Rural Sanitation in India: An Assessment of the Swachh Bharat Mission
As of 2015, around 60 percent (67 percent of rural households and 13 percent of urban households) of Indians reportedly lacked access to safe and private toilets. Lack of proper sanitation poses a serious threat to the health of children, with a number of diseases being transmitted through human waste. UNICEF reported that nearly 40 percent of Indian children were reported to be stunted, and that around 140,000 children, below the age of five, die each year in India due to diarrhea. The high population density in rural India increases the transmission of germs, leading to high health and economic costs for this demographic.
Under the Swachh Bharat Mission, the Government aims to make India “open defecation-free” by 2019 by constructing 120 million toilets in rural India at a projected cost of Rs 1.96 lakh crore. 90 percent of this proposed funding is earmarked for the construction of the toilets and 8 percent for awareness-related activities. By the end of 2015, it was reported that 10 million toilets were constructed across rural and urban India. However, less than 50 percent of the toilets constructed across urban and rural India were being used, with many being used to store grain or tether cattle.
A study attempting to understand sanitation behavior in rural India found that GDP per capita, poverty, education and water access do not explain the widespread prevalence of open defecation in India. In fact, 46 of the 55 countries that have a lower per capita GDP than that of India have lower open defecation; 23 of the 28 countries with lower literacy rates than that of India have lower open defecation; and, access to improved water sources does not correlate with reduced rural open defecation.
A Sanitation Quality, Use, Access and Trends (SQUAT) Survey conducted in five Indian states in 2014 uncovered the revealed and stated preference for open defecation. It found that amongst individuals living in households without a toilet, 55 percent of the individuals would continue to defecate in the open even if they received a toilet through any government support. This figure went up to 66 percent on for toilets that were fully government constructed. Awareness of a sanitation program did not translate into an increase in toilet usage.
In 2014 the Research Institute for Compassionate Economics (RICE) conducted a SQUAT survey in five Indian states. The study covered 22,787 individual household members in 3,235 households in 13 districts in rural India. To ensure a representative sample, a four-stage sampling selection strategy was followed:
Districts were chosen to match the state-level trend in rural household open defecation rates between 2001 and 2011
Villages were randomly sampled using probability proportionate to population size using the list of villages from the Government of India’s DLHS-2 survey
Households were randomly selected using a previously proven randomization technique (used in Pratham’s ASER survey)
An individual was chosen at random from each household for the individual interview after completing the roster of household members.
The SQUAT study corroborated findings from other independent studies. Indian cultural and social norms, including beliefs of purity and household pollution, coupled with the infrastructural challenges prevent the common use of simple, inexpensive latrines. Even in households with access to a latrine, open defecation is very common. Across studies of individuals both with and without access to toilets, the most common stated reason for open defecation is that individuals find it more comfortable, pleasurable and convenient. Open defecation is also viewed as having social benefits, such as through the activities of socialization, the ability to take a walk, view one’s fields and take in fresh air. Habit and tradition also played influential roles in the choice of open defecation. The SQUAT survey found that over 50 percent of rural Indians studied do not view open defecation as affecting their health adversely, and were either unaware or unconcerned by the health consequences.
The above stated findings show that rural Indians’ perceptions of value in open defecation is articulated relative to a reference level. This reference level is a state relative to which outcomes are evaluated as gains and losses. In the case of toilet usage, this reference level may be the existing status quo of open defecation. The outcomes could be categorized as social and cultural outcomes and health outcomes.
The cultural and social outcomes to open defecation are perceived as a gain relative to this reference level. A change in defecation behavior, towards a more health-driven approach, through the usage of toilets is then perceived to be a loss. There is considerable risk aversion even when the loss is miniscule relative the reference point. In this context, the perceived loss of social and cultural benefits of open defecation can explain the aversion towards a change in defecation behavior. As rural Indians are found to be unaware or unconcerned by the health consequences of open defecation, the health benefits to be gained from a shift in behavior do not offset the losses.
There exist significant infrastructural challenges which inhibit the use of government built toilets. Studies have found that subsidized latrines were not built properly, lacking a roof, a door, and any walls at times, causing concerns of privacy, especially for women. Hence, a policy intervention must incorporate both behavioral change measures and infrastructural improvement measures.
Behavioral change measures may take a number of forms, such as pushes for better behavior or a community deliberation and pledge approach. Efforts that focus on influencing individual behavior can play an important role in contributing to norm change. This may be done by harnessing the power of the health community worker who is well integrated into the local community to better explain both the individual level health benefits, and benefits to offspring, through the use of toilets. UNICEF used a Community-Led Total Sanitation intervention where facilitators encouraged the community to make a public pledge to each other that they will eliminate open defecation in their community. This framed open defecation in the context of breaking promises to one’s peers, not convenience.
The Government’s existing awareness campaigns do not effectively address behavior change, both in terms of budget, as well as in targeting change. Any policy that hopes to eliminate open defecation in the next 4 years will certainly need to take these important barriers into account.
The author is a Consultant at the World Bank and a student at Georgetown University’s McCourt School of Public Policy.