# 1. INTRODUCTION

“I stuck my neck out today when I said we have to break taboos because people didn’t even mention the word toilet in the UN [United Nations] five years ago ... We need to break taboos ... We don’t speak about [defecation], there’s a shame factor which is horrible. It is the most natural of human needs, which causes enormous problems which relate both to health and dignity.”— Jan Eliasson UN Deputy Secretary-General on his speech at the World Water Week in Stockholm on September 2, 2013 to the Guardian.

This paper studies the causal effect of voice and accountability ( _Voice_ , henceforth), which broadly captures transparent electoral processes and free media and accountability, on the access to sanitation in developing countries.<sup>1</sup> The paper also investigates the effect of _Voice_ on rural/urban gaps in access to sanitation. We do so by: (1) estimating the effect of _Voice_ on the percentage of people using basic sanitation for 73 developing countries; (2) examining whether _Voice_ increases access to sanitation in rural and urban areas; and (3) investigating whether _Voice_ closes the persistent rural-urban gap in access to sanitation in developing countries. Our core argument is that _Voice_ increases sanitation’s visibility as a public good, raises awareness of its benefits to households who demand its production, and pushes governments to respond to pressure to increase the supply of sanitation.<sup>2</sup> We instrument for _Voice_ using the average years of schooling in 1900. We find that _Voice_ has a positive, statistically and economically significant effect on access to sanitation services. This positive effect generally holds true in urban and rural areas. The results are also robust to different model specifications and estimation methods. Furthermore, the results show that _Voice_ can be used as an effective vehicle to close the persistent rural-urban inequality in access to sanitation.

Access to sanitation, measured as the percentage of people using at least basic sanitation services—improved sanitation facilities that are not shared with other households—is fundamental to improved human health. This measure encompasses both people using basic sanitation services as well as those using safely managed sanitation services.<sup>3</sup> Recent updates of Sustainable Development Goal 6 (SDG 6) show that the developing world has seen significant progress in the number of people with access to sanitation.<sup>4</sup> However, globally, 3.6 billion people still live without access to basic sanitation, and approximately 8 percent of the world’s population still practice open defecation (United Nations, 2021). Furthermore, it is well-documented that the sanitation crisis is most acute in rural areas, home to 91 percent of the people who defecate in the open and 72 percent of those without basic sanitation. Additionally, the lack of access to sanitation poses a serious threat to vulnerable populations as it exposes them to serious environmental health risks (Alz ́ua, Djebbari, and Pickering, 2020). In fact, poor sanitation is a leading risk factor for infectious diseases, including cholera, diarrhoea, dysentery, hepatitis A, typhoid, and polio. There is also strong evidence that lack of access to sanitation exacerbates malnutrition, and in particular, childhood stunting (WHO , 2019).<sup>5</sup> Access to sanitation also improves education outcomes. For example, Adukia (2017) finds that latrine construction increases female school enrollment in India, particularly those who may be vulnerable to illnesses caused by uncontained waste. Similarly, Spears and Lamba (2016) find that early exposure to a sanitation campaign through India’s Total Sanitation

> 1Throughout the paper, we often use voice and accountability to also capture free media and transparent elections.

> 2This argument is in line with Kaufmann et al. (2019), who find evidence that suggests that “voice”-related variables such as citizen voice and transparency has a larger effect on the public sector service delivery performance and corruption. More practically, recent sanitation policy iterations have targeted demand for sanitation through media campaigns, capacity building, and community activities (Pakhtigian et al., 2022). The focus has shifted to education and communication, coupled with a continued emphasis on direct infrastructure provision and subsidization. 3We follow the World Health Organization’s (WHO) definition of sanitation as access to facilities for the safe disposal of human waste as well as having the ability to maintain hygienic conditions. Improved sanitation facilities include flush/pour flush to piped sewer systems, septic tanks or pit latrines; ventilated improved pit latrines, compositing toilets or pit latrines with slabs.

> 4See details on SDG 6 here: https://www.un.org/sustainabledevelopment/water-and-sanitation/ at United Nations.

> 5https://www.who.int/news-room/fact-sheets/detail/sanitation

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