(di·chot·o·my noun: a difference between two opposite things : a division into two opposite groups)
A good way of blocking progress in an argument is to present two aspects of a whole as a dichotomy. The sanitation debate, in recent years, has suffered from a seemingly irreconcilable dichotomy when it comes to identifying the best approach towards ‘sanitation for all’. This is the one that pits subsidies against motivation and correspondingly, construction against behaviour change communication. And yet, in a comprehensive and prudent programme design, there is no need for these ideas to be opposed to each other. I call this then, the false dichotomy in the world of sanitation advocates.
The current sanitation programme in India has at its centre, a subsidy/incentive for individual households constructing toilets. This is a programme that has clearly not worked – irrespective of the minister or bureaucrat at the helm of affairs. India holds the ignominious record of having the largest number of people defecating in the open. At the same time, the popularity of the Community-led Total Sanitation (CLTS) approach has risen. This approach depends on using ‘shame and motivate’ as a call to action to build basic pit latrines (rejecting subsidies completely) and has worked in multiple countries around the world, as well as in certain states in India.
There is a catch here. Although there is sufficient evidence from locations that have used this approach that households construct latrines and start using them, there is little evidence that shows that these latrines continue to be used in the long-term. For instance, this study from Kenya, Uganda, Ethiopia and Sierra Leone reveals a slippage rate of nearly 90% – meaning, nearly 90% had gone back to unhygienic sanitation practices over a period of two years after the intervention. The study calls for identifying ways to help families upgrade their sanitation infrastructure alongside greater follow-up and continuous health messaging. CLTS does not address this infrastructure gap, neither does it support the poorest families in availing usable and lasting toilets.
This way of framing the debate ignores a key question – how can we ensure that all families in a geographic cluster (village/neighbourhood/slum) use a working toilet and the associated safe sanitary practices? Irrespective of the side one chooses of this false dichotomy, it is clear that an either-or solution is doomed for failure. Most importantly, one often forgets that open defecation is a public health hazard which can only be tackled if entire neighbourhoods adopt safe sanitation practices. Even one family refusing to use a toilet – whether they lack awareness or funds – poses a risk to everyone else, irrespective of how safe their own sanitation practices are. This in particular implies that solutions to open defecation have to involve a mix of motivation and tangible assistance with infrastructure.
Recent research that has been widely reported show that a large number of our rural countrymen (more than countrywomen) do not care about toilets. It then follows that what is required indeed is a change in attitudes and demand creation. Very well, thus far. However, the current reality is that the government’s existing sanitation programme churns out un-usable toilets that destroys any demand that might actually exist – for households that receive it, as well as anyone living in their vicinity. Therefore, the first step towards fixing this government programme is to ensure high standards in construction.
An intervention that sets out to do so will have to include multiple components: creating awareness so households buy-in to the programme; dealing with corruption on the ground; and community participation in monitoring and maintenance. Awareness campaigns for behaviour change is thus a key component that holds the intervention together – in ensuring both quality construction as well as usage thereafter. This might seem like a costly and drawn-out process, but not for nothing is sanitation often called a ‘wicked problem’.
What is also lost in this dichotomy is the opportunity to make progress in the way we design our interventions. Can provision of financing be structured in ways that it puts the onus back on local governments and individual households? Who should take the lead on communication campaigns and how should these be sequenced in combination with the construction work? What kinds of messages work for particular communities? How can households be encouraged to contribute in cash and kind towards their toilets, as well into the creation of a sanitation system (toilets, sewers/drains, maintaining clean drinking water sources, etc) that needs to be managed as a public good?
It is easy to see why the behaviour change-led zero subsidy approach makes for a seductive argument. Years of sanitation subsidies in countries like India have seen little impact and have sometimes lead to perverse incentives amongst both households and local governments. On the other hand, phlegmatic bureaucrats and contractors have no incentive in diluting the focus on infrastructure which maintains the status quo. However, unless we break out of this false dichotomy and bring both these approaches together in equal measure, our efforts at presenting a sustainable, inclusive and dignified solution is bound to fail.