A recently published Lancet paper looks at the impact of the erstwhile Total Sanitation Campaign in the coastal Puri district in Odisha. The study finds that the government’s rural sanitation programme, implemented by NGOs and community-based organisations, was unable to reduce exposure to faecal matter. As a result, this sanitation programme had no impact on the incidence of diarrhoea and malnutrition. The authors of the paper conclude that in order to realise concrete and sustainable health benefits, sanitation programmes need to increase both the coverage and use of toilets, as well as improved hygienic practices.
No one denies the importance of good sanitation and the impact it has on human health. It must follow therefore that the lack of positive impact is down to poor implementation of the sanitation programme in the study area. In fact, a process evaluation of the said programme concludes that the implementation was far from perfect, both in terms of the levels of coverage achieved and the levels of awareness. Over an implementation period of over a year (January 2011 – January 2012), the villages where the programme was implemented saw an increase in toilet coverage from 9% to 63%, but only 38% of the households had a functional toilet. It would have been interesting to learn more about the gap between toilet construction and usage (25 percentage points. In any case, the state of implementation, the authors point out, is typical of the prevalent Total Sanitation Campaign across the country.
On the one hand, the Total Sanitation Campaign of 2011 morphed into the Nirmal Bharat Abhiyan in 2012 and then, into the much-hyped Swachh Bharat Abhiyan of 2014. On the other hand, the essence of this public programme has hardly changed. An over-reliance on individual household subsidy for toilet construction continues to mark these schemes. The focus on individual households means that sanitation programmes try to move ahead rapidly with those families that are willing and able to construct toilets – much like a housing or livelihoods programme would. However, it has become amply clear that this approach does not work.
For one, without total coverage, the gains from improved sanitation cannot be realised in a community. Even before one begins to debate the balance of priorities between sound construction and behaviour change communication, implementers need to acknowledge that sanitation programmes follow an ‘all or nothing’ logic. Unless all families adopt hygienic sanitation practices, we will not make a dent on the incidence of disease prevalence. This is amply demonstrated by the findings from the Odisha study.
What is also striking is that implementation appears to have stopped at around the 60% mark. The process evaluation in fact shows that between February 2012 and March 2013, the coverage of toilets actually declined. Again, anecdotally, we have seen this happen over and over again. Villages get checked off the list as ‘covered’ when in fact, they lie partially or completely incomplete. This reflects two things: one, the failure to run an effective motivation – hygiene promotion – behaviour change campaign; and two, the failure to ensure construction of decent and usable toilets. From a policymaker’s perspective, it would be impossible to disentangle the two, to identify the real reason for the failure of the programme.
This brings me back to recent debates around whether sanitation programmes need to be toilet construction-led or behaviour change-led. This evidence from this study supports both camps. But more than either side, it supports the argument that in order to have a successful programme, you need to approach the problem from both sides with equal seriousness.
Nothing (other than a success story) about India’s Total Sanitation Campaign would be surprising for long-time observers of the water and sanitation sector around the world. This study does, however, contribute a solid piece of evidence, based on rigorous evaluation methods and relatively long observation time-frame, on how public sanitation programmes in India have failed to get it right, so far.