To stop open defecation, stop only building toilets, make people use them

Time now to shift focus from access to latrines to a pervasive behavioural change campaign promoting use of latrines

Nikhil Srivastav | October 1, 2014




Prime minister Narendra Modi, in his Independence Day speech, expressed his dream of making India open defecation-free by the 150th birth anniversary of Mahatma Gandhi in 2019. Eradicating open defecation is important not just because the Mahatma cared about it or because it is a matter of national shame, but because it inflicts a heavy loss on the country’s human capital. Open defecation not only kills babies, it also causes intestinal diseases among the children who survive. These diseases decrease the absorption of nutrients and inhibit a child’s physical and cognitive development.

Looking at the national and international figures on sanitation, India’s performance is embarrassing. India is home to 60% of all open defecators in the world; around 53% of households in the country do not have a latrine, and among these, 89% live in rural India. According to a World Bank study, open defecation in the country costs India '24,000 crore every year.
 
Defecation in open by choice
Many of us, living in urban areas, may think the only reason so many people answer nature’s call by going out in the open is because they cannot afford to have a latrine. This is not entirely true. Even poorer countries like Bangladesh (3%), Afghanistan (15%) and Uganda (8%) have far fewer people defecating in the open. Even after decades of economic growth, why is open defecation still so prevalent in India?

I am part of a research team which spent six months talking to people in the rural areas of Uttar Pradesh, Bihar, Rajasthan, Madhya Pradesh and Haryana about their sanitation attitudes and behaviour. We found that over 40% of households that have a working latrine also have at least one person who usually goes out and defecates in the open.

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We also found that individuals in households having government-built latrines, which are similar to the inexpensive latrines commonly used in many other developing countries, are more likely to defecate in the open than individuals in households who spend money on making their own latrines. People have an aversion to government latrines because they have small pits, which people believe will fill up soon, and because they are different from the expensive latrines which their relatives in the cities use.

In an unequal society like ours, dealing with faeces has been associated with dalits. Most people in rural India are inimical to the idea of cleaning their own latrine pit. Instead, they prefer building pits the size of underground rooms, which last for a generation. People who have government-built latrines try to save space in the smaller pit by using it only when it rains, at night or when someone is sick. They see latrine pits as a depletable resource because pit-cleaning services do not exist in rural India.

People are also unaware of the negative impact of open defecation. Almost 99% of people in our survey knew that health will improve if they stop drinking alcohol or chewing tobacco. But when asked directly about which is better for health, open defecation or latrine use, 43% of respondents stated that latrine use is no better for child health than open defecation.  Many people in rural India think that defecating in the open is actually good for health because one can get fresh air and some exercise. Whereas most people know the detrimental effects of smoking and drinking alcohol, these people are yet to be aware of the lethal effects open defecation has on their children.

On the one hand, the aversion to an inexpensive latrine stops people from building a latrine that most of them can already afford and from using the latrines that the government builds for them. On the other hand, the belief in the wholesomeness of open defecation keeps them satisfied with going in the open.

Focus on behaviour change, not construction
Since it is people’s attitudes and beliefs that keep them from wanting to use a latrine, any successful policy will have to change these attitudes. Though the total sanitation campaign (TSC) in letter says, “the programme gives emphasis on creating awareness through intensive information and education campaigns (IEC) to bring attitudinal and behavioural change for hygiene practices”, it mainly just focuses on building latrines. In fact, between 2001 and 2014, the government spent almost '15,000 crore on construction, compared to a meagre sum of  Rs 1,022 crore on IEC.

Even after calling it a demand creation programme, the TSC guidelines cap IEC funding to 15% of the total budget, and on top of this, they make it more difficult for district coordinators to spend the allocated IEC funds than construction funds. In fact, IEC plans need to be approved by the district water and sanitation committee (DWSC) whose members, bureaucrats of several departments and district-level politicians, are busy doing other things and often are not able to agree on a plan. This implicitly incentivises district coordinators (‘swachchhata preraks’) to build toilets rather than doing activities to create demand through behaviour change.

The bitter pill
Building latrines for people will not be enough to achieve an open defecation-free India by 2019. India is known for its prodigal legacy of providing subsidies and now is the time to shift focus from access to latrines to a pervasive behavioural change campaign promoting latrine use.

Making India clean will require changing people’s attitudes. Though this is hard to do, we can learn from one of the most successful community health drives, the pulse polio campaign. For decades, public health experts grappled with the burgeoning cases of polio across the country. It was only after the frequency of national and sub-national immunisation days (NIDs and SNIDs) increased since 1999 that the number of polio cases in India decreased. The success of NIDs and SNIDs depended a lot on the messaging that came from all the prominent figures in the country and the dedication of thousands of people working in the field. The Swachchh Bharat Mission needs similar heroes to knock on every door during national sanitation awareness weeks and convince people to pledge to use a latrine every day.

Constructing latrines alone is not the solution, so the cap on IEC budget should be exponentially increased. An increase in the IEC budget will make sanitation awareness weeks actually possible and will also allow stakeholders to experiment with IEC messages and activities. Along with the availability of funds, approval of the IEC plans at the district level should be swift, so that the process does not hold people back from trying out ideas.

Far too few people work on sanitation
The success of Swachchh Bharat Mission will depend a lot on the staff who will implement it. Having a dedicated and trained staff which actually believes in latrine use will be effective in convincing others in the village. Though the Nirmal Bharat Abhiyan has a provision to hire staff whose job is to promote sanitation at the district, block and gram panchayat levels, the district staff often consists of people who have been given sanitation as an additional charge. And many of the blocks and most of the gram panchayats do not yet have a person appointed. Most village motivators (‘swachchhata doots’), present in some villages, have not received any training and many defecate in the open themselves.

There are also far too few NGOs that do sanitation work in India. In fact, in the SQUAT survey, we found that only 6% of people knew of an NGO that works on sanitation. Compare this to Bangladesh, famous for its large NGO sector, where 78% of all big and small NGOs work on sanitation messaging.

India Inc can chip in too
Recently a lot of corporate houses like TCS, Bharti, Hindustan Uniliver and Aditya Birla Group have answered Modi’s call and pledged to build toilets. Their sense of responsibility deserves accolades. But the Swachchh Bharat Mission does not need more resources for construction; it needs experts to craft messages that will make people feel proud and responsible when they use an inexpensive latrine. Corporate India in the past has proved its legacy and resources in promoting and selling their respective brands even in the farthest and most inaccessible areas. They should use the same set of skills and resources to sell the idea of using inexpensive latrines.

Rural India, according to the census, has over 5 crore households with a latrine and the government is going to build many more. There is an untapped pit-cleaning market with a huge potential, waiting to be developed. Corporates should promote entrepreneurs to get involved and take up the cause. Promoting entrepreneurs to explore this market will not only release the rural families from the hassle of pit cleaning but will also generate employment.
A lot of people are surprised to learn that there are more mobile phones than toilets in India. This is because companies in this field have made using inexpensive mobile phones desirable and have developed and distributed a full product line of phones that are affordable to most people. Similarly, most of the poor countries which have been successful in abating open defecation were able to do so because they created the demand for inexpensive latrines and then bridged supply constraints. Corporate houses have the capacity to innovate – this capacity was used in the mobile phone revolution, and they should use it in making and distributing inexpensive latrine parts too.

Will Swachchh Bharat Mission achieve its target?
The PM has shown his courage and political will for a Swachchh Bharat by announcing sanitation as the top priority of his government. Now, whether the Mahatma will receive his gift depends a lot on whether those responsible for forming policy follow their profligate legacy of providing subsidies for latrines, which might not get used, or they take an empirical route of first changing people’s minds.

Srivastav is with the Research Institute for Compassionate Economics (RICE).

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