India is on the cusp of being declared free of the practice of open defecation, a critical step for the health and future of millions of children and their families.
According to a WHO study, the Swachh Bharat resulted in averting more than 3,00,000 deaths from diarrhoea and protein-energy malnutrition between 2014 and October 2019. With more than 110 million under five-year-olds in India, the stakes could not be higher for children.
Fittingly, India’s achievement comes at the time of commemorating the 150th anniversary of Mahatma Gandhi’s birthday. As the United Nations Secretary-General Antonio Guterres said this week at a special UN General Assembly event, “Gandhi understood the importance of advocacy and action around the issue of sanitation and led campaigns for clean drinking water and hygienic facilities when this issue was still deeply taboo.”
It has not been a simple or easy road to end open defecation in India. While there remains much more to do to consolidate this impressive achievement and strengthen other parts of the sanitation cycle, the lessons learned during the last five years are critical to sustain and expand the success at home, as well as for other countries and international development partners. Worldwide, more than 670 million people continue to suffer due to practices of open defecation, as shown in the latest Joint Monitoring Report released in 2019.
Why is ending open defecation critical for health and overcoming poverty?
Open defecation enables the spread of diseases such as cholera, polio, and hepatitis. Children are at a higher risk of diarrhoea, which in turn leads to malnutrition, a large-scale problem in India. In 2015, India lost approximately 117,300 children annually, or 320 children each day, to diarrheal disease, which was caused by poor sanitation and water supply.
There is a strong link between open defecation and stunting. Globally, a high percentage of children under five are stunted, and in India 35 percent of children are stunted. Stunting and other forms of under-nutrition are thought to be responsible for nearly half of all child deaths globally. Stunting is also associated with an under developed brain which has long-lasting consequences, including diminished mental ability and learning capacity, and increased risk of nutrition related chronic diseases.
Women are also among the worst affected due to lack of sanitation facilities, especially due to lack of safety and privacy. For pregnant women and new mothers, the risks from poor sanitation are compounded.
India’s path to ending open defecation can help other countries as they face this deadly challenge, as they study some of the key lessons from the last five years of action.
First, sanitation is more than building toilets, it is also about changing behaviour.
Five years ago, talking about open defecation in public was taboo in India, a very difficult subject to discuss. Not surprisingly, previous campaigns saw modest gains in sanitation coverage. In 2014, when the Prime Minister launched the Swachh Bharat Mission, top level political will was translated into sustained investment and action across all levels of government in health, education and local governance—from chief ministers, district collectors to village heads and committees as well as other sectors working relentlessly from village to village, across districts and states. Government at all levels focused funding, monitoring and taking accountability for cleaning up their own backyards.
The countrywide challenge of people defecating outside in fields and public spaces that wasn’t talked about is now being openly discussed on TV, radio and other media platforms including art and sports. Akshay Kumar’s Bollywood hit “Toilet – Ek Prem Katha” took the issue head-on. UNICEF Regional Goodwill Ambassador and legendary cricket captain, Sachin Tendulkar, reached out to millions through various awareness campaigns and offered ‘sanitation champions’ an opportunity to meet him personally.
Communities took up the discussion.
Over 100,000 women masons joined the men to construct toilets in their communities, and 500,000 Swachhagrahis (community motivators or volunteers) knocked on doors across India to take up the issue of human waste. UNICEF has been supporting many of the initiatives on the ground and has witnessed the unfaltering conviction of grassroots champions, led by the Sarpanches (local leaders) and the Swachhagrahis.
From grandmothers building toilets, to girls advocating to their parents to build toilets, to business leaders donating their salaries to ensure more schools have sufficient and separate clean toilets for both girls and boys, the drive by communities to end open defecation has matched the political will.
A group of scientists in Bengaluru and a self-help group in Jharkhand worked to turn human excreta into solid, odourless, pathogen-free manure. Entrepreneurs are recognising toilets as a business opportunity. Some studies estimate the sanitation economy to be worth US$62 billion in India.
Last year, almost 400,000 college students registered for the Swachh Bharat internship programme run by the Government. They reached out to large cross-sections of communities to change attitudes and behaviours. Programmes like the Swachchata Hi Seva (Cleanliness is Service) campaign, organised in the last fortnight of September, have seen participation from over 200 million people, who personally carry out sanitation and cleanliness messaging in their communities.
In the past two years, sanitation coverage has advanced with approximately 4,500 toilets being built an hour, reaching to a staggering total of 99 million toilets.
The economic benefits are also already being felt. According to a 2017 UNICEF assessment, based on data collected from 10,000 households across 12 states, households in cleaner/open defecation free areas save on average INR 50,000 per year by averting medical costs and death, loss of time and earnings. The biggest beneficiaries have been the poor who usually are at the greatest risk to hygiene related diseases and associated stunting and mortality.
India shows the way when it comes to achieving the 2015 Sustainable Development Goals which set the agenda to ending open defecation as a key step to eradicating poverty.
For India, toilet construction and usage are just the first steps. The country must now sustain the achievement by reinvesting in building up and strengthening the rest of the sanitation cycle, such as encouraging consistent hand-washing with soap, providing options for managing human waste safely, addressing the often under-addressed issue of child faeces, and investment in complementary programmes such as the newly initiated Jal Jeevan Mission (Water Mission), which aims to provide safe drinking piped water supply nationally.
For countries still struggling to address the deadly problem of open defecation and eradicating poverty, paying close attention to India’s lessons of the last five years of sustained effort and achievement could help produce lasting results for their people.
The writer is the UNICEF India Country Representative. Views expressed are personal.