Publication: Effects of a Community-Driven Water, Sanitation, and Hygiene Intervention on Diarrhea, Child Growth, and Local Institutions: A Cluster-Randomized Controlled Trial in Rural Democratic Republic of Congo
Loading...
Date
2025-02-19
ISSN
Published
2025-02-19
Editor(s)
Abstract
Diarrhea and growth faltering in early childhood reduce survival and impair neurodevelopment. This paper assesses whether a national program in the Democratic Republic of Congo reduced diarrhea and stunting and strengthened local water and sanitation institutions. The program combined (i) funds for latrine and water upgrades, (ii) institutional strengthening activities, and (iii) behavior change campaigns. In 2018, the program was randomly assigned, after stratifying by province and cluster size, with 50 intervention and 71 control clusters. In 2022–23, 3,283 households were interviewed, at a median of 3.6 years post-intervention. The intervention had no effect on diarrhea and no effect on length-for-age Z-scores in children. Villages in the intervention group had a 0.40 higher score on the water, sanitation, and hygiene institutions index. The percentage of villages in the intervention group with an active water, sanitation, and hygiene (or just water) committee was 21 percentage points higher than the control group. Households in the intervention group were 24 percentage points more likely to report using an improved water source, 18 percentage points more likely to report using an improved sanitation facility, and reported more positive perceptions of water governance. The Democratic Republic of Congo’s national rural water, sanitation, and hygiene program increased access to improved water and sanitation infrastructure, and created new water, sanitation, and hygiene institutions, all of which persisted for more than three years. However, these effects were not sufficient to reduce diarrhea or growth faltering.
Link to Data Set
Citation
“Quattrochi, John P; Croke, Kevin; Dohou, Caleb; Stanus Ghib, Luca; Lokaya, Yannick; Coville, Aidan; Mvukiyehe, Eric. 2025. Effects of a Community-Driven Water, Sanitation, and Hygiene Intervention on Diarrhea, Child Growth, and Local Institutions: A Cluster-Randomized Controlled Trial in Rural Democratic Republic of Congo. Policy Research Working Paper; 11070. © World Bank. http://hdl.handle.net/10986/42845 License: CC BY 3.0 IGO.”
Associated URLs
Associated content
Other publications in this report series
Publication Intergenerational Income Mobility around the World(Washington, DC: World Bank, 2025-07-09)This paper introduces a new global database with estimates of intergenerational income mobility for 87 countries, covering 84 percent of the world’s population. This marks a notable expansion of the cross-country evidence base on income mobility, particularly among low- and middle-income countries. The estimates indicate that the negative association between income mobility and inequality (known as the Great Gatsby Curve) continues to hold across this wider range of countries. The database also reveals a positive association between income mobility and national income per capita, suggesting that countries achieve higher levels of intergenerational mobility as they grow richer.Publication Engineering Ukraine’s Wirtschaftswunder(Washington, DC: World Bank, 2025-07-29)As Ukraine emerges from the devastation of war, it faces a historic opportunity to engineer its own Wirtschaftswunder—a productivity-driven economic transformation akin to post-war West Germany. While investment-led growth may offer quick wins, it is efficiency, innovation, and institutional reform that will determine Ukraine’s long-term economic trajectory. Drawing on rich micro-level firm data spanning 25 years, this paper uncovers deep structural distortions that have suppressed creative destruction and productivity in Ukraine. It finds that business dynamism is on the decline, alongside rising market concentration among incumbent businesses, including low productivity state owned enterprises. To inform priorities for reviving business dynamism, this study develops a model of creative destruction drawing on Acemoglu et al. (2018) and Akcigit et al. (2021). The quantitative assessment highlights that policies that discipline entrenched incumbents are the bedrock for reviving business dynamism and engineer Ukraine’s Wirtschaftswunder. Policies targeting specific types of firms have limited efficacy when incumbents run wild.Publication Fiscal Multipliers in Resource-Rich Economies: Evidence from the Gulf Countries(Washington, DC: World Bank, 2025-08-21)This paper utilizes the unique dynamics of fiscal budgeting in countries with a large hydro-carbon sector to estimate fiscal multipliers. The main identifying assumption rests on the idea that exogenously identified global hydrocarbon demand shocks can be considered plausible instruments for the fiscal space of countries in which that space is significantly dictated by hydrocarbon income, with such shocks being uncorrelated with non-hydrocarbon output at the same time. Using a local projection-instrumental variables (LP-IV) framework, the paper estimates that short-run fiscal expenditure multipliers to be in the ballpark of 0.1–0.4. In addition, the findings show that multipliers are at the upper end of this interval during recessions, indicating that fiscal policy in the Gulf countries is particularly effective during economic downturns.Publication Stress Testing Survey to Survey Imputation: Understanding When Poverty Predictions Can Fail(Washington, DC: World Bank, 2025-08-21)Accurate and timely poverty measurement is central to development policy, yet the availability of up-to-date high-quality household survey data remains limited—particularly in countries where poverty is most concentrated. Survey-to-survey imputation has emerged as a practical response to this challenge, allowing practitioners to update poverty estimates using recent surveys that lack direct welfare measures by borrowing information from other comprehensive surveys. A critical review of the method is provided, revisiting its statistical underpinnings and testing its limitations through extensive model-based simulations. Through these simulations, the analysis demonstrates how violations of parameter stability, omitted variable bias, and shifts in survey design can introduce substantial errors—particularly when imputing across time or under economic and structural change. Results show that standard corrections such as re-weighting or covariate standardization may fail to eliminate these biases, especially when imputing across time or under structural change. The performance of alternative model specifications is also evaluated under various methods, including performance under heteroskedastic errors, non-normality. The findings offer practical guidance for practitioners on when survey-to-survey imputation is likely to succeed, when it should be reconsidered, and how to communicate its limitations transparently in the context of poverty monitoring and policy design.Publication The Future of Poverty(Washington, DC: World Bank, 2025-07-15)Climate change is increasingly acknowledged as a critical issue with far-reaching socioeconomic implications that extend well beyond environmental concerns. Among the most pressing challenges is its impact on global poverty. This paper projects the potential impacts of unmitigated climate change on global poverty rates between 2023 and 2050. Building on a study that provided a detailed analysis of how temperature changes affect economic productivity, this paper integrates those findings with binned data from 217 countries, sourced from the World Bank’s Poverty and Inequality Platform. By simulating poverty rates and the number of poor under two climate change scenarios, the paper uncovers some alarming trends. One of the primary findings is that the number of people living in extreme poverty worldwide could be nearly doubled due to climate change. In all scenarios, Sub-Saharan Africa is projected to bear the brunt, contributing the largest number of poor people, with estimates ranging between 40.5 million and 73.5 million by 2050. Another significant finding is the disproportionate impact of inequality on poverty. Even small increases in inequality can lead to substantial rises in poverty levels. For instance, if every country’s Gini coefficient increases by just 1 percent between 2022 and 2050, an additional 8.8 million people could be pushed below the international poverty line by 2050. In a more extreme scenario, where every country’s Gini coefficient increases by 10 percent between 2022 and 2050, the number of people falling into poverty could rise by an additional 148.8 million relative to the baseline scenario. These findings underscore the urgent need for comprehensive climate policies that not only mitigate environmental impacts but also address socioeconomic vulnerabilities.
Journal
Journal Volume
Journal Issue
Collections
Related items
Showing items related by metadata.
Publication Water, Sanitation and Hygiene : Interventions and Diarrhoea(World Bank, Washington, DC, 2004-07-01)Many individual studies have reported results of interventions intended to reduce illness through improvements in drinking water, sanitation facilities and hygiene practices. This paper provides a formal systematic review and meta-analysis examining the evidence of the effectiveness of these interventions. Through a comprehensive literature search and bibliographic review, 2120 titles published prior to June 26th, 2003 were screened, 336 papers were obtained for a more thorough examination, and 64 of these papers (representing 60 distinct studies) were identified which detailed water supply, water quality, sanitation, hygiene or multifactorial interventions and examined diarrhoea morbidity as a health outcome in non-outbreak conditions. Data were extracted from these papers and pooled through meta-analysis to provide summary estimates of the effectiveness of each type of intervention. All interventions reduced diarrhoea morbidity, with pooled risk ratios ranging from 0.98 to 0.51 (where a risk ratio of 1.0 indicates no effect and lower risk ratios indicate stronger effects). The removal of poor quality studies from the analyses improved the strength of the intervention impact in most cases. The 95 percent confidence intervals (CIs) for the pooled risk ratios of various interventions overlapped, indicating their effects were not statistically significantly different from each other.Publication Promoting Handwashing and Sanitation : Evidence from a Large-Scale Randomized Trial in Rural Tanzania(World Bank Group, Washington, DC, 2015-01)The association between hygiene, sanitation, and health is well documented, yet thousands of children die each year from exposure to contaminated fecal matter. At the same time, evidence on the effectiveness of at-scale behavior change interventions to improve sanitation and hygiene practices is limited. This paper presents the results of two large-scale, government-led handwashing and sanitation promotion campaigns in rural Tanzania. For the campaign, 181 wards were randomly assigned to receive sanitation promotion, handwashing promotion, both interventions together, or neither. One year after the end of the program, sanitation wards increased latrine construction rates from 38.6 to 51 percent and reduced regular open defecation from 23.1 to 11.1 percent. Households in handwashing wards show marginal improvements in handwashing behavior related to food preparation, but not at other critical junctures. Limited interaction is observed between handwashing and sanitation on intermediate outcomes: wards that received both handwashing and sanitation promotion are less likely to have feces visible around their latrine and more likely to have a handwashing station close to their latrine facility relative to individual treatment groups. Final health effects on child health measured through diarrhea, anemia, stunting, and wasting are absent in the single-intervention groups. The combined-treatment group produces statistically detectable, but biologically insignificant and inconsistent, health impacts. The results highlight the importance of focusing on intermediate outcomes of take-up and behavior change as a critical first step in large-scale programs before realizing the changes in health that sanitation and hygiene interventions aim to deliver.Publication Water, Sanitation, and Hygiene(Washington, DC, 2003-11)Better hygiene and access to drinking water and sanitation will accelerate progress toward two millennium development goals (MDGs): 'reduce under-five child mortality rate by 2/3 between 1990 and 2015' and "by 2015 halve the proportion of people without sustainable access to safe drinking water and basic sanitation". Meeting the latter goal will require infrastructure investments of about US$23 billion per year, to improve water services for 1.5 billion more people (292,000 people per day) and access to safe sanitation for 2.2 billion additional people (397,000 per day). Water supply, sanitation, and hygiene are about more than health. Saved time, particularly for women and children, is a major benefit. Beneficiaries of water and sanitation projects in India reported these benefits: less tension/conflict in homes and communities; community unity, self-esteem, women's empowerment (less harassment) and improved school attendance (Water Aid 2001). Improved hygiene (hand washing) and sanitation (latrines) have more impact than drinking water quality on health outcomes, specifically reductions in diarrhea, parasitic infections, morbidity and mortality, and increases in child growth (Esrey et al 1991; Hutley et al 1997). Most endemic diarrhea is not water-borne, but transmitted from person to person by poor hygiene practices, so an increase in the quantity of water has a greater health impact than improved water quality because it makes it possible (or at least more feasible) for people to adopt safe hygiene behaviors (Esrey et al 1996).Publication Papua New Guinea : Sanitation, Water Supply and Hygiene in Urban Informal Settlements(Washington, DC, 2014-10)In 2012 Papua New Guinea undertook a national Service Delivery Assessment of rural water, rural sanitation, urban water and urban sanitation services to identify coverage and targets, how well services are being delivered and the financing shortfalls in these subsectors. Immediately following this assessment, stakeholders, through a national policy task force, have developed a draft of the country s first National Water, Sanitation and Hygiene (WASH) Policy. During the course of the assessment and policy development, peri-urban and informal settlements have been consistently identified as areas which are underserviced and overlooked for water and sanitation services. The need to provide affordable and appropriate services in settlements, as well as improve health and living conditions, was highlighted. Amongst stakeholders, it was agreed that baseline information on WASH conditions in settlements was needed in order to develop strategies and to respond appropriately to needs of settlements in the future. Previous settlement research has focused on urbanization, housing ownership, land issues, employment, and anthropology, but WASH has not been researched specifically or in depth. Therefore in 2014, the Water and Sanitation Program of the World Bank (WSP), together with key stakeholders, conducted research in informal settlements in the capital Port Moresby and a representative provincial town (Wewak) to understand the conditions, aspirations, barriers and opportunities to improve water, sanitation and hygiene for informal settlers.Publication Promoting Handwashing Behavior in Peru : The Effect of Large-Scale Mass-Media and Community Level Interventions(World Bank, Washington, DC, 2012-11)This paper analyzes a randomized experiment that uses novel strategies to promote handwashing with soap at critical times in Peru. It evaluates a large-scale intervention that includes a mass media provincial campaign and a district-level community component. The analysis finds that the mass media intervention alone had no significant effect on exposure to the handwashing promotion campaign messages, and therefore no effect on handwashing knowledge or handwashing behavior. In contrast, the community-level intervention, a more comprehensive intervention that included several community and school activities in addition to the communications campaign, was successful in reaching the target audience with handwashing promotion messages and in improving the knowledge of the treated population on appropriate handwashing behavior. Those improvements translated into higher self-reported and observed handwashing with soap at critical junctures. However, no significant improvements in the health of children under the age of five were observed. The results are consistent with earlier literature, which indicates that substantively changing behavior to improve health is a complex task requiring intensive and more personalized interventions.
Users also downloaded
Showing related downloaded files
Publication Business Ready 2024(Washington, DC: World Bank, 2024-10-03)Business Ready (B-READY) is a new World Bank Group corporate flagship report that evaluates the business and investment climate worldwide. It replaces and improves upon the Doing Business project. B-READY provides a comprehensive data set and description of the factors that strengthen the private sector, not only by advancing the interests of individual firms but also by elevating the interests of workers, consumers, potential new enterprises, and the natural environment. This 2024 report introduces a new analytical framework that benchmarks economies based on three pillars: Regulatory Framework, Public Services, and Operational Efficiency. The analysis centers on 10 topics essential for private sector development that correspond to various stages of the life cycle of a firm. The report also offers insights into three cross-cutting themes that are relevant for modern economies: digital adoption, environmental sustainability, and gender. B-READY draws on a robust data collection process that includes specially tailored expert questionnaires and firm-level surveys. The 2024 report, which covers 50 economies, serves as the first in a series that will expand in geographical coverage and refine its methodology over time, supporting reform advocacy, policy guidance, and further analysis and research.Publication Digital Progress and Trends Report 2023(Washington, DC: World Bank, 2024-03-05)Digitalization is the transformational opportunity of our time. The digital sector has become a powerhouse of innovation, economic growth, and job creation. Value added in the IT services sector grew at 8 percent annually during 2000–22, nearly twice as fast as the global economy. Employment growth in IT services reached 7 percent annually, six times higher than total employment growth. The diffusion and adoption of digital technologies are just as critical as their invention. Digital uptake has accelerated since the COVID-19 pandemic, with 1.5 billion new internet users added from 2018 to 2022. The share of firms investing in digital solutions around the world has more than doubled from 2020 to 2022. Low-income countries, vulnerable populations, and small firms, however, have been falling behind, while transformative digital innovations such as artificial intelligence (AI) have been accelerating in higher-income countries. Although more than 90 percent of the population in high-income countries was online in 2022, only one in four people in low-income countries used the internet, and the speed of their connection was typically only a small fraction of that in wealthier countries. As businesses in technologically advanced countries integrate generative AI into their products and services, less than half of the businesses in many low- and middle-income countries have an internet connection. The growing digital divide is exacerbating the poverty and productivity gaps between richer and poorer economies. The Digital Progress and Trends Report series will track global digitalization progress and highlight policy trends, debates, and implications for low- and middle-income countries. The series adds to the global efforts to study the progress and trends of digitalization in two main ways: · By compiling, curating, and analyzing data from diverse sources to present a comprehensive picture of digitalization in low- and middle-income countries, including in-depth analyses on understudied topics. · By developing insights on policy opportunities, challenges, and debates and reflecting the perspectives of various stakeholders and the World Bank’s operational experiences. This report, the first in the series, aims to inform evidence-based policy making and motivate action among internal and external audiences and stakeholders. The report will bring global attention to high-performing countries that have valuable experience to share as well as to areas where efforts will need to be redoubled.Publication Global Economic Prospects, January 2025(Washington, DC: World Bank, 2025-01-16)Global growth is expected to hold steady at 2.7 percent in 2025-26. However, the global economy appears to be settling at a low growth rate that will be insufficient to foster sustained economic development—with the possibility of further headwinds from heightened policy uncertainty and adverse trade policy shifts, geopolitical tensions, persistent inflation, and climate-related natural disasters. Against this backdrop, emerging market and developing economies are set to enter the second quarter of the twenty-first century with per capita incomes on a trajectory that implies substantially slower catch-up toward advanced-economy living standards than they previously experienced. Without course corrections, most low-income countries are unlikely to graduate to middle-income status by the middle of the century. Policy action at both global and national levels is needed to foster a more favorable external environment, enhance macroeconomic stability, reduce structural constraints, address the effects of climate change, and thus accelerate long-term growth and development.Publication State and Trends of Carbon Pricing 2024(Washington, DC: World Bank, 2024-05-21)This report provides an up-to-date overview of existing and emerging carbon pricing instruments around the world, including international, national, and subnational initiatives. It also investigates trends surrounding the development and implementation of carbon pricing instruments and some of the drivers seen over the past year. Specifically, this report covers carbon taxes, emissions trading systems (ETSs), and crediting mechanisms. Key topics covered in the 2024 report include uptake of ETSs and carbon taxes in low- and middle- income economies, sectoral coverage of ETSs and carbon taxes, and the use of crediting mechanisms as part of the policy mix.Publication Global Economic Prospects, June 2025(Washington, DC: World Bank, 2025-06-10)The global economy is facing another substantial headwind, emanating largely from an increase in trade tensions and heightened global policy uncertainty. For emerging market and developing economies (EMDEs), the ability to boost job creation and reduce extreme poverty has declined. Key downside risks include a further escalation of trade barriers and continued policy uncertainty. These challenges are exacerbated by subdued foreign direct investment into EMDEs. Global cooperation is needed to restore a more stable international trade environment and scale up support for vulnerable countries grappling with conflict, debt burdens, and climate change. Domestic policy action is also critical to contain inflation risks and strengthen fiscal resilience. To accelerate job creation and long-term growth, structural reforms must focus on raising institutional quality, attracting private investment, and strengthening human capital and labor markets. Countries in fragile and conflict situations face daunting development challenges that will require tailored domestic policy reforms and well-coordinated multilateral support.