# **VI. Implications and Concluding Remarks**

This paper estimates the impact of children’s exposure to unimproved sanitation early in life (at ages 1–2) on their primary school enrollment later in life (at ages 6–9) in Bangladesh. Children’s primary school enrollment is adversely affected by their earlier exposure to poor sanitary conditions. This is consistent with our hypothesis that children who suffer poor health due to their exposure to poor sanitation early in life are more likely to experience delayed school enrollment. Our results from the logistic regressions are robust to potential omitted variable biases, and placebo effects. They are further confirmed to be consistent through doubly robust causal estimations across multiple matched samples.

Two notable findings in our study merit further discussion. The first is that while exposure to poor sanitation early in life has a significant negative impact on primary school enrollment across the ages 6 to 9 years, the effect is stronger among children ages 6–7 than ages 8–9. This likely confirms our hypothesis that parents of children in poor health as a result of exposure to poor sanitation are motivated to delay enrolling their children in school until they are slightly older and healthier.

The second finding is that the effect of exposure to poor sanitation early in life is much stronger for children living in rural areas than for children in urban areas. In fact, the effect is statistically insignificant for children in urban areas. There are a few plausible explanations for this. One is the difference in the magnitude of health care coverage between the urban and rural areas. Because of a deficit of professional health care staff, it is estimated that close to 90 percent of the rural population in Bangladesh does not receive adequate health care. In urban areas, this share is estimated at 78 percent (Scheil-Adlung, 2015).<sup>26</sup> Fewer than 20 percent of the health care facilities across the country are providing services to more than 75 percent of the rural population (World Bank, 2015).<sup>27</sup> There appears to be a persistent “urban bias” in the government health care workforce (Ahmed et al., 2011). Moreover, there is also a significant gap in terms of the quality of water and sanitation facilities available between health care facilities in the urban and rural areas. Health care facilities in the rural areas, for example, are more susceptible to water shortages (World Bank, 2018). While urban health care facilities have almost universal sanitation coverage, the coverage for rural health care facilities is 85 percent. Thus, both the differences in availability and quality of health-care services across urban and rural areas could have confounded the effect of poor sanitation on school enrollment. The availability of health care services in urban areas, for example, would make it easier for parents to seek medical help, preventing their children from suffering longer-term health deficits.

> 26 Based on data collected in 2011.

> 27 It was also shown that the doctor-to-population ratio is 1:1,500 in urban areas, but it is 10 times worse in rural areas – 1:15,000 (Mabud 2005).

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