Investment in health within the agriculture, water, sanitation and hygiene nexus for rural households in Bangladesh

Abstract

Water, sanitation and hygiene (WASH) related burden of disease is one of the most important aspects of human capital formation. As WASH is a system issue, it needs to be investigated with many other complementary factors to establish the possible synergy effects with nutrition and human capital. By identifying the possible linkage between WASH and nutrition, this thesis strives to identify the impact of improved water infrastructure and behavioural change investment on health and nutrition. In doing so, it investigates the impact of publicly supplied piped water on water and food quality, health, and child nutrition for rural households in north-western Bangladesh. Having examined the ineffectiveness of the piped water on health and nutrition, this study applies a Randomized Controlled Trial (RCT) experiment of Food Hygiene Education (FHE) to the rural households to evaluate how behavioural change investment towards WASH could benefit health and nutrition. <br /> Using a nationally representative panel data of rural Bangladesh, the first analytical chapter finds that improved water and sanitation infrastructure is found to reduce diarrhoea related morbidity and the level of malnutrition in children under-five. Moreover, education, household dietary diversity score and water purification are found to improve diarrhoea and child nutrition but are sensitive to the maintenance of proper hygiene and cleanliness. In addition, irrigating poses some risks and increases diarrhoea incidence, possibly because the situation is worsened if adequate hygiene and water purification are not practiced. Having livestock in the household plays a positive role in reducing malnutrition if and only if the personal, food and environmental hygiene standards are maintained properly. Therefore, it is the hygiene level which mostly matters for reduction of malnutrition even after controlling for the other household characteristics such as household size, income, education and location. For maintaining proper hygiene, investment is required for personal, food and environmental cleanliness.<br /> One such investment is in the area of access to clean drinking water. In the next chapter, the study uses propensity score matching to investigate the association between a public piped water infrastructure programme (BMDA) and gains in water-sanitation, hygiene and health outcomes in north-western Bangladesh. In terms of food safety, there is no evidence of improvement in the quality of drinking water, measured by E. coli count per 100 ml of water at the point of use (i.e. the pots and jars used to store it). Food utensils were tested positive for E. coli in both the control and treatment group, thus showing no improvement through the BMDA intervention. Hygiene behaviour such as handwashing with soap after defecation or before feeding children also does not improve. In addition, the study finds no evidence of health benefits, such as decreased diarrhoea incidence in children under-five or improved nutritional outcomes such as stunting, underweight and wasting. Although access to BMDA piped water in the premises is subject to a fee, it seems this incentive mechanism is not strong enough to improve water behaviour or its outcomes: treated households are as poor as the non-treated in terms of maintaining hygiene and water quality, possibly because of a lack of information. <br /> Consequently, the final chapter presents an RCT experiment of FHE. It aims to fill the information gap between the households and identify potential changes in water, sanitation and hygiene related behaviour in the marginalized rural households in the same communities of north-western Bangladesh. The treatment combines three elements - microbiological test results of contamination from E. coli bacteria in drinking water and on food preparing utensils, training to maintain food hygiene at the household level and a poster of hygiene messages to be hung in the dining area. The evidence suggests that the FHE treatment has a positive impact on the microbiological quality of drinking water and kitchen utensils. The percentage of households with E.coli in the drinking water was reduced after one and two months of intervention, compared with the control group. Households’ hygiene practices and cleanliness have increased significantly in the treated households without significant increases in the costs of water, sanitation infrastructure and related investment. In this randomized phased-in evaluation, the former treated households reduced the incidence of child diarrhoea and significantly reduced child wasting by 5% in the two month period compared to the later treated households. The FHE experiment thus results in positive health and nutritional gain for children under-five in the rural households. However, the study only investigates the impact over a two month period. The long term outcomes of FHE are unknown and require further research.