The issue of open defecation persists in India leaving millions vulnerable to disease. Is India’s Swacch Bharat Abhiyan (SBA) or Clean India Mission the solution to this deeply entrenched social and structural issue?
Train travel on Indian railways – one of the largest train networks in the world – offers a delightful view of the country. Early mornings offer warm tea, omelets in bread and first-row seats to a view of squatty-bottoms – of the millions who use the fields and other ‘empty’ spaces across rural and urban areas, often along railways lines, to complete their morning ablutions. Even the open toilets aboard the trains leave a proud trail of poo – one which is perhaps nothing, but a reflection of the (lack of) priority modern sanitation has traditionally received in the country.
Adequate sanitation is a basic human right. The lack of adequate sanitation exacerbates social inequities, increases vulnerability to disease, increases living costs, impacts a household’s ability to spend on education and nutrition. In fact, diseases caused by lack of hygiene and sanitation have a huge impact on people’s health and financial resources. The issue of sanitation is particularly pressing for a country such as India, which still has the largest number of people defecating in the open. Adequate sanitation is critical for a country which has expressed ambitious plans of economic growth and development, and yet continues to lag behind in terms of basic health and development indicators.
Some telling stats, perhaps. In 2011, almost 53% of households in India did not have access to toilet facilities, resulting in almost 595 million people defecating in the open. In China, Mao famously proclaimed “women make up half the sky”; Modi might want to consider an Indian version for his ‘Clean India Mission’ (see below) – something with “let’s clean up half the soil”, perhaps. The implications of this range from proximity to feces and the risk of disease, vulnerability to snake and insect bites, and often as in the case of millions of young girls and women, vulnerability to sexual abuse. For example, every year, diarrhea kills 188,000 children under five in India. Even when diarrhea does not kill, it severely debilitates, making children susceptible to a host of conditions such as acute respiratory infection and chronic undernutrition. Further, recurring diseases impact household expenditure on health; they also have implications on other development objectives such as education and nutrition.
In the case of women and young girls, the need to access safe, clean toilets becomes even more necessary at the time of menstruation and pregnancy. In fact, 35% of schools do not have private toilets available, and only 55,7% of them had usable girls’ toilets in 2014. This has implications on the willingness of girls to attend school during menstruation. An estimated 23% of girls in India drop out of school when they start menstruating. Research data also suggest that pregnant women who are accustomed to open defecation are more likely to have premature delivery or give birth to an underweight baby than those who use toilets, issues perhaps linked to poverty and poor nutrition – issues which again tie in with access to sanitation and hygiene.
But, this is not news anymore. At least not for the average Indian.
In recent years, there has been some progress, though. The percentage of urban population with access to sanitation facilities increased from 55% to 63% between 2001 to 2015, but much more muscle is needed as in rural areas only 24.7% of the households have access to sanitation. As already hinted at above, almost a year ago, the Indian Prime Minister, Mr. Narendra Modi launched the Swacch Bharat Abhiyan ‘Clean India Mission’ – a plan aimed to make India ‘clean’ by October 2, 2019. Eliminating open defecation is an explicit goal of the mission. For the moment, even though the central government has delivered toilets to 8 million households against a target of 110million, the campaign could fail to achieve its objectives.
Indeed, although important, infrastructure, i.e. constructing toilets is but one aspect of tackling the issue of sanitation and/or open defecation. You can build toilets, but this needs to go hand-in-hand with access to water, both for toilets and for hand washing etc.; access and money for soap, and of course intense behavior change communication strategies. Since the start of the campaign there have been plenty of efforts in the form of articles, radio jingles, television spots and others to increase awareness both on the campaign, as well as on sanitation and hygiene. Changing habits and beliefs is not an easy task, though. Some widely employed methods such as the Community-led total sanitation-CLTS have had limited results. CLTS is an innovative methodology for mobilizing communities to completely eliminate open defecation (OD). Clearly, communities must be involved more. Prominent members of the community, men and women need to be brought in to design their programs, and implement strategies to improve use and access of toilets, reduce open defecation and adopt other practices for overall sanitation and hygiene. The Jharkhand’s case is very useful in this sense. In fact, the Government of Jharkhand has successfully established a workable strategy for creating and sustaining Nirmal Grams (clean villages) through a people-centred, participatory and demand-driven approach. This initiative aims to create Open Defecation Free villages through the construction of a functional toilet in every household. Having been successfully piloted in Gadri village, the initiative is being scaled up across the state, with convergence and community involvement as its underlying principles.
In India, even though states have engaged frontline workers for the Swacch Bharat Mission, there are no mechanisms yet for proper training, management, and supervision. These gaps make it difficult to achieve the levels of effectiveness needed at the central and local government level. Earmarked investments for frontline worker recruitment are required. Earmarked funding is also needed to allow schools to implement sanitation workshops and programs as they are instrumental to better knowledge of the benefits of an open defecation-free society. Local governments should act in unison in order to improve awareness. In the end however, much like other aspects of health a multi-pronged approach involving health, education, information and poverty alleviation would be needed to improve sanitation related health indicators. Supplying toilets is just one face of the coin. Earmarked funding for frontline worker recruitment is required. What is a major asset to accomplish the ‘Clean India Mission’ is the – now obvious – political will. As such, it is good news that just a few days ago in the Uttar Pradesh State, the Gonda District Magistrate announced that government employees and officials without a toilet in their homes would be immediately denied salaries. The slogan “civil servants in India without toilets will lose half their salary” comes to mind. Might be a game changer.
This move unveils that changes are feasible and that the Indian government is producing bold efforts in the right direction even though a more comprehensive approach would likely result in gains well beyond those harvested so far. Anyway, the road taken seems good. Foreseeably, it will pave the way for India to tackle open defecation. Might make the train journeys a bit less romantic, perhaps… but this is the 21st century.
Pietro received some editorial input from Radhika Arora (consultant).