Title: Family and social effects on adoption of preventative health measures
Funder: Economic and Social Research Council

Abstract: The proposed research has both academic and policy objectives. Academic objectives: The overall academic objective of the proposed research is to gain a deeper understanding of the effect of social constraints on households' investments in preventive health in low-income settings. We will focus particularly on investments in sanitation in India. The research is structured around four distinct but inter-linked projects, each of which aims to make significant contributions to the economics, sanitation, global health, and, more broadly, development literatures. Through this combination of projects, we will be able to study the implications of different social constraints in the use of private and public sanitation facilities. The specific objectives are: 1. To shed light on the role of intra-household bargaining in the use of community toilets (CTs) in slums in 2 Indian cities. We will provide causal evidence on whether quality improvements of CTs and information campaigns on the benefits of CTs affect men's and women's willingness-to-pay (WTP) for CT use differently, and how this translates into actual use via intra-household bargaining. This first project will also make an important methodological contribution to the modelling of intra-household bargaining, by exploiting an unused feature of the data on men's and women's WTP for CT tickets. 2. To analyse couples' choices over making a large one-off preventive health investment (private household latrine) rather than repeated bargaining over small CT fees as in project 1. We will analyze whether the translation of sanitation microcredit into actual toilet investments differs depending on the couple's perceptions of costs and benefits of sanitation, and the women's bargaining power within the household. Both of these studies will have important implications for the targeting of sanitation interventions, including sanitation microfinance schemes. 3. To produce important understanding as to how leaders within microcredit groups affect whether and how microfinance (MF) joint-liability lending actually produces changes in sanitation investment, contributing to academic understanding of the role of leaders within MF groups in general, and in sanitation decisions in particular. 4. To advance our understanding of how the incentives of men, and in particular young men entering the marriage market, may be a key driver of sanitation investment decisions. Specifically, we will model and estimate how - anticipating the kinds of intra-household dynamics explored in studies 1 and 2 - sanitation may be used as a pre-marital investment strategy by grooms. This is again crucial for understanding the targeting of sanitation programmes, particularly at young men. We will disseminate our findings to academic audiences through workshops and conferences and academic papers. Policy objectives: In addition to making important academic contributions, a further objective is for generated evidence to support decision-making and intervention design and targeting within the sanitation sector, both within India and globally. It will thereby contribute to efforts of achieving universal and sustainable access to safe sanitation, again both within India and internationally. The Government of India (GoI) has endorsed the Sustainable Development Goals, including SDG 6 which calls for clean water and sanitation for all people, and aims to eliminate open defecation within its country long before the UN's goal of 2030. With sanitation taking centre-stage in India, the proposed research is therefore extremely timely. Moreover, each of the proposed projects has been motivated and shaped through long-standing and ongoing engagement with key sector stakeholders, including implementing agencies (WaterAid, FINISH, Grameen Koota) and funders (3ie, WB, BMGF). To achieve this impact, we will circulate findings through workshops, policy briefs, blog posts, and stakeholder meetings.

Lay abstract: 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).

Research activity codes: 3.1 PRIMARY PREVENTION INTERVENTIONS TO MODIFY BEHAVIOURS OR PROMOTE WELL-BEING;3.2 INTERVENTIONS TO ALTER PHYSICAL AND BIOLOGICAL ENVIRONMENTAL RISKS
Health categories: INFECTION