NB Health Care

Thursday
December 11
2014

NextBillion Editor

Champions of the Toilet: The best way to solve open defecation, the authors say, is to focus on demand, not construction

This post was written by Adrien Couton, Romit Mehta and Ahmed Nadeem Khan of Dalberg.

One out of every two people practicing open defecation globally lives in India. In fact, India has more than double the number of people practicing open defecation (OD) than the next 18 countries combined. The practice negatively affects health and is a leading cause of diarrhea, which kills 300,000 children each year in India, according to WHO. Moreover, lack of access to sanitation facilities can cause malnutrition even among those who are food secure.

Complicating the situation, access to toilets doesn’t always fix the problem – health benefits from toilet use come only when communities as a whole use toilets. Partial coverage generates insignificant health benefits. Therefore, to address India’s malnutrition and health crisis, it is imperative to aggressively promote widespread adoption of toilet use and eradicate open defecation

The newly elected government in India under Prime Minister Narendra Modi recognizes the severity of this problem and has placed access to toilets at the forefront of the national agenda. To stress its urgency, Modi used the politically important Independence Day address to focus on the issue, and promised a toilet for every house by 2019.

Generating Demand for Toilets

This will not be the India’s first sanitation program focusing on toilet use. The government of India launched a Total Sanitation Campaign (TSC) in 1999 that was meant to be a community-led, demand-based program to increase rural access to toilets. TSC provided subsidies for household toilet construction and the campaign appointed district-level sanitation coordinators (Swachhata Prerak) to build awareness for toilets and monitor and implement the program in their districts.

However, the policy’s execution departed greatly from its design. On the ground, TSC was supply-led and infrastructure-focused. Information, education and communication (IEC) was considered secondary and budget for IEC activities was capped at 15 percent of the program’s total budget. Spending by the district coordinators was further mired in bureaucratic red tape. In the end, only 6 percent of the program budget was spent on programs sparking demand for toilets and educating about the health effects of OD.

The TSC program failed to meet its objectives – only 47 million toilets were constructed by the end of 2012, against a target of 120 million. Real coverage, as per census data, was 31 percent at the end of 2012 as opposed to government’s claims of 68 percent. These statistics indicate that a large majority of toilets were either missing, had become unusable or were simply not built.

Furthermore, a survey conducted in five states by the Research Institute for Compassionate Economics found that 40 percent of households in the sample that had a toilet had at least one person who was still defecating in the open. Further inquiries revealed that people believed it much healthier to defecate in the open with 74 percent citing “pleasure, comfort and convenience” as the key reason for OD. The failure of household adoption of toilets showed a stark disconnect between sanitation infrastructure and toilet use.

Ideally, further programs will use a holistic approach combining hardware subsidies with awareness generation. This is not necessarily a simple solution – current projects show that community-wide information, education and communication efforts take anywhere between three to eight months along with considerable financial resources to successfully demonstrate the need for toilet adoption. They require a dedicated and trained staff working in local communities.

Emphasizing Behavior Change Over Hardware

Countries like Indonesia and Bangladesh have reduced OD by focusing exclusively on behavior change, without providing any subsidies for toilet construction. In India, community-wide behavior change efforts have also yielded positive results and provide a framework to increase toilet adoption.

Gramalaya, an NGO, runs a successful toilet adoption program in partnership with the local government in Tiruchirappalli through community management of sanitation facilities. Gramalaya establishes multiple Self Help Groups (SHGs) in a community who are encouraged to construct and maintain pay-per-use community toilets. Each SHG member is caretaker of the community toilet for a day and collects user fees and maintains the accounting. The mix of community participation with a focus on encouraging use of toilets has met with success – several communities have been declared open defecation-free.

Cambodia provides another model of success in sanitation marketing. The Water and Sanitation Program (WSP)-supported Sanitation Marketing Pilot Project produced an affordable pour flush latrine (Easy Latrine) and trained local enterprises to produce and sell it at profit. Toilets were promoted as aspirational products to prioritize in household spending. The project’s promotion strategy included advertising messages such as “Have a latrine – have a good life.” The campaign was successful – about 10,600 latrines were purchased during the pilot. In 601 monitored villages, there was an approximate 7.5 percentage point increase in improved sanitation coverage from the baseline – six times higher than the background rate of increase. The toilets went on to be widely adopted. More than 100,000 units have sold in two years.

What Works in Demand-Driven Sanitation Programs

Dalberg’s research in Cambodia found appointing sanitation champions as decentralized sales agents for latrines had a significant impact on selling latrines. Being close to potential customers, the sanitation champions undertook a range of awareness-building activities and focused on generating demand for toilets. The efforts were successful and the commune Trapeang Sala Khang Lech became open defecation-free.

Success in curbing open defecation can only be achieved by generating demand for toilets through a consistent focus on behavior change. Infrastructure-focused programs are by themselves inadequate in solving the problem of open defecation. The Indian government needs to remember this lesson as it embarks on an ambitious path to provide a toilet to every household.

Adrien Couton is a partner in Dalberg’s Mumbai office and leads Dalberg’s WASH Practice. Romit Mehta is an associate consultant at the Mumbai office of Dalberg. Ahmed Nadeem Khan is an analyst at Dalberg’s Mumbai office.

Categories
Education, Health Care
Tags
education, global health, health care, leadership, public health, sanitation