Tag: PUBLIC HEALTH

Origin of Problem and Current Context
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).

Because of the extraordinarily low rates of access to and use of latrines and improved sanitation, the population of India faces severe negative health effects. India alone accounts for approximately one third of all deaths from diarrheal disease (Patil 2014, p 3), driven largely by the relatively high population density of Northern villages which can often multiply the negative externalities of open defecation (Coffey, p 24). The outlook is particularly bleak for children. Poor sanitation access among children in rural, Northern India has been linked to the prevalence of enteropathy, stunted growth, malnutrition and intestinal worm infections, which can cost on average three and three quarters IQ points worth of brain development during every infestation (Child Feces, p 3). The long term consequences caused by repeated fecal-oral transmission of parasites have even been traced to poor cognitive development, lower school attendance, reduced educational attainment, reduced literacy and higher risk of chronic disease in adulthood (Andres 2014, p 6) (Spears 2013, p 3,17-18, & 28). The gaps between ODF and non-ODF communities come into full clarity when one considers that the children of Muslim Indians, despite lower household incomes, lower consumption levels, worse educational attainment and worse access to piped water, have a lower overall infant mortality rate than their Hindu counterparts primarily because of resistance to latrine use among Hindu fundamentalists (Geruso, p 3).

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.

Critique of Policy Options
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).

Policy Recommendations
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.

Phase two of the Total Sanitation Campaign and Nirmal Gram Puraskar should strike at the heart of past policy failures by emphasizing latrine use rather than construction, creating safeguards against caste-based discrimination, challenging perceptions about latrines and raising awareness about the program itself. Apart from the financial incentives to build latrines, the bulk of the NGPs for ODF Gram Panchayats and households in ODF GPs should be disbursed only after independent auditors evaluate a GP for latrine use in one, two, three, five and eight year intervals after a GP enters the program (Robinson, p 49). Moreover, a financial incentive for workers in the locally-administered sanitation organizations should be tied to these evaluations as a means of incentivizing community engagement and education in the period between evaluations. This will shift the incentive away from construction and toward fostering a culture that makes ODF communities a priority, while improving baseline statistics, allowing for decentralized management and providing independent accountability (Monitoring Systems 2010, p 4 & 12). Independent auditors will schedule evaluations without proactive warnings for GPs, will be randomized among the GPs and will meet with the members of the local sanitation organizations and Sarpanch only after submitting an initial report, to curtail possibilities for corruption and eliminate the potential for biased reporting linked to the caste of a Sarpanch. Coupled with this new focus on external verification, local sanitation organizations must work hard to relay the message that the low-cost latrines funded by the TSC are a transitory step along the path to the high quality latrines many Indians envision and underscore that successful achievement and maintenance of ODF status in a GP will lead to financial grants that may be used to upgrade latrine quality (Patil, p 9). By framing the move to latrine use as a step in a process yielding larger and larger payoffs over time and by incorporating local sanitation organizations, the new TSC and NGP will foster a culture of latrine use over the long-run and become more familiar to targeted villages than their predecessor programs.

In keeping with the overall plan of taking a bold step toward eliminating open defecation, the policy goal will be to cut open defecation in half by the eighth year of the revised programs and will be evaluated through a series of benchmark checks with accompanying performance grants for post-NGP outcomes (Robinson, p 49). While local sanitation organizations governed by Gram Panchayats can effectively act to provide timely monitoring at block, district and GP levels they will be financially compensated for providing regular updates on sanitation information and for successful implementation of strategies to promote latrine use after one year, two years, three years, five years and eight years (What Works, p 5). Financial incentives from the NGP will be broken up to reward communities at each time interval for retaining ODF status and reimbursements will be provided to cover the recurrent costs of maintenance of latrines to sustain sanitation outcomes, extending the effectiveness of the plan well into the time horizon (Robinson, p 49).

Conclusion

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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