By Daniel Firoozi
Reducing Open Defecation in Rural, Northern India
Open defecation poses one of the single most significant health and safety challenges to the people of the provinces of rural, Northern India. Eliminating the practice could save thousands of lives per year through reduced infant mortality, improve early childhood development and curb both malnutrition and the spread of disease. Existing policy options have succeeded at expanding access to improved sanitation, but have failed at making comparable reductions in the rate of open defecation, due largely to individual preferences. Policymakers must overhaul the Total Sanitation Campaign and Nirmal Gram Puraskar to focus on latrine usage, local leadership, long-term goals and accountability to build on the progress made in latrine access.
Statement of Problem
As India continues along its path of long-run economic growth, it grapples with an array of health crises ranging from malnutrition, to elevated rates of infant mortality and widespread instances of diarrheal disease, even when compared to countries with lower per capita incomes, because of open defecation. Despite representing only one sixth of the world’s population, at 597 million people, Indians are the majority of the world’s remaining practitioners of open defecation (Progress 2014, p 21-22). Although 291 million Indians have gained access to improved sanitation since 1990, 792 million continue to lack access to latrines and other forms of improved sanitation facilities, concentrated largely in Northern and rural provinces (Progress, 19-20 & 60). For key demographic groups, particularly Hindus, Dalits, the rural poor, women, children and the elderly, open defecation contributes to a broad degree of disparities in outcomes for healthcare, education, economic opportunity and even personal safety. In the enclosed report, we will (1) explore the origins of the continuing open defecation crisis in India, (2) analyze and critique the Total Sanitation Campaign (TSC), a recently implemented broad-based program aimed at expanding access to latrines and the Nirmal Gram Puraskar (NGP), a financial incentive to promote latrine use, (3) issue a revised plan for phase two of the Total Sanitation Campaign built on demand stimulation, more funding for NGPs and a set of local sanitation divisions administered at the Gram Panchayat (GP) level which will compete for long term financial awards for latrine use and maintenance and (4) conclude with a summary of these findings and rationale for renewal of the TSC with amendments.
On balance, the evidence suggests that while traditional approaches to moving toward an open defecation free (ODF) India have emphasized and been successful in boosting construction of and access to latrines, they have not succeeded at achieving corresponding gains in the reduction of open defecation due to engrained group preferences for the practice. While expanding access to improved sanitation facilities continues to be of great importance, a substantially larger degree of focus should be placed on stimulating demand for latrine use via educational campaigns and future policy approaches must factor in long-term GP, district and block oriented sanitation strategies to build a culture of use and maintenance for existing latrines. By taking large strides towards ODF communities, India may dramatically reduce incidence of diarrheal disease, malnutrition, sexual assault, parasitic infection and infant mortality, as well as promote better outcomes for early childhood development and educational attainment in the long run.
Open defecation has been a longstanding problem on the Indian subcontinent, tracing its historical roots to a period long before British colonization and has been engrained in the lifestyles of most rural Indians. Many households display a strong preference for open defecation over latrine use, often citing pleasurability and a belief in the health benefits of the practice as primary motivators (Coffey 2014, p 1). However, the data from healthcare outcomes robustly suggest that the ubiquity of open defecation in rural, Northern India poses strains on the indigenous population and entails severe negative consequences. One half of all Indians regularly practice open defecation (Lamba 2013, p 1593), including nearly two thirds of rural households and a majority ofpeople living in households with a government provided toilet (Coffey, p 1). Open defecation is more common in India than many countries with lower indicators for per capita income and approximately one third of the global population of open defecators live in just five Indian provinces: Bihar, Uttar Pradesh, Rajasthan, Madhya Pradesh and Haryana (Coffey, p 5). For key demographic groups rates of open defecation can be even higher and pose additional risks to individual health and safety. Indians from scheduled castes (Lamba, p 1593), men (Coffey, p 13), children (Child Feces 2015, p 1) and Hindus (Geruso 2015, p 2) are more likely to engage in open defecation than their demographic counterparts. Often the subgroups most in need of latrines, women with safety concerns, the disabled and the elderly, are precisely the groups with the least amount of economic clout within their household (Coffey, p 13).
Local governments, organized into districts, blocks and Gram Panchayats (GPs) led by Sarpanches, local elected leaders, are the most critical stakeholders in sanitation policy. Since villages are the core political unit across the rural region of Northern India, they are primary stakeholders in the struggle to construct more latrines and combat the prevalence of open defecation (Lamba, p 1594). Traditionally, administration of sanitation policy has been conducted at the local level, because of the need for political autonomy and flexibility to address the wide variation in climate, water access and cultural differences across the subcontinent. Both rural families and government institutions have a vested interest in improving sanitation access, but the federal government has been slow to act and unresponsive to the unique challenges facing the GPs. Local administrators are also on the frontline of contacting and working with individual households, which often have latrines but may have individual family members who refuse to use them, giving them a unique opportunity to educate and motivate on a personal level.
In 1999, the federal government of India launched the Total Sanitation Campaign, with the stated goal of achieving universal latrine use and the elimination of open defecation by 2012, but the project failed to achieve a dramatic reduction of open defecation despite contributing to a 19% increase in the availability of improved sanitation (Patil, p 1). An accompanying program, the Nirmal Gram Puraskar, was established to provide funding to Gram Panchayats and households, particularly those below the poverty level, upon the construction and verification of the use of latrines (Lamba, p 1594). Taken in total, the Indian government allocated the equivalent of $1.4 billion for the Total Sanitation Campaign and $1.5 billion for the NGP, providing approximately Rs 820 per household for the construction of a latrine, Rs 30 Lakh for the NGP grant to each Gram Panchayat achieving ODF status and Rs 8,000 for NGP grants to each household in Gram Panchayats that successfully achieved ODF status (Robinson 2008, p 20 & 38-40). While these policies were effective in contributing to a nineteen percentage point increase in latrine coverage in participating villages relative to control villages, the evidence seems to suggest that the policy intervention resulted in latrine construction but fell well short of achieving total sanitation due to the low rates of latrine use (Patil, p 5). According to one analysis, if the Total Sanitation Campaign and NGP awards were extended to cover every village in the rural, Northern provinces, open defecation in the region would only fall from sixty four percent to forty six percent, because the marginal rate of latrine use among latrine owners remains low (Coffey, p 18).
The wedge between latrine ownership and latrine use, which proves the biggest obstacle to the elimination of open defecation, can be traced to social, political, economic and religious factors. Among households with a government constructed latrine, one third of such latrines are not used by anyone at all and rates of open defecation were twice as high as rates for households that constructed latrines without government assistance (Coffey, p 3 & 14). Likewise for Gram Panchayats with Sarpanches from scheduled castes, like Dalits, figures point to high rates of toilet construction on par with that of other participating Gram Panchayats, but the frequency of receiving the NGP proved far lower because of lower rates of latrine use conditional on latrine construction (Lamba, p 1602-1604). In fact, a contributor to both the dearth of households constructing affordable latrines and the use of affordable government sponsored latrines seems to be that many rural Indians in the Northern provinces have an expensive concept of what an acceptable latrine looks like and thus are less likely to build or use facilities that do not meet their personal standards (Coffey, p 7-8). The TSC and NGP programs have both neglected to consider reaching out to local religious institutions and leaders who often give guidance to their worshippers regarding the practice of open defecation (Geruso, p 5-7). Finally, it seems that in spite of the companion programs’ noticeable impact on latrine construction household surveys reflect similar rates of awareness of the programs between villages receiving the policy intervention and control villages (Patil, p 14).
The Indian Ministry of Drinking Water and Sanitation should recommit itself to a substantial reduction of open defecation in the rural, Northern provinces and launch a second phase of the Total Sanitation Campaign and Nirmal Gram Puraskar by (1) setting up latrine demand stimulation campaigns and triggers, (2) increasing NGP awards by 25% across the board and (3) setting up a system of local sanitation organizations, administered at the Gram Panchayat level, which will compete for new long-term NGP block grants awarded for latrine use, reduction of open defecation and latrine maintenance. As the TSC and NGP have already demonstrated, the larger the financial incentive for latrine construction, the greater the rate of expanded access to improved sanitation, but such plans alone are insufficient for guaranteed latrine use and curtailing open defecation (Patil, p 21).
The policy intervention outlined in this report will tackle current problems and context by challenging existing notions surrounding open defecation, promoting demand for latrine use, targeting relief and demand stimulation to key groups and engaging local policymakers as stakeholders in the process. With fifty one percent of people without latrines believing that open defecation is at least as beneficial to health as latrine use, any proposal geared at curbing open defecation must begin with latrine demand stimulation and program triggers (Coffey, p 21). A revamped TSC must tout not only the health benefits of ODF communities, but must recognize existing social roles and make targeted appeals to personal safety of children and adolescents, personal privacy for women and low costs for men (What Works 2014, p 5). Local leaders and households should indicate a desire for behavioral change prior to the disbursement of funds for latrine construction and the allotment of construction grants should be tied to a participatory rural appraisal process that would gauge the fraction of people in a Gram Panchayat interested in pursuing to an ODF community, ask for a reasonable target date for ODF status and target funds at the GPs with the strongest commitments (What Works, p 6 & 9). Rather than emphasizing disgust and shame in the context of open defecation, the initial educational campaign should rely on the pride, dignity and security associated with latrine use as well as the most effective messaging surrounding convenience, children’s safety from insects and animals, reductions of sexual assault and safety from the rains to appeal to middle age fathers, the holders of most economic clout in the rural provinces (What Works, p 10-11). Lastly, the educational program must be administered at the local level, with Sarpanches indicating a firm commitment to participation, setting up a sub-GP governing structure and drafting a time table for policy implementation, before a village is deemed eligible for participation in the renewed TSC and NGP programs.
To achieve dramatic improvement in health, educational and life outcomes India’s federal government must overhaul its rural sanitation policies to prioritize latrine use, rather than latrine access as a means of combating open defecation. Despite measurable progress in latrine construction in rural, Northern India, the country has not achieved parity declines in open defecation, making it a laggard among its non- industrialized peers on a variety of health indicators. Without substantial reform of the TSC and NGP, India will continue to subsidize construction of improved sanitation facilities rather than stimulate their demand, fail to address systemic inequalities on the basis of gender, caste, religion and age and will continue to face stubbornly high rates of preventable illness and infant mortality. With the population burgeoning and growing increasingly mobile, the federal government must prioritize slashing rates of open defecation to hedge against the growing threat of communicable disease. Local governments and families should commit themselves to better sanitation practices to not only raise their standards of living, but improve childhood development and save young lives.
The most achievable and pragmatic approach to curbing open defecation involves launching a second phase of both the TSC and NGP programs, while making a clear break with their previous top-down, near term, construction-focused approach. By allocating funds for the establishment of a network locally administered sanitation organizations, shifting focus to latrine demand stimulation and providing a new set of
long term grants for achieving non-construction goals, policymakers may best address the factors which limited the success of past initiatives. These clean breaks with the structure of past policies prove necessary because of the high rates of disuse of existing sanitation infrastructure, the disparities between demographic groupings and the political realities of rural village life in each of the provinces. The revamped proposal for the implementation the Total Sanitation Campaign and Nirmal Gram Puraskar ought to receive the full support of the Ministry of Drinking Water and Sanitation to improve the efficiency of the existing programs and the Minister Chaudhry Birender Singh should propose an increase in the allocation for these programs in the annual federal budget to cover the higher expenditures associated with a restructured grant system and new public worker salaries.
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