens for several weeks, caregivers reported extensive benefits, ranging from perceived safety to developmental and hygiene benefits for infants and relief from physical stress and worry for caregivers. We observed many playpens contaminated with Escherichia coli after weeks of use, though at concentrations below those of the common room floor on which infants might otherwise have played. Caregivers reported daily playpen use, but for intervals likely insufficient to protect infants from pathogen exposure affecting growth. We determine that playpens alone cannot plausibly protect infants from environmental contamination, but our results support further exploration of the potential benefits and commercial viability of scaling up use of playpens in rural, agricultural households as part of a comprehensive approach to child development and women's empowerment.

Urban Water Services in Fragile States: An Analysis of Drinking Water Sources and Quality in Port Harcourt, Nigeria, and Monrovia, Liberia.

Establishing and maintaining public water services in fragile states is a significant development challenge. In anticipation of water infrastructure investments, this study compares drinking water sources and quality between Port Harcourt, Nigeria, and Monrovia, Liberia, two cities recovering from political and economic instability. In both cities, access to piped water is low, and residents rely on a range of other private and public water sources. In Port Harcourt, geographic points for sampling were randomly selected and stratified by population density, whereas in Monrovia, locations for sampling were selected from a current inventory of public water sources. In Port Harcourt, the sampling frame demonstrated extensive reliance on private boreholes and a preference, in both planned and unplanned settlements, for drinking bottled and sachet water. In Monrovia, sample collection focused on public sources (predominantly shallow dug wells). In Port Harcourt, fecal indicator bacteria (FIB) were detected in 25% of sources (N = 566), though concentrations were low. In Monrovia, 57% of sources contained FIB and 22% of sources had nitrate levels that exceeded standards (N = 204). In Monrovia, the convenience of piped water may promote acceptance of the associated water tariffs. However, in Port Harcourt, the high prevalence of self-supply and bottled and sachet drinking water suggests that the consumer's willingness to pay for ongoing municipal water supply improvements may be determined by service reliability and perceptions of water quality.

Explaining low rates of sustained use of siphon water filter: evidence from follow-up of a randomised controlled trial in Bangladesh.

OBJECTIVE: To assess sustained siphon filter usage among a low-income population in Bangladesh and study relevant motivators and barriers. METHODS: After a randomised control trial in Bangladesh during 2009, 191 households received a siphon water filter along with educational messages. Researchers revisited households after 3 and 6 months to assess filter usage and determine relevant motivators and barriers. Regular users were defined as those who reported using the filter most of the time and were observed to be using the filter at follow-up visits. Integrated behavioural model for water, sanitation and hygiene (IBM-WASH) was used to explain factors associated with regular filter use. RESULTS: Regular filter usage was 28% at the 3-month follow-up and 21% at the 6-month follow-up. Regular filter users had better quality water at the 6-month, but not at the 3-month visit. Positive predictors of regular filter usage explained through IBM-WASH at both times were willingness to pay >US$1 for filters, and positive attitude towards filter use (technology dimension at individual level); reporting boiling drinking water at baseline (psychosocial dimension at habitual level); and Bengali ethnicity (contextual dimension at individual level). Frequently reported barriers to regular filter use were as follows: considering filter use an additional task, filter breakage and time required for water filtering (technology dimension at individual level). CONCLUSION: The technological, psychosocial and contextual dimensions of IBM-WASH contributed to understanding the factors related to sustained use of siphon filter. Given the low regular usage rate and the hardware-related problems reported, the contribution of siphon filters to improving water quality in low-income urban communities in Bangladesh is likely to be minimal.

Learning to dislike safe water products: results from a randomized controlled trial of the effects of direct and peer experience on willingness to pay.

Low-cost point-of-use (POU) safe water products have the potential to reduce waterborne illness, but adoption by the global poor remains low. We performed an eight-month randomized trial of four low-cost household water treatment products in Dhaka, Bangladesh. Intervention households (n = 600) received repeated educational messages about the importance of drinking safe water along with consecutive two-month free trials with each of four POU products in random order. Households randomly assigned to the control group (n = 200) did not receive free products or repeated educational messages. Households' willingness to pay for these products was quite low on average (as measured by bids in an incentive-compatible real-money auction), although a modest share was willing to pay the actual or expected retail price for low-cost chlorine-based products. Furthermore, contrary to our hypotheses that both one's own personal experience and the influence of one's peers would increase consumers' willingness to pay, direct experience significantly decreased mean bids by 18-55% for three of the four products and had no discernible effect on the fourth. Neighbor experience also did not increase bids. Widespread dissemination of safe water products is unlikely until we better understand the preferences and aspirations of these at-risk populations.

What point-of-use water treatment products do consumers use? Evidence from a randomized controlled trial among the urban poor in Bangladesh.

BACKGROUND: There is evidence that household point-of-use (POU) water treatment products can reduce the enormous burden of water-borne illness. Nevertheless, adoption among the global poor is very low, and little evidence exists on why. METHODS: We gave 600 households in poor communities in Dhaka, Bangladesh randomly-ordered two-month free trials of four water treatment products: dilute liquid chlorine (sodium hypochlorite solution, marketed locally as Water Guard), sodium dichloroisocyanurate tablets (branded as Aquatabs), a combined flocculant-disinfectant powdered mixture (the PUR Purifier of Water), and a silver-coated ceramic siphon filter. Consumers also received education on the dangers of untreated drinking water. We measured which products consumers used with self-reports, observation (for the filter), and chlorine tests (for the other products). We also measured drinking water's contamination with E. coli (compared to 200 control households). FINDINGS: Households reported highest usage of the filter, although no product had even 30% usage. E. coli concentrations in stored drinking water were generally lowest when households had Water Guard. Households that self-reported product usage had large reductions in E. coli concentrations with any product as compared to controls. CONCLUSION: Traditional arguments for the low adoption of POU products focus on affordability, consumers' lack of information about germs and the dangers of unsafe water, and specific products not meshing with a household's preferences. In this study we provided free trials, repeated informational messages explaining the dangers of untreated water, and a variety of product designs. The low usage of all products despite such efforts makes clear that important barriers exist beyond cost, information, and variation among these four product designs. Without a better understanding of the choices and aspirations of the target end-users, household-based water treatment is unlikely to reduce morbidity and mortality substantially in urban Bangladesh and similar populations.

End-user preferences for and performance of competing POU water treatment technologies among the rural poor of Kenya.

Household point-of-use (POU) water treatment technologies targeted at vulnerable populations are microbiologically effective and, in small trials, improve health. We do not understand the factors that influence preference for and adoption of these technologies by target end-users. We cycled 400 rural subsistence farm households in western Kenya through three randomly ordered two-month trials of three POU products: dilute hypochlorite solution, porous ceramic filtration, and a combined flocculant-disinfectant powdered mixture to compare relative end-user preferences and usage. Households reported higher usage of both dilute hypochlorite and filters than the flocculant-disinfectant. Averaged among all participating households, Escherichia coli reductions in treated water were generally higher among those that received dilute hypochlorite solution than among those receiving either of the other two products. Among those households that self-reported product usage, the E. coli reductions achieved by dilute hypochlorite and the flocculant-disinfectant are statistically equivalent to one another and higher than the reductions achieved by filters. At the same time, households ranked filters most frequently as their most preferred product.