A sanitation campaign in the Lao People’s Democratic Republic reveals that reducing open defecation has unexpected benefits across households and communities.
In 2001, the World Toilet Organization declared World Toilet Day, recognizing the critical role of toilets in promoting public health, human dignity, and personal safety. Since then, November 19 has been a global day for inspiring action to achieve Sustainable Development Goal 6: ensuring availability and sustainable management of water and sanitation for all.
In the two decades since the first World Toilet Day, the share of the global population without access to improved sanitation (facilities that hygienically prevent contact with excreta) has fallen from 39% to 14%. But nearly 700 million people still practice open defecation, and over 2 million deaths per year are caused by unsafe water or inadequate sanitation. These losses are heavily concentrated in rural areas.
Due to their remoteness and poverty, rural households lag behind their urban counterparts in access to hygienic sanitation facilities that prevent contact with human waste, such as flush toilets and septic tanks. This allows spread of infectious diseases, with dire health consequences.
In a previous blog post, we discussed how a large-scale subsidy experiment conducted in 160 villages of southern Lao People’s Democratic Republic increased toilet ownership caused a reduction in child stunting. The effect was driven by health spillovers – children did not benefit from their own household building a toilet per se. Rather, it was the toilet ownership of surrounding households that determined whether a child’s growth trajectory improved after the sanitation campaign.
A follow-up analysis of that experiment suggests that the benefits of the program extended beyond children’s health, and demonstrates how using safe toilets leaks positively into other dimensions of rural life. Rural households are not only disadvantaged when it comes to access to clean toilets: they are also less likely than urban households to have access to clean drinking water.
Only 74% of the world population has access to safely managed drinking water, and globally, access to an improved water source is ten percentage points higher for urban households than for rural households. In areas where clean, piped water is unavailable, purifying water (most efficiently by boiling, but also by chlorination, filtering, and other methods) is essential. The benefits of water treatment for child health in such settings are well-documented.
What is less researched is how improvements in sanitation and water treatment interact. Following the subsidy experiment, the share of households that owned a toilet increased from 45% to 62%, while the percentage of households that boiled water before drinking it declined from 60% to 45% - a rapid and large decline. The reduction was largely driven by poor households – those least likely to be able to afford bottled water.
Only 74% of the world population has access to safely managed drinking water.
In a vacuum, such a decline in water-boiling could be worrying. Boiling water is a critical preventative health measure where water supplies are unsafe. But our findings show that the reduction in water boiling was a direct and rational response to the improved coverage of sanitation. Evidence from the experiment reveals that households reduced their water boiling because sanitation had improved, and we infer that this was because households recognized that boiling water had become less important as the local environment improved.
The next question is whether this was a well-informed decision. Did the reduction in water-boiling offset the positive health impacts of improved sanitation? It appears not – households reduced water boiling behavior the most in villages where toilet coverage had increased the most, and where therefore the benefits from boiling water was lowest.
In any given context, the necessary preventative health behaviors evolve with the local environment. Smallpox vaccination was once an essential preventative health behavior, but it became obsolete when the disease was eradicated. Similarly, the importance of treating water declines as the quality of local environment improves.
Having established that the reduction in water-boiling did not have adverse health costs, we can reflect on what benefits may have resulted from this change in behavior. Much attention is rightly given to the burden of collecting water, which is a highly gendered activity in many developing countries.
According to UNICEF, in 80% of homes without running water, girls and women are responsible for collecting water. But the pursuit of clean drinking water in remote areas does not stop there. The responsibility of treating the collected water (whether by boiling or other methods) is time and energy intensive, requiring households to collect and chop wood, and also disproportionately falls on women. According to the Lao Expenditure and Consumption Survey (2018), women participate in 72% of households that collect firewood, and are solely responsible in 60% of households.
When households are spared from water-boiling by environmental improvements, there are both health benefits and economic benefits. Exactly how much time is saved, by whom, and to what activities that time is diverted would be a fascinating topic for further study.
In the meantime, the findings from this experiment in the Lao People’s Democratic Republic provide yet another example of how sanitation investments have wide-ranging benefits for rural development.