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Access to toilets leads to public health gains

posted Oct 22, 2019, 8:55 PM by Gaurav Mishra

At least 100.7 million toilets were built under the Swachh Bharat Mission (SBM) across the country to take the toilet coverage from 38.7% on Oct 2, 2014, to 100% on October 2, 2019, according to the jal shakti ministry data. The coverage is seen to have contributed to rural India achieving the open-defecation free (ODF) status within five years

Experts say while the last mile challenges like access to safe water and functioning soak pits for human excreta remain, providing an estimated 500 million toilets to prevent open defecation has brought measurable public health gains.

Three of the top seven causes of disease and death in India – malnutrition, dietary risks, and poor WASH (water, sanitation, and hygiene) practices -- are directly linked with poor sanitation services and poor hygiene practices.

Poor sanitation is the leading cause of frequent diarrhoea, malnutrition, cholera, hepatitis A and E (jaundice), worm infestations, typhoid, and other enteric fevers. They lead to chronic malnutrition and lowered immunity that further feeds the infectious disease cycle.

Improved sanitation has prevented at least 300,000 deaths from diarrhoea and protein-energy malnutrition between 2014 and October 2019, according to a World Health Organisation (WHO) estimation of the health impacts of SBM.

The estimation was done in 2018 using data from two large nationally representative surveys -- the Rapid Survey on Children, which was conducted shortly before the launch of the SBM in 2014, and the National Family Health Survey from 2015/2016 – as well as third-party surveys.

“Unsafe sanitation led to an estimated 199 million cases of diarrhoea, which spreads through food and water contaminated by untreated faecal matter, annually before the start of the SBM in 2014. These have been reducing steadily since India accelerated safe sanitation services and ended open defecation, with the modelling showing diarrhoea deaths will be almost eliminated when India achieves universal coverage and use of safe sanitation facilities is achieved,” said WHO South-East Asia’s regional director Dr Poonam Khetrapal Singh.

Experts say along with toilets, working sewage-disposal systems, waste-disposal management, protection of water supply from contamination and promotion of handwashing practices were needed to improve the nutrition status and immunity of children.

Malnourished children are underweight, stunted or wasted, and are more likely to die of childhood infections like pneumonia and tuberculosis. About 38.4% of children are stunted or have a lower height for their age and 35.7% are underweight, according to the National Family Health Survey-4 (2015-16).

The decline in stunting and underweight children has been marginal over the past decade while wasting (low weight for height) has gone up from 19.8% in 2006 to 21% in 2016. Safe sanitation is expected to lead to rapid reductions in all three indicators in the next NHFS. 

"Improving sanitation is helping India meet SDGs [Sustainable Development Goals] by improving health, nutritional status, gender equity by keeping girls in school, reducing poverty, and providing people a life of dignity,” said Singh.

Children have done their bit to push for ODF, according to Unicef. “When we talk about SBM, we have to understand how children have been involved. Twenty million children wrote to PM Narendra Modi on how they wanted to take action. Children instigating change has made participation even stronger,” Dr Yasmin Ali Haque, Unicef’s India representative.

First Published: Oct 02, 2019 23:43 IST


Proper handwashing matters for your health

posted Oct 22, 2019, 8:49 PM by Gaurav Mishra   [ updated Oct 22, 2019, 8:50 PM ]

Proper handwashing may seem trivial to some, but it is more important than many realise – in schools, in healthcare facilities, and in the home. Global Handwashing Day, observed on October 15th, is an important reminder of an often neglected practice. 

UNICEF India points out the importance of handwashing, noting its connection with diarrhoea – the most common cause of infectious disease outbreaks in India and the second most common cause of death among children under five worldwide according to the World Health Organization (WHO). Every day, at least 1,300 children die due to diarrhoea and diseases linked to infections of the respiratory tract. Of these deaths, 320 happen in India. 

As UNICEF notes, of the 1.5 million child deaths which occur yearly due to diarrhoeal diseases, forty percent can be prevented by “handwashing with soap at critical times – including before eating or preparing food and after using the toilet.” Similarly, acute respiratory infection deaths can be prevented 23 percent of the time by proper handwashing practices and the habit can also be linked to a number of improved health outcomes. Newborn survival rates improve by 55 percent if proper handwashing practice is followed, whilst controlling the spread of infectious diseases and viruses ranging from pneumonia to severe acute respiratory syndrome (SARS) can be bolstered if handwashing is helped. 

Proper handwashing matters for your healthA public toilet opposite the Karni Mata temple in Rajasthan. Expanding access to toilets and other sanitation facilities has been a priority of the Modi government. Image credit: Sandra Cohen-Rose and Colin Rose from Montreal, Canada [CC BY-SA 2.0 (]. Source: Deshnok Art DecoIn India, improved sanitation has been a flagship priority of the Narendra Modi government. This is perhaps best exemplified in its Swachh Bharat (Clean India) campaign which has achieved considerable success in expanding access to sanitation facilities such as toilets throughout the country and reducing rates of open defecation. 

The campaign does not neglect handwashing. An editorial penned by Sanjay Banka and published last year on the Global Handwashing Partnership website notes that “Swachh Bharat Abhiyaan (Clean India Mission) program and subprogram Swachh Bharat – Swachh Vidyalaya (Clean India – Clean Schools) are working to improve WASH services and practices across India.” WASH refers to water, sanitation, and hygiene, of which handwashing is a vital component. 

In addition, Banka points to efforts by the private sector to support Swachh Bharat Abhiyan. A partnership between electrical goods firm Havells and social enterprise Banka BioLoo, of which Banka is executive director, “has already installed bioloos with handwashing stations in over 350 schools” he wrote at the time. According to Every Woman Every Child, in 2018 alone, Banka BioLoo installed 800 bioloos in 100 schools.

Despite these encouraging efforts, handwashing practices in India are poor among the populace. As a study reported in 2017, “only 26.3 percent washed hands before child feeding, 14.7 percent before breastfeeding, 16.7 percent after disposing child faeces, and 18.4 percent after cleaning a child’s bottom.” 

Proper handwashing matters for your healthA female urinal at a government-run school in the Cuddalore district of Tamil Nadu. 24 percent of schools in India do not have access to sanitation services and 41 percent lack access to hygiene services. Image credit: David Crosweller [CC BY-SA 4.0 (]. Source: Sanitation First, UKSchools are a key part of the equation. Globally, Yahoo Finance reports that “53 percent of schools worldwide lack handwashing facilities with water and soap. Additional research found that globally children lose 443 million school days each year because of water-related illnesses.” In India, WASHWatch reports that 69 percent of schools have access to basic water services; of the remainder, 22 percent have access to limited water services and nine percent do not have any access to a water service. Urban schools are more likely to have access to water services than those in rural areas. These disparities translate to access to sanitation and hygiene — a divide which is notable across healthcare as a whole. 

Concerningly, 24 percent of schools in India do not have access to any sanitation services (73 percent have access to basic sanitation and services and three percent have access to limited services). For hygiene services, the figures are even more dismal: 54 percent have access to basic hygiene and five percent to limited hygiene. This means that 41 percent of schools in India do not have access to any form of hygiene services. 

Not only do staggering numbers of schools lack access to these basic and essential amenities, it is prevalent in hospitals too. Two billion people worldwide do not enjoy access to basic sanitation services in their healthcare facilities, including 1.5 billion who do not have access to any sanitation services. 

Proper handwashing matters for your healthTaps in a college bathroom. Handwashing facilities are a must – in the home, in schools, and at hospitals. 

Handwashing is among the most simple ways of reducing the risk of hospital-acquired infections, which occur at a rate of one in every four hospital visits in India. Hygiene has been pinpointed as a major driver of this. As previously reported by Health Issues India“despite hygiene protocols — covering both usage of medical devices and basic practices such as hand washing — being in place, a lack of compliance with infection control guidelines has resulted in an increased infection rate.” 

As previously noted by Dr Bruce Gordon, the WHO’s coordinator of its work on water and sanitation, “the one thing that you need to do is wash your hands, whatever bug it is, whatever resistance it has. It’s not a matter or diarrhoeal disease, it’s a matter of any opportunistic infection that can just happily live on skin, or get in cuts, and get inside your body and give people sepsis.”

Lack of sanitation and hygiene facilities in hospitals are major drivers of infectious diseases. The WHO has issued guidelines for handwashing for medical professionals, but every person should take note of proper handwashing procedure, with recommendations available here. Meanwhile, any sanitation drive undertaken by policymakers must take into account the need for basic WASH services at the least and to raise public awareness of why handwashing is not a trivial activity, but one which can save lives. 


Swachh Bharat Mission: The last push

posted Oct 22, 2019, 2:02 AM by Gaurav Mishra

Call it the result of a strong political will or a multipronged assault on a nagging problem, what India is witnessing now is no less than a civilisational leap forward. Till five years ago, open defecation was a way of life for most in the country. The government was over and again pulled up at international platforms for hosting 60 per cent of the global population that defecates in the open. But at the last count on September 23, villages and cities in all the 37 states and union territories had declared themselves ODF. With verification pending for just 22 per cent of the districts, the country was on track to attain ODF on October 2.

There is a sense of triumph among officials and community leaders who have been part of this sanitation programme, dubbed the largest in the world. Data with the Department of Drinking Water and Sanitation shows in October 2014, when the mission was launched, sanitation coverage in rural areas was just 38.7 per cent. Some 550 million people, or almost half of the country’s population, were defecating in the open.

Since then, a massive 100 million household toilets have been built across 600,000 villages; another 5.8 million household toilets and about 500,000 community and public toilets constructed across 4,303 cities. By the government’s own admission, “SBM has changed the behaviour of hundreds of millions of people with respect to toilet access and usage.” By March this year, notes its press release, 500 million people in rural parts of the country had stopped defecating in the open.

The National Annual Rural Sanitation Survey (NARSS) 2018-19 by the Independent Verification Agency under the World Bank, which has offered financial assistance for SBM-Gramin, reconfirms the claims. The agency, during its survey between November 2018 and February 2019, found that 93.1 per cent of the households had toilets; 96.5 per cent of them were using the toilets.

Such massive toilet coverage has helped the government achieve another milestone much ahead of the target. In 2015, when the United Nations prepared the list of 17 sustainable development goals (SDGs) to be achieved by 2030, one of its foremost agendas required countries to “achieve access to adequate and equitable sanitation and hygiene for all and end open defecation”. Meeting SDG 6.2 then seemed a humongous task for India that topped the list of laggard countries and is often described as an Asian enigma by researchers.

India has a much larger prevalence of open defecation than in other countries with similar economic status, wrote Dean Spears, founding executive director, the Research Institute for Compassionate Economics (r.i.c.e.), in the August 2018 issue of the Journal of Development Economics. Spears says open defecation in such a densely populated country could be the reason many health outcomes are much worse than what would otherwise be predicted based on its GDP per capita.

For instance, India’s infant mortality rate is about one-third higher than those of poorerBang ladesh and Nepal. Anaemia, too, is poorly explained by income and is common in India despite it lacking a high malaria burden similar to sub-Saharan Africa.

Officials say health indicators are fast improving since SBM. “Diarrhoea, a leading cause of death among under-five children in India, accounted for 11 per cent of deaths in 2013,” notes the Economic Survey 2018-19. Its sample analysis shows diarrhoea cases reduced significantly — by 18.4 per cent — in areas where more toilets were installed.

Improvements are evident in malaria, still births and low-birth weight cases, notes the report, which reviews developments in the Indian economy over the past financial year. Citing a World Health Organization report, it says deaths due to unsafe sanitation have also significantly reduced.

Source: Swachh Bharat Mission—Preliminary estimations of potential health impacts from increased sanitation coverage by the World Health Organization, as cited in Economic Survey 2018 -19 based on data available till June 2018

These are no mean feats for a country that has been trying to provide safe sanit ation to all its citizens for over three decades now. However, there was no dramatic shift in the access rates for toilets until SBM was launched, says Economic Survey, adding, “SBM is the first one to emphasise behaviour change as much as, if not more than, const ruction of toilets.”

The December 2015 report of the Comptroller and Auditor General of India shows during the sanitation programmes implemented between 2009-10 and 2011-12, money for information, education and communication (IEC) was spent on unrelated activities like booking meeting halls. By comparison, shows the June 2019 assessment by international policy advisory firm Dalberg, Rs 3,500 crore to Rs 4,000 crore was spent on IEC under SBM-Gramin. This mobilised an equivalent investment worth Rs 22,000 crore to Rs 26,000 crore — almost half of the budget allocated under SBM.

On an average, a person in rural India was exposed to between 2,500 and 3,300 SBM-related messages over the last five years. To initiate behavioural change, 650,000 swachhagrahis were recruited. When new toilets are built and used, says the report, they serve as nudges for people to adopt safe sanitation behaviour.

This is part of Down To Earth's print edition dated 1-15 October, 2019 


Declaring India 'Open Defecation Free' Doesn't Mean Sanitation Goals Have Been Met

posted Oct 21, 2019, 10:49 PM by Gaurav Mishra

Overcoming resistance to toilet usage requires addressing values, norms and beliefs that will lead to behaviour change, and ultimately the health and economic benefits.

October 2, 2019, marked the five-year anniversary of the Swachh Bharat Mission (SBM) – an ambitious programme aimed at declaring the country free from open defecation.

There is much to celebrate. As per government data, in rural areas alone, over 10 crore toilets have been built in the last five years, representing a staggering 38 toilets built per minute. While questions remain on the true extent of coverage or usage, there is no doubt that the country has seen an unprecedented rise in access to individual household toilets. Today, many more are aware of sanitation than ever before and those for whom access was the main barrier, have seen an increase in the usage of sanitation facilities.

But the processes involved in the implementation of Swachh Bharat are also a clear reminder that while mission-mode programmes work relatively well in achieving short-term, measurable, defined objectives such as toilet construction, sustaining momentum or dealing with wicked-hard problems such as changing social norms or maintaining the water-sanitation-health continuum are much tougher. And herein lies the challenge of Swachh Bharat going forward.

The goal of Swachh Bharat is safe sanitation – for its contribution to improvements in health and nutrition. Recognising this, the rural arm of SBM had advocated for a low-cost, on-site sanitation technology known as the twin leach pit model for its safe and sustainable containment and management of faecal waste.

However, the rush to build toilets fast, with an insufficient focus on awareness (not just of households but also of masons), has meant that in many cases, these guidelines have not been followed. As per the latest National Annual Rural Sanitation Survey (NARSS 2018), only 29% of households with toilets had the twin leach pit model. Instead, many households have built larger, single pit toilets, containment chambers or septic tanks, often even ignoring the recommended distance from water sources or the water table. These toilet types require more water and external systems for removal, transportation and treatment of the excreta. Failure to do so effectively could have catastrophic health and nutrition impacts. Moreover, the unavailability of effective systems for emptying them – particularly in rural settings – could lead to the inadvertent promotion of the illegal and inhuman practice of manual scavenging. As our own survey of ODF gram panchayats in Udaipur district had found, as many as 86% of the sampled households reported reverting to manual scavengers for pit cleaning.

The other challenge is of course on sustaining usage or getting communities often with ‘rational’ reasons for not using toilets, to change their behaviour. Overcoming this resistance to toilet usage requires addressing values, norms and beliefs that will lead to behaviour change, and ultimately the health and economic benefits. While the programme attempted a number of different strategies for awareness and behaviour change, the overemphasis on messages about women’s safety and honour have diluted the core message of safe sanitation for its benefits to health and instead reinforced gender-stereotypes.

Finally, in a mission-mode programme, the likelihood of continuing efforts towards an objective that has already been declared as met, are limited. Our Udaipur study found that post ODF declaration, efforts at behaviour change communication or even monitoring came to a standstill. The government’s own verification data shows that the second level of verification is progressing at a slower pace. As of today, 96.5% of the villages that have been declared ODF have undergone one level of verification but only 25% have undergone the second level.

The good news is that the recently released ten-year strategy for sanitation in rural areas (2019-2029) implicitly (and at times even explicitly) recognises a number of these pitfalls. The next phase (described as ODF-Plus) aims at sustaining toilet usage and maintenance and ensuring access to solid and liquid waste management at the village-level. This, as the strategy states, will require a focus on three aspects: access (for new households and anyone left behind), developing or retrofitting infrastructure (such as conversion  of single-pit toilets to double leach pit and ensuring proper solid liquid waste management), and sustaining behaviour change through continuous communication and capacity building.

These are important ‘what next’ guidelines for the sanitation sector. However, in order to truly achieve linkages across nutrition, health, water, sanitation and gender, our policies need to be intersectional and cover the entire implementation value chain. It can’t be that building toilets is the work of Swachh Bharat, preventing diseases is the work of the Health Department, while dealing with nutritional outcomes that of the Ministry of Women and Child Development.

This is a hard ask and one whose onus is not on the sanitation department alone. It would require a significant overhaul of how we design and finance social policy interventions in India. Currently, every policy (including this one) speaks about the need for institutional convergence. Yet, operational clarity of the same remains a challenge and convergence has become synonymous with coordination. While the 73rd and 74th amendments to the constitution espouse decentralisation particularly for provision of core services, most programmes continue to be designed as top-down schemes or specific missions with separate fiscal and institutional architectures running in parallel.

To solve ‘wicked-hard’ problems such as sanitation, we need to do away with these narrow schematic models and move towards a broader, cross-sectoral  approach. Such an attempt at effective co-convergence will require comprehensive decentralised planning, disaggregated data and truly untied finances. As a recent paper by the International Food Policy Research Institute on nutritional convergence noted:  it is imperative to not just ensure that all interventions reach all target households, but also that they reach them in the right time-frames.

In the 150th birth year of Mahatma Gandhi, the time is ripe for big, bold ideas. Let’s hope we do not repeat the same mistakes and all the effort put in making safe sanitation for health and nutrition a national priority does not go in vain.

Author: Avani Kapur is Director of the Accountability Initiative and Fellow at the Centre for Policy Research (CPR).  Sanjana Malhotra is a Research Associate with Accountability Initiative, CPR.


India lags in drinking water, sanitation and hygiene facilities: Study

posted Oct 21, 2019, 10:46 PM by Gaurav Mishra

The Harvard University study is based on the performance of India’s 543 parliamentary constituencies on — unsafe disposal of child stool, unimproved drinking water supply, and sanitary facilities.

India continues to lag in proper drinking water, sanitation and hygeine facilities, according to a new study by Harvard University.

Parliament constituencies in Bihar, Odisha, Jharkhand and Madhya Pradesh shared the highest burden of unsafe child stool disposal.

Three constituencies in Odisha — Bargarh (95.85 per cent), Jajapur (95.65 per cent) and Kandhamal (95.28 per cent) — had the highest prevalence of unsafe child stool disposal in the country, showed the study.

The findings are based on the performance of India’s 543 parliamentary constituencies on three important indicators of Water Sanitation and Hygiene (WASH) index: Unsafe disposal of child stool, unimproved drinking water supply and sanitary facilities. 

The data was collected by generating precision-weighted estimates of each indicator at the constituencies-level, based on the recently developed methodologies of linking cluster GPS data from the National Family Health Survey (NFHS-4), 2016, to potential constituencies.  

“Unsafe child stool disposal has received limited attention in sanitation policy in India with the country’s historic focus on household toilet infrastructure,” according to the paper published in the Journal of Development Policy and Practice.

The World Health Organization (WHO) defines (child) safe stool disposal as “when the child uses a toilet/latrine; and/or the faeces is put/rinsed in the toilet/latrine or buried”.

Based on mothers’ report in the NFHS-4, if the child’s faeces were left in the open/not disposed of, put/rinsed into a drain/ditch, or thrown in the garbage, the disposal was coded as ‘unsafe’.

The fourth round of NFHS conducted in 2015-2016 was based on a total sample size of 628,900 households across India. The survey was designed to provide estimates of key indicators related to population health and nutrition at the national, state and district levels.

Sanitary facilities were very poor in parliamentary constituencies in northern and eastern India. Budaun (90.69 per cent) and Ambedkarnagar (89.80 per cent) in Uttar Pradesh and Bhagalpur (87.14 per cent) in Bihar were the constituencies with the highest prevalence of poor sanitation facilities.

On the other hand, constituencies in Lakshadweep (0.19 per cent), Sikkim (0.91 per cent) and Idukki (0.96 per cent) and Alappuzha (0.97 per cent) in Kerala had the lowest prevalence of poor sanitary facilities.

Interestingly, Maharashtra, which seems to perform far better on WASH indicators than Uttar Pradesh, had far more constituencies with high burden of poor sanitary facilities than the latter, the study showed.

The paper also found a strong correlation between unsafe child stool disposal and poor sanitary facilities.   

Monitoring of Swachh Bharat Mission (SBM) data at the constituencies’ level will allow parliamentarians to effectively improve WASH conditions in their constituencies and the approach is better than that focussed on state or district means, the researchers suggested.   

Parliamentary constituencies in north-eastern and southern India — particularly in Manipur, Meghalaya, Andhra Pradesh and Telangana — shared the highest burden of poor drinking water source.

The constituencies with the highest prevalence of poor drinking water were Inner Manipur (64.17 per cent) and Outer Manipur (59. 86 per cent) in Manipur; and Kadapa (46.62 per cent) and Kakinada (42.73 per cent) in Andhra Pradesh.

Constituencies in the northern and eastern parts of India had the lowest prevalence of unimproved drinking water sources. Fatehgarh Sahib (0.75 per cent), Ludhiana (0.58 per cent), and Jalandhar (0.35 per cent) in Punjab shared the lowest prevalence of poor drinking water. 


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