Even those with access don’t always use them
The recent Emory University study highlighting how construction of toilets alone hasn't improved India's public health and sanitation indicators could not have come at a better time. It serves as an important reminder to the BJP-led NDA Government, which has just initiated the massive Swachch Bharat Abhiyan, to learn from the mistakes of its predecessors to ensure more effective utilisation of public funds. While Prime Minister Narendra Modi deserves full credit for putting sanitation at the centre of the public discourse in India, the fact is that the Indian Government's efforts towards cleanliness, especially its fight against open defecation, go back several decades. Official records show that since 1986, India has spent over three billion dollars on constructing toilets across the country. Under the small Central Rural Sanitation Programme that ran from 1986 to 1999, nine million toilets were constructed; in 1999, the more ambitious Total Sanitation Campaign was launched, and over the years, it has added more than 97 million toilets. Renamed as the Nirmal Bharat Abhiyan by the UPA regime, the campaign aimed to eradicate open defecation by 2017 and was supposedly one of the world's biggest sanitation programmes. Yet, today India is still home to two-thirds of the 1.1 billion people who defecate in the open worldwide, one-third of the 2.5 billion people worldwide who don't have access to improved sanitation, and a quarter of the 1.5 million who die annually from diarrhoeal diseases. Clearly, there is a disconnect between the construction of toilets and the impact it is expected to have on health and sanitation indicators.
The Emory University research compares the health indices of villages that have better toilet coverage with those that don't have adequate coverage. The researchers found in both cases the exposure to faecal pathogens and the instances of soil-transmitted helminth infection were similar. In other words, access to toilets did not improve public health levels. The researchers assume that this is because of the weak correlation between the construction and usage of toilets — a fact that has been supported in other studies. Earlier this year, the Sanitation Quality, Use, Access and Trends Survey (popularly known as Squat), showed that over 40 per cent of households with a working toilet have at least one member who still defecates in the open. Squat researchers interviewed over 3,000 adults about their defecation practices, and collected individual level latrine use data for almost 23,000 household members, across five north Indian States. They concluded that a change in popular mindset is necessary, if sanitation campaigns have to succeed.
While excretion is an individual bodily process, the ideas of cleanliness and sanitation are defined by the community. This has been underlined by another study that investigated toilet-use in the villages of West Bengal and Himachal Pradesh. The study found that successful sanitation depends on three factors. First, political will which must be shared with civil society players for the long term; second, ground-level social pressure for the adoption of better sanitation practices, and finally, an ecology is needed that is supportive of these practices. In India, the first element is already in effect. There is also a greater emphasis on the second element — for example, through media campaigns urging new brides to insist that their spousal homes have toilets or asking students to pressure their teachers and parents for toilets in schools. The third element, however, is still a work-in-progress — for example, many toilets lie unused because they don't have water supply. This is where the Government has to come in and plug the gaps in policy implementation.