Public infrastructure and health in low- and middle-income countries

Public infrastructure provides the services that allow societies to function and economies to thrive. Economic research has been very useful at identifying the social returns to investing in public infrastructure, once projects are completed and in use. Yet, we know little about what made these infrastructure projects successful in improving living standards in the first place. A key policy question moving forward is not “how much” but “how well” we invest in public infrastructure. In thinking about the “how well”, we need to look at both supply and demand side factors during infrastructure development. This thesis explores these separate, but interlinked, research agendas in the form of three papers. The specific focus is on the sanitation market and its link to public health in low- and middle-income countries. In the first paper, “Can White Elephants Kill? Unintended Consequences of Infrastructure Development in Peru”, I analyse the consequences of a common inefficiency in the supply of public infrastructure: unfinished projects. I specifically evaluate the effect of unfinished sewerage projects on early-life mortality —the outcome this intervention aimed at improving— in Peru. I use an instrumental variable strategy, exploiting geographic characteristics and partisan alignment. The large variation in the number of unfinished projects is generated by the high prevalence of mid-construction abandonment and delays. I find that unfinished infrastructure —the so called “white elephants”— can cause high social costs: it can kill children. The mechanisms behind these non-trivial effects are: i) water cuts force the population to rely on unsafe sources of water and jeopardise their sanitation practices, (ii) open ditches filled with stagnant water become pools of infection, and together these cause (i) increased deaths due to water-borne diseases; and (iii) construction works increases deaths due to accidents. Finally, the results suggest that the social benefits of completed sewerage projects may not fully manifest due to less than universal connectivity rates. A natural question arising from the first paper is how to promote the use of public sanitation infrastructure once it is completed. In the second paper, “Challenges to Promoting Demand for Shared Infrastructure: Experimental Evidence from Slums in India”, I explore the demand-side of the sanitation market. In this co-authored chapter (with B. Augsburg and A. Armand), I specifically study the market of community toilets, which suffer from rampant free-riding and a remarkably low valuation and usage. We use a randomised field experiment to test the effectiveness of two interventions aimed at breaking the vicious cycle of low quality public health infrastructure and low willingness to pay: (i) a “supply push” that rehabilitates the infrastructure and promotes cleanliness; and (ii) a complementary campaign aimed at generating awareness of the importance of payment and the negative externalities resulting from unsafe sanitation behaviour. We find that externally funding public infrastructure rehabilitation backfires. The “supply push” reduces willingness to pay at a time when households appreciate improvements in infrastructure; and attitudes towards paying a user fee deteriorate further with time. In addition, the “supply push” shifts the demand for public intervention away from other pressing issues in the community towards the maintenance of community toilets. Altogether, these findings provide evidence that external funds crowd-out private contributions in our study context. The third paper titled "Running the Last Mile: Sewerage Connectivity Density and Child Height" provides a comprehensive picture of the sanitation market at the point at which supply meets demand for infrastructure. Even in “equilibrium”, achieving safe sanitation environments depends on three key factors: the local adoption level, the population density and the quality of the sanitation solution. In this paper, I aim to bring together these three factors by exploring the relationship between child health and the local connectivity density of sewerage —i.e. the interaction between the share of neighbouring households connected to sewerage and the population density. I specifically focus on height because it has been widely recognized as an important measure of human capital with long-lasting consequences. I present three complementary analyses: (i) a cross-country analysis among LMICs; (ii) a within-country analysis focusing specifically on Latin American countries; (iii) a withincountry analysis in Peru aimed at improving the internal validity of the association of interest using an instrumental variable strategy. I find that sewerage connectivity density increases child height. Interestingly, the increase goes beyond the sewerage connectivity of the child’s household, which serves as evidence of a positive externality. I document two mechanisms behind the results: improvements in the disease environment and malnutrition. The results also reveal that sewerage connectivity density decreases the mortality of children under the age of five. Altogether, the thesis suggests that while barriers to adequate supply and demand for sanitation infrastructure can pose threats to public health, once these are released, this infrastructure protects early life survival and promotes human capital accumulation

Exposure to sewage from on-site sanitation and child health: a spatial analysis of linkages and externalities in peri-urban Bolivia

Exposure to fecal contamination is a leading cause of childhood infectious diseases in low- and middle-income countries. Low-quality sanitation infrastructure and inadequate maintenance can make on-site solutions prone to spillage, exposing children to sewage. This paper uses a unique dataset with independent verification of sewage in and around the parcels of more than 20,000 houses with on-site sanitation in peri-urban Bolivia. We analyze the relationship between exposure to sewage from overflowed sanitation infrastructure and the incidence of diarrhea in children under age five. The presence of sewage is associated with a 4 percentage point increase in the probability of diarrhea incidence – a relative increase of 22%. This relationship is driven by sewage within the boundaries of the property where the child resides, which is associated with a relative increase of 30% in the probability of the incidence of diarrhea. Our spatial analysis of sewage density shows that the probability of the incidence of diarrhea increases with the concentration of sewage in the immediate vicinity of the child’s residence, suggesting negative spillovers from neighbors with overflowed on-site sanitation facilities. These potential negative health externalities provide a persuasive argument in favor of public interventions that adequately remove and treat fecal sludge

Experimental evidence from a mobile phone-based campaign in India

We investigate how religion concordance influences the effectiveness of preventive health campaigns. Conducted during the early stages of the COVID-19 pandemic in two major Indian cities marked by Hindu–Muslim tensions, we randomly assigned a representative sample of slum residents to receive either a physician-delivered information campaign promoting health-related preventive practices, or uninformative control messages on their mobile phones. Messages, introduced by a local citizen (the sender), were cross-randomized to start with a greeting signaling either a Hindu or a Muslim identity, manipulating religion concordance between sender and receiver. We found that doctor messages increased compliance with recommended practices and beliefs in their efficacy. Our findings suggest that the campaign’s impact is primarily driven by shared religion between sender and receiver, leading to increased message engagement and compliance with recommended practices. Additionally, we observe that religion concordance helps protect against misinformation.publishersversionpublishe

Countering misinformation with targeted messages: Experimental evidence using mobile phones

Widespread misconceptions can be critical, especially in times of crisis. Through a field experiment, we study how to address such wrong or inaccurate beliefs using messages delivered to individual citizens using mobile phones. We focus on misinformation related to the COVID-19 pandemic in a hard-to-reach population – India’s slum residents. We randomly allocate participants to receive voice and video messages introduced by a local citizen, the messenger, and in which medical practitioners debunk misconceptions. To understand the role of targeting, we randomly vary the signaled religious identity of the messenger into either Muslim or Hindu, guaranteeing exogenous variation in religion concordance between messenger and recipient. Doctor messages are effective at increasing knowledge of, and compliance with, COVID-19 policy guidelines. Changes in misconceptions are observed only when there is religion concordance and mainly for religious-salient misconceptions. Correcting misconceptions with information requires targeting messages to specific populations and tailoring them to individual characteristics. (JEL D04, D80, D83, I10, I15, Z12

COVID-19 vaccine acceptance and hesitancy in low- and middle-income countries

Widespread acceptance of COVID-19 vaccines is crucial for achieving sufficient immunization coverage to end the global pandemic, yet few studies have investigated COVID-19 vaccination attitudes in lower-income countries, where large-scale vaccination is just beginning. We analyze COVID-19 vaccine acceptance across 15 survey samples covering 10 low- and middle-income countries (LMICs) in Asia, Africa and South America, Russia (an upper-middle-income country) and the United States, including a total of 44,260 individuals. We find considerably higher willingness to take a COVID-19 vaccine in our LMIC samples (mean 80.3%; median 78%; range 30.1 percentage points) compared with the United States (mean 64.6%) and Russia (mean 30.4%). Vaccine acceptance in LMICs is primarily explained by an interest in personal protection against COVID-19, while concern about side effects is the most common reason for hesitancy. Health workers are the most trusted sources of guidance about COVID-19 vaccines. Evidence from this sample of LMICs suggests that prioritizing vaccine distribution to the Global South should yield high returns in advancing global immunization coverage. Vaccination campaigns should focus on translating the high levels of stated acceptance into actual uptake. Messages highlighting vaccine efficacy and safety, delivered by healthcare workers, could be effective for addressing any remaining hesitancy in the analyzed LMICs

COVID-19 vaccine acceptance and hesitancy in low- and middle-income countries

Widespread acceptance of COVID-19 vaccines is crucial for achieving sufficient immunization coverage to end the global pandemic, yet few studies have investigated COVID-19 vaccination attitudes in lower-income countries, where large-scale vaccination is just beginning. We analyze COVID-19 vaccine acceptance across 15 survey samples covering 10 low- and middle-income countries (LMICs) in Asia, Africa and South America, Russia (an upper-middle-income country) and the United States, including a total of 44,260 individuals. We find considerably higher willingness to take a COVID-19 vaccine in our LMIC samples (mean 80.3%; median 78%; range 30.1 percentage points) compared with the United States (mean 64.6%) and Russia (mean 30.4%). Vaccine acceptance in LMICs is primarily explained by an interest in personal protection against COVID-19, while concern about side effects is the most common reason for hesitancy. Health workers are the most trusted sources of guidance about COVID-19 vaccines. Evidence from this sample of LMICs suggests that prioritizing vaccine distribution to the Global South should yield high returns in advancing global immunization coverage. Vaccination campaigns should focus on translating the high levels of stated acceptance into actual uptake. Messages highlighting vaccine efficacy and safety, delivered by healthcare workers, could be effective for addressing any remaining hesitancy in the analyzed LMICs.Publisher PDFPeer reviewe

Can white elephants kill? Unintended consequences of infrastructure development

I provide evidence of the severe social costs imposed by infrastructure projects that are being implemented (i.e., projects started but not yet completed) in the context of sewerage in Peru. Using a counterfactual implementation predicted from geography-based cost considerations as an instrument, I show that implemented projects increase infant and under-five mortality. These results are driven by hazards, poor hygienic conditions and unsafe behavior, which increase deaths by waterborne diseases and accidents. Delays and mid-construction halting are common, and exacerbate the lethal effects of projects. Failing to take the implementation phase into account could severely bias the welfare evaluation of infrastructure