Évaluation des stratégies pour réduire l'arsenic - Recherche en IA spécialisée au MIT

Évaluation des stratégies pour réduire l'arsenic
Poisoning in South Asia: A View
from the Social Sciences
Matthew Krupoff, Ahmed Mushfiq Mobarak, et
Alexander van Geen∗

The World Health Organization has
labeled the problem of arsenic
contamination of groundwater in South Asia as “the largest mass poisoning in
human history.” Various technical solutions to the problem fall into one of two
broad categories: (je) cleaning contaminated water before human consumption
et (ii) encouraging people to switch to less contaminated water sources.
In this paper, we review research on the behavioral, sociale, politique, et
economic factors that determine the ﬁeld-level effectiveness of the suite of
technical solutions and the complexities that arise when scaling such solutions
to reach large numbers of people. We highlight the conceptual links between
arsenic-mitigation policy interventions and other development projects in
Bangladesh and elsewhere, as analyzed by development economists, that can
shed light on the key social and behavioral mechanisms at play. We conclude
by identifying the most promising policy interventions to counter the arsenic
crisis in Bangladesh. We support a national well-testing program combined with
interventions that address the key market failures (affordability, coordination
failures, and elite and political capture of public funds) that currently prevent
more deep-well construction in Bangladesh.

Mots clés: arsenic, health behavior, water quality
Codes JEL: I12, O15, Q53

je. Introduction

Much of the world’s disease burden is due to environmental threats (Pruss-
Ustun and Corvalan 2006). People often respond to environmental health risks
by adopting technologies that reduce the risk (Pattanayak and Pfaff 2009). Pour
example, people can invest in preventive health products such as bed nets to reduce

∗Matthew Krupoff: Yale University, Yale Research Initiative on Innovation and Scale (Y-RISE); Ahmed
Mushﬁq Mobarak (corresponding author): Yale University, Y-RISE; Deakin University; Center for Economic Policy
Research; and National Bureau of Economics Research. E-mail: ahmed.mobarak@yale.edu; Alexander van Geen:
Columbia University. Alexander van Geen’s arsenic-related research has been supported by NIEHS grant P42
ES010349, NSF grant ICER1414131, and several grants from the Earth Institute at Columbia University. We would
like to thank the managing editor and the anonymous referee for helpful comments and suggestions. The Asian
Development Bank recognizes “Orissa” as Odisha. The usual ADB disclaimer applies.

Revue du développement en Asie, vol. 37, Non. 2, pp. 21–44
https://doi.org/10.1162/adev_a_00148

© 2020 Asian Development Bank and
Asian Development Bank Institute.
Publié sous Creative Commons
Attribution 3.0 International (CC PAR 3.0) Licence.

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22 Revue du développement en Asie

their risk of malaria or chlorine tablets to reduce the risk of acute gastrointestinal
diseases like diarrhea. Arsenic contamination of drinking water is one such
important challenge, and this paper describes the scope of that problem, technique
solutions that can reduce contamination, and the design of policies to encourage
widespread adoption of a solution that could effectively address this public health
threat.

An estimated 45 million Bangladeshis consumed drinking water with arsenic
concentration levels exceeding what is deemed dangerous to the human body
according to a report published in 2009 (Bangladesh Bureau of Statistics and
UNICEF 2011). The World Health Organization (WHO) referred to chronic
exposure to arsenic from drinking well water in Bangladesh as “the largest mass
poisoning of a population in history” (Forgeron, Lingas, and Rahman 2000). Comme
a response, the government and various nongovernment organizations (NGOs)
have implemented strategies to mitigate exposure to arsenic. Some of the initial
attempts at arsenic mitigation focused on the technological aspects of arsenic
removal. These efforts can only be successful to the extent that the technology
is widely implemented by policy makers and/or adopted and used by households
drinking contaminated water. Complexities in implementation, the political calculus
of policy makers, coordination failures in the community, or simply household
aversion to behavior change can undermine the promise of technically effective
solutions.

Certain ﬁelds within social science, such as development economics and
behavioral economics, have developed insights that can help us understand the
sources of aversion to behavior change and the challenges of implementing
technically effective solutions. Par exemple, economic analysis can shed light on
the reasons for low demand for point-of-use ﬁlters despite their apparent large
beneﬁts. Mechanism design can be used to overcome collective action failures. Et
randomized controlled trials and other techniques can be used to rigorously evaluate
the effects of policy interventions and advise policy makers on the strategies that
work best.

This paper analyzes the behavioral, économique, and institutional challenges of
implementing arsenic mitigation interventions and identiﬁes solutions that appear
most promising according to the evidence base. The interventions we review fall
under two broad classes of strategies: (je) either remove arsenic from contaminated
water before it enters the human body or (ii) encourage consumers to switch to a
different water source with a lower arsenic concentration. The paper also discusses
the complexities of scaling up arsenic-mitigation interventions to address the needs
of tens of millions of people.

This paper is organized as follows. Section II provides a background on
the arsenic poisoning crisis in South Asia and other parts of the world. Section
III discusses the two thematic behavioral strategies to reduce arsenic exposure,
potential solutions that fall under these strategies, challenges in implementation,

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Évaluation des stratégies visant à réduire l'empoisonnement à l'arsenic en Asie du Sud 23

and interventions that overcome those challenges backed by empirical evidence.
Section IV discusses the complexities of scaling interventions that address the issue.
Section V concludes with policy recommendations.

II. Background

Arsenic contamination is not unique to Bangladesh, but it is the most affected
country in the world by far. Arsenic is naturally released into groundwater by
Himalayan sediments. Par conséquent, the groundwater in many countries in South
and Southeast Asia (including India, Myanmar, Nepal, Pakistan, Cambodia, le
Lao People’s Democratic Republic, and Viet Nam) is contaminated to some degree
(Ravenscroft, Brammer, and Richards 2009). Bangladesh is especially affected,
with an estimated 45 million Bangladeshis consuming drinking water with arsenic
concentration exceeding the WHO guideline of 10 micrograms per liter (Smedley
and Kinniburgh 2002; Fendorf, Michael, and van Geen 2010).

There was a massive shift toward groundwater in Bangladesh in the 1970s
and 1980s due to public health concerns about bacterial contamination of surface
water sources. Excess infant mortality from diarrheal diseases, cholera, et autre
waterborne illnesses led governments, international donors, and NGOs to undertake
massive programs promoting shallow tube-well installation across the country to
reach aquifers free of pathogens.

The presence of arsenic in groundwater was ﬁrst noted in the early 1980s
in the geologically similar neighboring Indian state of West Bengal, when visible
manifestations of the disease were identiﬁed and attributed to water from shallow
tube wells (Chakraborty and Saha 1987). It was not until the late 1990s when the
scale of the problem was fully understood, prompting massive public health action
by the Government of Bangladesh and multinational organizations like the World
Bank to test tube wells across the country (Dhar et al. 1997). Par 2005, 1.4 million
shallow wells with groundwater with an arsenic concentration above Bangladesh’s
drinking water standard of 50 micrograms per liter were painted red; another 3.5
million wells that were below the contamination threshold were painted green. La plupart
tube wells have been replaced since then and very few were ever retested after the
national testing campaign ended in 2005 (Ahmed et al. 2006, van Geen et al. 2016).
Some early efforts to mitigate the arsenic crisis focused on switching from
groundwater to surface water from hand-dug wells, rainwater storage devices,
et (ﬁltered) pond and river water (Ahmad, Khan, and Haque 2018). Whereas
switching to surface water sources can reduce arsenic consumption, it can also
have the unintended consequence of increasing the risk of disease through fecal
contamination (Lokuge et al. 2004, Howard et al. 2006, Johnston et al. 2014).

The health impacts of chronic arsenic exposure are severe (Vahter et al.
2010). It is estimated that 6% of total mortality in Bangladesh is due to chronic

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24 Revue du développement en Asie

exposure to arsenic (Flanagan et al. 2012). The main cause of the excess mortality
is cardiovascular disease and not the types of cancer that researchers have linked
to arsenic elsewhere (Forgeron, Lingas, and Rahman 2000; Chen et al. 2011). Chronic
exposure has also been linked to increases in stillbirths, infant mortality, and motor
and intellectual impairment of children (Wasserman et al. 2004, Parvez et al. 2011,
Quansah et al. 2015).

Arsenic exposure negatively affects productivity. Pitt, Rosenzweig, et
Hassan (2020) estimate that reducing Bangladeshi arsenic retention to United
States levels would, on average, increase household income by 9% per male
worker. Flanagan et al. (2012) estimate that arsenic-related mortality is expected
to cost Bangladesh $12.5 billion from lost productivity over the next 20 années. The authors base this estimate on the productivity loss associated with deaths from the types of cancer known to be related to arsenic poisoning. Cependant, this may be an underestimation because this economic loss does not account for health-care expenditures and other costs to society. III. Strategies to Reduce Arsenic Consumption Solutions that reduce arsenic in the water supply involve different categories of interventions as well as coordination between policy makers, implementers, communautés, and end users. There are two broad strategies to address arsenic poisoning. The ﬁrst is to clean the contaminated water before it enters the body by means of technological solutions like ﬁltration systems. The second is to have people switch to clean sources of water by means of well testing and building low- arsenic deep tube wells. Both strategies require households to change their behavior. Barriers to a household’s willingness to invest in preventive health products, coordination failures, and political economy factors are all challenges that must be addressed through careful policy design. Removing arsenic from water or inducing people to switch to cleaner sources may require households to invest resources into buying water ﬁlters or installing deeper wells. Research by development economists in a variety of settings has found puzzlingly low rates of preventive health investments among poor households despite the long-run beneﬁts (Kremer and Miguel 2007; Ashraf, Berry, and Shapiro 2010; Meredith et al. 2013). Factors such as liquidity constraints, information failures, peer effects, and intra-household conﬂicts over health are found to be responsible for the low demand (Brun, Mobarak, and Zelenska 2014). These barriers to technology adoption will be discussed in more detail in the following sections as they relate to speciﬁc arsenic mitigation approaches. We will highlight successful policy interventions that have managed to overcome such barriers in other settings. l Téléchargé à partir du site Web : / / direct . m je t . / e du a d e v / art – pdlf / / / / / 3 7 2 2 1 1 8 4 6 8 0 8 a d e v _ a _ 0 0 1 4 8 pd . f par invité 0 7 Septembre 2 0 2 3 Évaluation des stratégies visant à réduire l'empoisonnement à l'arsenic en Asie du Sud 25 Some solutions require community members to make collective decisions on the locations of clean water sources and to coordinate community contributions in cash, labor, and maintenance (Cocciolo, Habib, and Tompsett 2019). Failure to coordinate between group members, such as free riding, can hurt the long-run sustainability of community-based programs. Public goods are sometimes delivered in a decentralized way where investments are delegated to local governments. Par exemple, decisions about deep tube wells in Bangladesh—wells over 150 meters that are low in arsenic— are delegated to and ﬁnanced by local governments. Decentralization of service delivery is thought to be efﬁcient because local governments may have more accurate local information to better target services (World Bank 2003). Cependant, taking a decentralized approach in rural communities with poverty, socioeconomic inequality, and a lack of political awareness can lead to distortions in targeting toward elites (Bardhan and Mookherjee 2000). UN. Cleaning Up before It Enters the Body Filtering methods to clean contaminated water was promoted by the National Arsenic Mitigation Policy in response to the discovery of arsenic in well water. Pond sand ﬁlters and small community slow sand ﬁlters were promoted because they could purify readily available surface water from ponds and rivers. Cependant, support for sand ﬁltration diminished because of the susceptibility to fecal contamination (Howard et al. 2006). Early efforts to remove the arsenic from groundwater using large arsenic removal plants were ineffective in reducing arsenic poisoning due to technical problems and poor maintenance (Hossain et al. 2005). Some household-level ﬁltration devices may be effective, but demand for such products is low. Community ﬁltration systems that serve large numbers of people are promising, provided that maintenance efforts are properly coordinated. This section will go over these options, their challenges, and recommendations. 1. Point-of-Use Treatment Point-of-use arsenic puriﬁcation ﬁlters—such as SONO water ﬁlters, three- pitcher ﬁlters, and READ-F ﬁlters—have been shown to effectively reduce arsenic levels (Hussam and Munir 2007, Sutherland et al. 2002). Cependant, ﬁeld tests have found disappointing results on their adoption and usage (Johnston, Hanchett, and Khan 2010). One example is Sanchez et al. (2016), who provided households with READ-F ﬁlters—an easy-to-use device that ﬁlters arsenic from shallow well water—and encouraged their use over the 6-month duration of the intervention. Initially, participants showed a reduction in urinary arsenic levels, which is an objective indicator of intake and exposure. Cependant, the beneﬁts eroded over time l D o w n o a d e d f r o m h t t p : / / direct . m je t . / e du a d e v / art – pdlf / / / / / 3 7 2 2 1 1 8 4 6 8 0 8 a d e v _ a _ 0 0 1 4 8 pd . f par invité 0 7 Septembre 2 0 2 3 26 Asian Development Review and arsenic in urine returned to preintervention levels by the end of the study period. After 1 année, 95% of the ﬁlters had been abandoned. More research is needed to ascertain how much households are willing to pay for point-of-use ﬁlters for arsenic removal and how to encourage their use. Research on other water puriﬁcation products have shown that demand has been low among poor households (Ahuja, Kremer, and Zwane 2010). In Ghana, Par exemple, Berry, Fischer, and Guiteras (2019) measured the demand for Kosim water ﬁlters, which are effective at removing more than 99% of E. coli in trials. Their assessment found that households are willing to pay only 10%–15% of the cost of manufacturing and delivery. De la même manière, Ahuja et al. (2010) found low willingness to pay for point-of- use chlorine treatment in Kenya when households were given coupons to redeem at local stores. Liquidity constraints are cited as a key reason why demand for health products in developing countries is low despite their high beneﬁts. People in poor rural areas may not have the liquidity necessary to pay large lump-sum costs for preventive health products. Par exemple, SONO ﬁlters which remove arsenic through chemical reactions with iron, cost about $40 (Hussam and Munir 2007).
High prices and the low willingness to pay suggest that price subsidies may
be a sensible policy to increase the adoption of point-of-use ﬁlters. However—
in addition to concerns about the ﬁscal capacity to provide subsidies—there
are concerns that lower prices may affect how people value the product and
subsequently use them. The psychological bias called the sunk cost fallacy posits
that higher prices cause people to value a product more than if they got it free.
Screening effects are when higher prices screen buyers who place a relatively high
valuation on a product and thus would likely use it more than someone who is less
willing to pay (Thaler 1980, Bagwell and Riordan 1991).

The Read-F ﬁlters used in Sanchez et al. (2016) were provided for free
and the low usage they observe may lend support to concerns about sunk cost
fallacy and screening effects. Cependant, without observing adoption decisions under
experimentally varied prices, this remains inconclusive. Field experiments that
explicitly test for sunk cost fallacy and screening effects suggest that these concerns
are unfounded (Ashraf, Berry, and Shapiro 2010).

Information failures may cause people to underestimate the true
beneﬁts of certain decisions from school choice or adopting new agricultural
technologie. Households may thus underinvest
in preventive health decisions
because they lack information about health risks (Somanathan 2010). There is some
evidence that providing information about water quality increases adoption of water
ﬁlters. In India, Jalan and Somanathan (2008) found that 45% of those surveyed
did not equate contaminated water with diarrhea. The researchers tested the water
and informed a randomly selected group of households about the contamination
status and the various puriﬁcation methods that are available. Households with
contaminated water increased efforts to purify water before consumption once

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Évaluation des stratégies visant à réduire l'empoisonnement à l'arsenic en Asie du Sud 27

they were informed. Information programs have also been designed for arsenic
mitigation in Bangladesh and have proven to be highly effective in reducing
consumption through inducing households to switch to cleaner wells (Madajewicz
et autres. 2007).

Community Filtration Systems

Centralized community-based water treatment systems are an alternative to
household point-of-use ﬁlters. These can supply arsenic-free water to around 100–
200 families (German et al. 2019, Sarkar et al. 2010). Current units can produce up
à 1 million liters of clean water before needing replacement (Sarkar et al. 2010).
Community ﬁltration systems have certain advantages over household ﬁlters. Pour
example, arsenic levels are easier to monitor with centralized ﬁltration systems
because the tests only need to be administered at one community unit, instead
of household ﬁlter units that are spread out. Centralized systems also make it
easier to coordinate proper waste disposal compared to household ﬁlters (Johnston,
Hanchett, and Khan 2010). Cependant, the high cost and regular maintenance needs
lead to concerns about long-run sustainability. This has led to concerns about the
capacity of governments and NGOs to successfully deliver services.

Certain institutional arrangements in which community members organize
funds and provide maintenance may address sustainability issues with rural water
infrastructure. In such arrangements, village water committees collect small fees
from villagers that contribute to the cost of maintenance. Maintenance itself is
conducted by caretakers who are appointed by the committee. In some models,
committees have little explicit public authority for revenue collection, but such
cases do not show promising results. Par exemple, Miguel and Gugerty (2005)
report
que 50% of borehole wells in Kenya that were maintained using a
community-based maintenance model on a voluntary basis were inoperable by
2000. In rural Tanzania, free riding and a lack of coordinated maintenance
decisions decreased the functionality rate of NGO-installed clean water pumps
and consequently lowered rates of child survival and school attendance (O’Keeffe-
O’Donovan 2019).

then it becomes difﬁcult

Clean water is a public good and maintaining it has positive externalities
for other people in the community. If there are coordination failures and
free riding,
to maintain quality under community-
based arrangements. Many community-level interventions experience coordination
difﬁculties. One example is community toilets in India, where a study showed
that one in six toilet seats was entirely nonusable (J-PAL 2012). Communal
arrangements must be structured to ensure that incentives are correctly aligned, et
the community can monitor its members (Duﬂo, Galiani, and Mobarak 2012).

Some evidence suggests that private contracting maintenance systems are an
efﬁcient way of maintaining water sources (Kremer et al. 2011). For point-of-source

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28 Revue du développement en Asie

chlorine dispensers in Kenya, Ahuja et al. (2010) found that paying contractors
to maintain the system increased the level of maintenance signiﬁcantly. Water
collection fees can discourage free riding, leading to an increase in functionality
(O’Keeffe-O’Donovan 2019). Current community-based ﬁltration systems that
charge user fees as low as $0.15–$0.30 a month and compensate unit caretakers have
been found to be ﬁnancially sustainable and lead to local job growth (German et al.
2019). Complementing a system with delivery services can also increase demand
and revenue generation (Johnston, Hanchett, and Khan 2010; Sarkar et al. 2010;
German et al. 2019).

Switch to Groundwater That Is Already Low in Arsenic

The second strategy to mitigate arsenic poisoning is to encourage people to
switch from a high-arsenic water source to a clean water source. Individuals choose
their water source to maximize their welfare subject to the constraints they face and
their information set. Consuming arsenic-contaminated water may be indicative of
information failures or a lack of alternative clean water sources. Par exemple, depuis
arsenic levels in groundwater vary greatly over small distances, informing people
of the status of their wells can induce them to switch to neighboring clean wells.
Heureusement, concentrations of arsenic usually do not change over time, bien que
some aquifers and wells need to be monitored more frequently than others (Fendorf,
Michael, and van Geen 2010). Increasing a household’s access to clean water by
installing new low-arsenic deep tube wells is also a strategy worth considering.

Information and Testing

People may drink from contaminated wells if they lack information about
the arsenic concentration in their shallow well relative to other nearby wells. Le
distribution of arsenic in groundwater varies greatly, even over small distances
and most owners live within walking distance of an uncontaminated well. Testing
the groundwater concentration is therefore essential to provide the necessary
information for people to switch (van Geen et al. 2002).

Arsenic tests are attractive because of the low cost to administer them. Dans
previous interventions, the cost of a simple test was as low as $2.30, with the cost of supplies only amounting to $0.30 per test. Because of the large health consequences
of chronic exposure to arsenic, simply providing information through arsenic tests
can therefore be a highly cost-effective intervention as long as people respond to the
new information. Evaluations show that providing test data to households, in some
cases along with various forms of reinforcement, has induced between one-quarter
and one-half of exposed households to stop using contaminated wells (Madajewicz
et autres. 2007, Bennear et al. 2013, Balasubramanya et al. 2014, Pfaff et al. 2017).

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Évaluation des stratégies visant à réduire l'empoisonnement à l'arsenic en Asie du Sud 29

One issue with arsenic tests is how they should be provided and who should
provide them. Public provision has not met the needs for testing. Recent estimates
show that despite the national well-testing campaign between 2000 et 2005, à
least one-half of the currently used tube wells in Bangladesh have never been tested
for arsenic (van Geen et al. 2014, Jamil et al. 2019). National testing campaigns
have not been repeated and most wells have by now been replaced and therefore
were never tested.

Private testing may be a useful complement to public provision. The prospect
of a private market for arsenic testing can induce local entrepreneurs to identify
untested wells and market their services (Barnwal et al. 2017). Despite the low
coût, poor households may not be able to afford arsenic test kits. An evaluation
in the neighboring Indian state of Bihar shows that while demand for test kits is
substantial, it is also highly price sensitive: the take-up level falls from 69% à 22%
when cost increases from $0.16 à $0.80. This steeply downward-sloping demand
curve is reminiscent of the elastic demand for other effective preventive health-
care products such as insecticide-treated bed nets and deworming pills (Kremer and
Miguel 2007, Cohen and Dupas 2010). Subsidizing testing kits may be efﬁcient
policy if encouraging initial usage helps neighbors learn about the value of testing
and increases the demand for future testing. Barnwal et al. (2017) ﬁnd that demand
for test kits rose from 27% à 45% within 2 years of the initial subsidy campaign
without any change in the nominal sales price.

Households will switch away from contaminated to cleaner wells after testing
only if they know about the health consequences of arsenic in the ﬁrst place.
Interventions that combine tests with education about arsenic poisoning have been
shown to increase switching (George et al. 2013, Chen et al. 2007, Pfaff et al. 2017).
Par exemple, Khan et al. (2015) found higher switching rates among children after
an arsenic education curriculum designed to raise awareness of arsenic poisoning
was administered in elementary schools in Araihazar, Bangladesh.

Tests are commonly provided by representatives from organizations outside
of the village who leave once tests are administered, leaving little opportunity
to reinforce that information. Training community members to deliver arsenic
education concurrently with testing may be a more cost-effective way to monitor
arsenic levels and reinforce information about health consequences. Such types
of community health worker programs are a widely used intervention to improve
the quality of health-care services—from health education to family planning and
distribution of preventive care products—around the world. Cependant, in one study,
engaging community members did not decrease arsenic exposure any more than
outside testers (George et al. 2012). Poor monitoring and a lack of incentives—
common problems with other community health worker programs—may have been
a reason why there was no difference. Providing monetary incentives to health
workers, or better monitoring, may help improve performance and lead to better
résultats (Björkman et al. 2017, BenYishay and Mobarak 2019).

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30 Revue du développement en Asie

2. Well-Sharing Arrangements

Many shallow wells are privately owned, and arsenic concentration levels
vary between wells; donc, exposure varies from household to household.
Sharing arrangements between owners of clean shallow wells and owners of dirty
wells can increase the proportion of the population consuming clean water. Tel
arrangements are possible in areas where houses are geographically close to one
another and people interact on a regular basis, which is often the case in small
village economies (Barnwal et al. 2017). Cependant, households may not be willing
to share with people outside their social network and low-income households may
be less able to barter for access to a neighbor’s clean well than households that
are better off (Madajewicz et al. 2007). Social constraints may also be important
determinants of water source usage (Mosler, Blochliger, and Inauen 2010; Inauen
et autres. 2013). Households with unsafe wells have also been found to purposefully
conceal the results of the test, suggesting that social stigma could partially be to
blame (although this could also be explained by concerns that the reveal would
lower property value) (Barnwal et al. 2017).

These results suggest

that we need to design mechanisms that are
cognizant of such social constraints. Par exemple, combining testing with a group
commitment component where groups of households make a public commitment to
their group before seeing test results—that if their well is tested and found clean,
then they would promise to share water with those who have unclean wells—can
address free riding and aversions to water sharing. If households are risk averse, alors
such a “risk-sharing contract” with ex ante commitments can improve joint welfare
for the group of households and help to develop positive social norms about water
sharing. Tarozzi et al. (2020) test this theory through a randomized controlled trial
in Sonargaon, Bangladesh in which groups of buyers were offered tests and asked
to sign an informal agreement about sharing water from their clean wells with those
who had negative well-testing results. This form of soft commitment showed higher
switching rates to clean water from dirty water among those who received a negative
result compared to the treatment group where well tests were done at the individual
level.

Public commitments have been shown to be effective in changing behavior,
having been tested for other public health goals such as latrine adoption. Pour
example, community-led total sanitation programs are an intervention aimed at
changing social norms about open defecation by having communities pledge
to become open-defecation-free. Bakhtiar, Guiteras, and Mobarak (2019) show
that combining a form of a community-led total sanitation program, dans lequel
community members make public pledges in front of their neighbors, was effective
in increasing the adoption of latrines when compared to private pledges and group-
level ﬁnancial incentives. In the context of arsenic, Inauen et al. (2014) show that
public commitments enhance the effects of information on well switching.

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Évaluation des stratégies visant à réduire l'empoisonnement à l'arsenic en Asie du Sud 31

Installing Deeper Wells

In addition to well testing and well sharing, another promising approach is
to install wells that reach deeper aquifers where arsenic concentrations are lower.
In some areas, such aquifers are accessible at a depth of less than 90 meters and
therefore reachable by local drillers using manual methods (Gelman et al. 2004).
In one study area, many households switched to private intermediate-depth wells
in response to early well testing in 2003 (Jamil et al. 2019). Cependant, the cost
of well construction increases linearly with well depth, and installation costs at
this depth reach $200 per well. Estimates from blanket well tests in Araihazar, Bangladesh suggest that digging these expensive wells may still have positive net beneﬁts since around 60,800 inhabitants experienced reduced exposure through this form of mitigation at an average cost of $28 par personne.

Interventions to alleviate liquidity constraints may be necessary to help
households afford the installation costs. En particulier, providing microcredit to
ﬁnance large purchases can enable households to invest and reap the long-run
beneﬁts. Credit provision can increase investments in preventive health. In India,
providing access to microconsumer loans for insecticide-treated bed nets led to a
large increase in uptake (Tarozzi et al. 2014). In Morocco, providing households
access to credit to purchase a home water connection from a local water utility
company led to 69% of households buying a connection, compared to just 10% in a
control group (Devoto et al. 2012). In Cambodia, microloans signiﬁcantly increased
the willingness to pay for household latrines by 45 percentage points compared to a
control group without the option to ﬁnance (BenYishay et al. 2017).

If there are learning externalities, then subsidies can induce others to
subsequently adopt. Understanding the social dynamics of demand is useful
to target subsidies efﬁciently. Par exemple, targeting well subsidies to certain
groupes, such as highly inﬂuential people in a social network or people of lower
socioeconomic status, can lead to greater subsequent adoption if neighbors learn
more about the beneﬁts and costs of the new technology, or by changing social
norms. Social learning appears to have been important for nontraditional cookstove
adoption in Bangladesh, where households made inferences about the new stoves
based on information from people in their social network (Miller and Mobarak
2015). It was also relevant for hygienic latrines in Bangladesh (Guiteras, Levinsohn,
and Mobarak 2019).

Deep tube wells that are deeper than 150 meters are more consistently low in
arsenic but beyond the ﬁnancial reach of most households. A deep tube well, quand
properly located, can meet the needs of several hundred villagers for years while
requiring little maintenance (van Geen et al. 2003). Sur 200,000 deep wells were
installed as of 2007 by both NGOs and the Government of Bangladesh (Department
of Public Health Engineering and Japan International Cooperation Agency 2009).
Despite their engineering promise, the installation costs, inclusive of labor and

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32 Revue du développement en Asie

materials, can reach up to $850, which is beyond what most rural households can afford (Ravenscroft et al. 2014). Private deep wells therefore do not seem to be a feasible solution absent ﬁnancial support or encouraging community members to pool their resources to jointly invest and share the well water. Khan et al. (2014) ﬁnd that households are willing to pay on average 5% of their disposable annual household income for a communal deep-well fund. Variation in willingness to pay across households implies that one needs to solve a complicated problem to determine how much each member should be asked to contribute. There are nontrivial challenges to successfully coordinating investments across households. Cocciolo, Habib, and Tompsett (2019) found that in a community-based program where members collectively made funding, location, and maintenance decisions for deep tube wells, larger groups led to fewer households participating in community meetings and less time spent deliberating over source location. En outre, they found that fewer households contributed to the cost of installation. Par conséquent, larger groups saw smaller increases in the use of deep wells compared to smaller groups. More empirical evidence is needed about the drivers of collective action failure and on how community networks change as interventions scale. The choice of where to place deep wells creates important complexities. Over half of the deep wells that have been installed by governments and NGOs were sited in areas where the prevalence of contaminated shallow wells is modest (Department of Public Health Engineering and Japan International Cooperation Agency 2009, van Geen et al. 2016). Households in heavily affected areas live too far from installed deep wells, beyond the 100–150-meter walking distance that previous studies have found to be the maximum that members of rural Bangladeshi households are willing to walk to fetch water (van Geen et al. 2003, Opar et al. 2007). From a blanket survey of all wells across Araihazar, van Geen et al. (2016) ﬁnd that less than one-third of arsenic-contaminated shallow wells are located within walking distance (100 meters) of at least one of the 915 deep or intermediate- depth wells in the study area. If deep wells had been more evenly distributed, the percentage of shallow wells covered could have increased to 74%. Even when the engineering and ﬁnancing constraints are addressed, there still appears to be some issue with the spatial distribution of deep-well placement (Chiffre 1). One possible explanation for this inefﬁcient deep-well placement is elite capture of this valuable public resource. Local government ofﬁcials in Bangladesh have large discretionary authority over the siting of deep wells. In Araihazar, a subdistrict where much arsenic research has been conducted, the central government allocated funds to local government ofﬁcials to install 50–100 deep wells each year over a decade. The location of a well is determined on the basis of input from the bureaucrat in charge of the subdistrict (Upazila Nirbahi ofﬁcer), the senior local government ofﬁcial (Upazila Parishad chairman) who is directly elected, et le 12 Union Parishad chairmen who are also elected (van Geen et al. 2016). This l D o w n o a d e d f r o m h t t p : / / direct . m je t . / e du a d e v / art – pdlf / / / / / 3 7 2 2 1 1 8 4 6 8 0 8 a d e v _ a _ 0 0 1 4 8 pd . f par invité 0 7 Septembre 2 0 2 3 Évaluation des stratégies visant à réduire l'empoisonnement à l'arsenic en Asie du Sud 33 Chiffre 1. Clustering of Deep Wells l D o w n o a d e d f r o m h t t p : / / direct . m je t . / e du a d e v / art – pdlf / / / / / 3 7 2 2 1 1 8 4 6 8 0 8 a d e v _ a _ 0 0 1 4 8 pd . f par invité 0 7 Septembre 2 0 2 3 Remarques: Panel (un) shows the overlapping circles with a radius of 100 meters around installed deep wells and shows that 29% of contaminated well (red) were within 100 meters of a deep well. Panel (b) shows the optimal placement of a subset of the wells from a regular-spaced grid. Source: van Geen, Alexander, Kazi Matin Ahmed, E.B. Ahmed, and Imtiaz Choudhury. 2016. “Inequitable Allocation of Deep Community Wells for Reducing Arsenic Exposure in Bangladesh.” Journal of Water Sanitation and Hygiene for Development 6 (1): 142–50. decentralization of deep-well provision can be prone to elite capture, in which wells are preferentially targeted toward political, sociale, or economic elites in the community. Evidence of elite capture of deep-well placement has mounted. Dans 2017, Human Rights Watch accumulated anecdotal evidence based on village interviews that politicians were preferentially placing wells near political supporters (Human Rights Watch 2016). Van Geen et al. (2016) report that about one-third of deep wells were placed in inaccessible locations such as inside the compounds of private households. Madajewicz et al. (2017) ﬁnd that a community participation intervention that was designed to limit the inﬂuence of elites led to an increase in clean water access. Enfin, Mobarak, van Geen, and Mangoubi (2019) investigated 34 Asian Development Review the extent of elite capture by combining geospatial data on well placement and newly collected geocoded data on the location of political and economic elites. The authors ﬁnd strong evidence that local politicians are more likely to have deep wells built near them during periods when their political party is in power. This form of elite capture accounts for about one-ﬁfth of the inefﬁcient spatial allocation of deep wells. IV. Complexities of Scaling Policy Interventions Large-scale public health problems such as arsenic poisoning across Bangladesh require scalable solutions. Implementing the strategies discussed in this article—treating contaminated groundwater or switching to low arsenic groundwater—is challenging and complexities may arise when going from a project in one district to a nationwide policy. As a program scales, Par exemple, there may be spillover effects on nonbeneﬁciaries, friends and neighbors, and markets; political reactions from voters and governments; macroeconomic, growth, and welfare impacts; as well as concerns about the external validity of small-scale pilot results (Davis and Mobarak 2020). Interventions may have spillover effects onto neighboring households or communities, interact with social networks, and affect market prices and wages. Par exemple, the more that people use ﬁlters, purchase well test kits, or engage in well-sharing arrangements, the more attractive these behaviors may become to other members in a social network. The installation of more deep wells or community ﬁltration systems in a given area could increase demand for spare parts, tools, and skilled labor, leading to positive spillovers in maintenance costs and better functionality. If people are less exposed to arsenic, they may become more productive employees, leading to more employment opportunities and higher wages in the community. More research on spillover effects can inform policy makers on unintended costs and beneﬁts that can remain hidden in small-scale programs. This can motivate cost-effective intervention designs. Par exemple, subsidies for test kits or ﬁlters may only need to be provided to a subset of households if demand for such products is interlinked between households, thus lowering the cost of the program substantially. People may also adapt and react to policies in ways that can produce unintended effects. Some of those consequences might be negative. Par exemple, Field, Glennerster, and Hussam (2011) hypothesize that the widespread switching to surface water after the discovery of arsenic in 1994 might have led to higher exposure to fecal–oral pathogens, which in turn increased infant and child mortality. On the other hand, people may also adapt in ways that produce unintended beneﬁts. Keskin, Shastry, and Willis (2017) show that mothers react to arsenic exposure risk by increasing the propensity and the duration of breastfeeding, which provides infants some measure of protection against arsenic contamination, and this in turn l D o w n o a d e d f r o m h t t p : / / direct . m je t . / e du a d e v / art – pdlf / / / / / 3 7 2 2 1 1 8 4 6 8 0 8 a d e v _ a _ 0 0 1 4 8 pd . f par invité 0 7 Septembre 2 0 2 3 Évaluation des stratégies visant à réduire l'empoisonnement à l'arsenic en Asie du Sud 35 reduces infant mortality. The effects of any arsenic mitigation policies at scale will be inclusive of such adaptation and behavioral responses. For comprehensive policy evaluation, it is important for social scientists to provide rigorous analysis on these types of questions. As an arsenic mitigation program scales up, it may change the behaviors of politicians and policy makers in response to the program. Par exemple, if politicians have control of discretionary funding of deep wells, they may choose to install more in their home areas to gain votes or target placement near other politicians to gain political supporters. If funding for wells is externally funded by international NGOs, programs could erode political accountability if leaders claim credit for successful programs (Deaton 2013). On the other hand, externally funded programs may elicit political or ﬁnancial support, as found in the case of externally funded sanitation programs in Bangladesh (Guiteras and Mobarak 2016). Research has already shown that political factors have led to inefﬁcient deep-well placement in Bangladesh through elite capture. More research is needed on how best to address these political inﬂuences. Par exemple, research on community participation in deep-well placement that imposed rules designed to limit the appropriation of projects by elites effectively expanded access to clean water sources (Madajewicz et al. 2017). Changes in individual behavior induced by a program can, at scale, have macro-level impacts. Large-scale interventions that reduce arsenic consumption could boost human capital and labor productivity, which can lead to long-run growth. Cependant, macroeconomic models often require parameters to properly predict macro-level impacts. Rigorous evidence from randomized controlled trials can help calibrate these models to more accurately determine these impacts in the medium to long run, and even simulate alternative policy scenarios. Net welfare impacts are also important when evaluating a program but are difﬁcult to measure without modeling. Par exemple, people may experience nonmonetary disutility by walking a longer distance to a communal deep well as they may be more vulnerable to crime if they must walk far and/or at night. Modeling can be used to answer normative questions about welfare trade-offs that are important for policy decisions. Social science research aspires to generate evidence that policy makers can use to scale promising programs. Even if the research discussed above produced internally valid estimates of the policies studied at pilot scale, there are open questions about how programs would work outside the context of those evaluations. Replication studies and subsequent meta-analyses will be useful to aggregate results from different contexts. V. Policy Recommendations There are trade-offs in expanding access to clean water through well testing versus installing deeper, more expensive low-arsenic wells. Jamil et al. (2019) l Téléchargé à partir du site Web : / / direct . m je t . / e du a d e v / art – pdlf / / / / / 3 7 2 2 1 1 8 4 6 8 0 8 a d e v _ a _ 0 0 1 4 8 pd . f par invité 0 7 Septembre 2 0 2 3 36 Asian Development Review Figure 2. Cost-Effectiveness of Different Interventions Note: This ﬁgure shows the number of people whose exposure was reduced in Araihazar, Bangladesh compared to the cost per person of each type of intervention. Source: Jamil, Nadia, Huan Feng, Kazi Ahmed, Imtiaz Choudhury, Prabhat Barnwal, and Alexander van Geen. 2019. “Effectiveness of Different Approaches to Arsenic Mitigation over 18 Years in Araihazar, Bangladesh: Implications for National Policy.” Environmental Science and Technology 53 (10): 5596–604. conducted a cost-effectiveness analysis of alternative strategies in a particular area and found that free nationwide well testing would be the most cost-effective way of reducing exposure (Chiffre 2). Well testing alone reduced the exposed population in their study area of Araihazar in the short term by an estimated 130,000 people. The next most effective way was installing private intermediate-depth wells, which lowered exposure for 60,000 people at a cost of $30 par personne. In contrast,
installation of deep tube wells and piped-water supply systems by the government
reduced the exposure of little more than 7,000 inhabitants at a cost of $150 par personne (see Table on Comparison of Interventions). These numbers are a strong argument in favor of free well testing. Simply providing test results addresses an information failure, which has to the adoption of preventive health been found to be a major impediment technologies in a variety of contexts. Informing people about the level of arsenic they are exposed to bolsters their demand for alternative sources of water. Donc, well tests must precede investments in alternative sources in order to maximize the effectiveness of testing. If well testing were complemented with interventions that make private intermediate-depth wells more affordable, such as with subsidies or microcredit, it could induce adoption and reduce exposure. A national database of well locations with test results can help policy makers target subsidies to areas with a high density of contaminated shallow wells. Designing subsidies that encourage sharing private intermediate-depth wells with neighbors can also increase the coverage. l Téléchargé à partir du site Web : / / direct . m je t . / e du a d e v / art – pdlf / / / / / 3 7 2 2 1 1 8 4 6 8 0 8 a d e v _ a _ 0 0 1 4 8 pd . f par invité 0 7 Septembre 2 0 2 3 Évaluation des stratégies visant à réduire l'empoisonnement à l'arsenic en Asie du Sud 37 ) $
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Although Jamil et al. (2019) ﬁnd that deep-well construction is much less
cost-effective, the analysis by Mobarak, van Geen, and Mangoubi (2019) suggests
that much of that is due to inefﬁcient placement and elite capture. Deep wells are
often forcibly “privatized” by politicians to use as a personal resource. This prevents
other households from gaining access to clean water, even after expensive deep-
well construction. Institutional reform that limits the discretion of public ofﬁcials
to site deep wells as they please would increase the efﬁciency of public funds that
are deployed for well construction. Increasing either voter awareness or national
government supervision of local politicians might put pressure on politicians to
distribute deep wells in a fairer and more efﬁcient way. We think that combining
a national well-testing program with policy interventions that address these market
failures currently preventing deep-well construction is required to properly address
this massive health crisis in Bangladesh.

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3 Evaluating Strategies to Reduce Arsenic image

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