Referee Report
Sanitation, Financial Incentives and Health Spillovers: A Cluster Randomized Trial
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Overview
Most developing nations are affected by poor sanitation and its negative consequences. The paper also examines the health effects of improved sanitation through financial subsidies in terms of kids’ growth and the degree of health spillovers. The article thus conducted a clustered randomized test in 160 communities in Lao PDR to assess the effectiveness of using both financial incentives and Community-Led Total Sanitation (CLTS), which is a largely used behavior change program. The paper then located villages into four groups randomly, provided them with CLTS but used different types of subsidy (none, village, household, or both). The paper accomplished its aim by using data from a random sample of the household to indicate that household incentives improved sanitation mainly amongst the non-poor. The findings of the paper indicate that improved sanitation results in positive health spillovers, where it ked to a 10 percent point upsurge in the sanitation of the village that reduced the likelihood of childhood stunting by 3% points.
Contribution
This paper is not the first to address this issue as it builds on the research carried by Guiteras et al. (2015), who assessed the work of consumer subsidies used along with an NGO-implemented CLTS program that was carried out in Bangladesh. The article’s main contribution is that they have examined household investment in enhanced sanitation in response to much smaller grants in the framework of a large, government-funded initiative. The article compares with other research such as Gertler et al. (2015) that also used randomized intercessions to assess the form of this relationship and found a linear connection between community open defecation rate and child height. However, the paper goes further and examines the exogenic village-level variation produced by their experimental design to assess whether the public toilet coverage produces health externalities. The paper is good for the journal where it was submitted as unlike most of the research that is observative, the article exploits randomized interventions.
Data
The authors of the article use quantitative data to answer their research questions. The data used is statistical and is typically designed making the study defined and rigid. The article uses numbers and values to measure data, making the paper warrant its publication. The paper uses 160 randomly assigned villages to one of four equally-sized treatment groups entailing 40 people each. The article conducted a longitudinal household survey of 2,400 households where each home must have had at least one child below two years at baseline. These data are particularly well-suited to answer the research questions as the research questions are close-ended. The data used in this paper is unique as it can be analyzed statistically using regression analysis. The paper also used administrative data provided by the Ministry of Health to estimate the analog of the equation and estimate the effect of incentives of village-level sanitation.
Mechanisms
I find the research paper and the story the authors are telling reliable as it has utilized other mechanisms other than observational analysis. The results provided in this article support the conclusion from other researches that even small incentives might have a hugely positive effect on the uptake of healthier traits in areas with poor resources. Some of the previous studies with a similar story include Morris et al. (2004) and Benerjee et al. (2010). Also, the village estimates used in this paper are most directly comparable with the findings from their representative sample and state that the paper’s small subsidy increased toilets ownership by a similar amount. The authors have made the best use of their data as they have answered all the research questions in detail. The mechanisms explore is the right ones as the authors further compare their data with non-experimental studies such as that carried out by Harris et al. (2017) and Fuller et al. (2016) that researched the effect of coverage with a radius of between 200 to 500 of a particular household respectively. The story told by the authors is compelling as it has found a linear relationship between stunting for age and community coverage suggesting the existence of constant returns on investment in sanitation at the village level. There are no plausible stories that emerge from the article as despite using point estimates twice as large as those used by Gertler et al. (2015), both results are similar.
8 Threats to Validity
The most significant assumption embedded in the empirical strategy is that the authors use large point estimates of the household toilet, corresponding to a 19 %-point decrease in the probability of stunning. As such, the paper, as with height-for-age z-score (HAZ), does not have sufficient precision to reject this null hypothesis. This assumption may be violated as it can be said to be lacking compelling evidence to support similar non-experimental studies due to the use of large points of estimates. Apart from comparing it with one other similar research Gertler et al. (2015), the paper does not include robustness checks. The paper only relies on the randomized distribution of the incentives as instruments for village reporting. As such, the lack of exhaustive robustness checks does not therefore adequately address potential violations. There might be an issue of loss of statistical power caused by the much-reduced sample size in the case of stunting.
9 Comments/Questions
The authors have not omitted any keywords in their literature review. The tables and graphs are self-contained and easy for the reader to follow. The research paper would have been better served if there were additional graphs and tables and especially on village estimates. The paper is well-written and easy to comprehend as it is clear and well defines. However, the paper requires an additional explanation of the vocabulary and regression analysis used, to make it more clear to the reader. Given the number of villages, more tables and graphs would have made the data more valid. Finally, all the policy implications of the paper have been spelled out especially concerning the funding of the projects. The article also observed ethical measures such as seeking approval from the National Ethics Committee for Health Research, especially for the randomized samples. All parties involved in conducting the research have been mentioned for clarity.
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