Chief Executive Officer, NITI Aayog
The Cost of Poor Sanitation
SANITATION IS A critical determinant of health. Inadequate sanitation especially affects children under the age of five, as their immunity is not yet strong enough to fight off various diseases. Research has shown that long-term malnutrition, as a result of parasites in the child’s body, not only prevents necessary physical and cognitive development but also results in stunted physical and cognitive growth. Children who fall ill frequently also miss school often, leading to poor learning outcomes. An ailing child is also likely to spread infections to his or her peers. When girl students reach adolescence, the absence of proper toilets in schools is a problem, and keeps them from attending school while menstruating, causing them to eventually drop out of school. Sanitation alone can thwart many of these effects among children. In addition to the ill-effects on the health and education of young girls and women, the lack of safe sanitation facilities also makes them vulnerable to fear, shame and harassment during open defecation.
A 2006 World Bank study estimated that inadequate sanitation accounted for a loss of $53.8 billion in India, which formed 6.4 per cent of the country’s GDP in that particular financial year. The study analyzed the evidence with respect to the adverse economic impacts of inadequate sanitation, including the costs associated with death and disease, accessing and treating water, as well as losses in education, productivity, time and tourism.
How Swachh Bharat Is Different
Under the Swachh Bharat Mission (SBM), sanitation coverage in rural India has increased from 39 per cent in October 2014 to 99.3 per cent as of June 2019. Over 9.7 crore toilets have been constructed in rural India since the Mission began. More than 5.6 lakh villages and 622 rural districts of India have declared themselves Open Defecation Free (ODF). As per the National Annual Rural Sanitation Surveys (NARSS) 2018–19 and 2017–18, the Quality Council of India (QCI) Survey of 2017, as well as the National Sample Survey Office (NSSO) survey of 2015, more than 90 per cent of toilets in the country are being used by household members – this shows a discernible behaviour change in the sanitation habits of rural India.
As we witnessed this grand revolution and the incredible impact it was already making on the ground, some naysayers were bound to surface. A popular misconception among critics in this respect has been that SBM is just another sanitation programme, much like other initiatives that have been implemented by previous governments over the decades. It’s always useful to set the record straight.
Firstly, with SBM, the programme has been supported right from the get-go by strong political will and inspiring leadership at the highest levels. The Prime Minister himself is personally championing the cause of a Clean India at multiple national and international fora. In fact, the Mission was launched following a clarion call issued by the Prime Minister to make the country ODF by 2 October 2019, Mahatma Gandhi’s 150th birth anniversary. SBM has always found mention in the Prime Minister’s monthly ‘Mann Ki Baat’ addresses and other public speeches, inspiring the masses to become a part of the sanitation revolution in India. In fact, since his first ever ‘Mann Ki Baat’ broadcast in 2014, the Mission has figured 37 times in his first 50 addresses! It is his personal commitment towards ensuring the success of the Mission that has further encouraged other senior political leaders including Union Ministers, Chief Ministers, Members of Parliament, Members of the Legislative Assemblies, and even local leaders to spread the message of swachhata in their respective spheres of influence. Consequently, government officials too have put sanitation high on the agenda in their respective Ministries and Departments.
The second aspect of SBM that distinguishes it from other programmes focused primarily on construction of toilets is the Mission’s emphasis on behaviour change and its focus on outputs and outcomes. The other schemes mistakenly assumed that the use of a constructed toilet was a given, and progress was reported in all these previous programmes in terms of simply ‘toilets built’. SBM is the first sanitation programme in India that has been demand-driven, as opposed to being supply-driven, and has measured success in terms of ODF villages and districts, instead of mere toilet construction.
Decentralized Monitoring and Use of Technology
A relatively lesser-known aspect of the Mission is its unwavering focus on decentralized monitoring through the extensive use of modern technology. Villages declared ODF are verified within three months of declaration by block and district officials. Almost 90 per cent of villages declared ODF have been verified successfully as of the writing of this piece and concurrent verification continues to happen as more and more villages progressively declare themselves ODF. In case any gaps are identified during verification, block officials are informed and asked to take corrective measures in a timely manner, following which another round of verification is done. This process is continued till a village is satisfactorily verified to have become genuinely ODF. Meanwhile, all components of the Mission – construction, payment of incentives, ODF declaration, verification, and even active personnel in every village – are all reported on a real-time basis by states, districts, gram panchayats and villages on the Integrated Management Information System (IMIS) of SBM.
Every toilet constructed under the Mission is mandatorily geotagged so as to ensure that the process is completely transparent. SBM has a special geo-tagging app which is designed exclusively for this purpose and is used widely by swachhagrahis and ground-level officials working in the villages, blocks and districts of India. As I write this, 90 per cent of toilets built under the Mission so far have been geotagged, and this number is rising on a daily basis. Technology is also being used heavily for capacity building at scale through virtual learning and a master trainer ecosystem, so as to sustain the lessons learned and behaviour change effected by the Mission in these five years.
The SBM-Grameen dashboard has become somewhat of a symbol of progress in action, with its ticking clock of toilets that shows the constant and speedy progress the Mission has been making on the ground in real time. This dashboard is connected, at the back end, to IMIS in real-time that is tracking progress on the ground as reported by districts and states concurrently. The IMIS has a plethora of data and information about the programme available on it, and the dashboard merely pulls the highlights out of it. The level of detail to which the IMIS goes, however, in tracking not just the building of toilets but a plethora of factors around it – geo-tagging of toilets, conversion of previous programmes’ dysfunctional toilets into functional, community toilets, behaviour change communication, details of swachhagrahis in every village – is a testimony to the commitment of the Mission to absolute transparency.
Aspirational Districts and Other Government Programmes
The Government of India launched the Aspirational Districts programme in January 2018, to improve the socio-economic conditions in 117 backward districts in the country. The programme focuses on five key themes, including access to water and sanitation infrastructure. All themes have a direct bearing on the quality of life and economic productivity of citizens. It is a testimony to the all-pervasive success of SBM that it has been able to deliver equally and successfully in these challenging districts as well. The rural sanitation coverage in these districts is almost at par with the national sanitation coverage, which speaks volumes about the programme’s overarching impact across the entire nation.
Even more recently, the Ministry of Women and Child Development launched the POSHAN Abhiyaan, a multi-ministerial convergence mission with the vision to ensure attainment of malnutrition-free India by 2022. Not only is SBM a critical component towards achieving the targets set out by the POSHAN Abhiyaan, it has also inspired the scheme in its strategy for implementation. Along the lines of the cadre of 500 young Zila Swachh Bharat Preraks, who stormed the districts across rural India and supported SBM implementation, a new cadre of Swasth Bharat Preraks has been created to function as catalysts for fast-tracking the implementation of the POSHAN Abhiyaan.
Impact of the Mission
The progress figures are not even the most impressive achievement of the Mission. The true proof of the pudding is in the impact it has already started showing on health, safety, dignity and environmental outcomes.
As per a 2018 World Health Organization report, it is estimated that SBM will have prevented over 3 lakh diarrhoeal deaths by the time India becomes ODF on 2 October 2019 – a milestone not far from us. UNICEF (2017) has estimated that each family in an ODF village in India saves approximately Rs 50,000 per year on decreased medical costs, fewer sick days and the value of lives saved. Similarly, a study conducted by the Bill & Melinda Gates Foundation highlighted that there were 46 per cent fewer cases of diarrhoea among children in villages that had been declared ODF as compared to villages that had not achieved that status. A UNICEF 2019 study also found that ODF villages are 12.7 times less likely to have groundwater contamination traceable to human faecal contamination.
The Way Forward: Sustaining the Progress
Based on the current rate of progress, the entire country will achieve ODF status well before the end of the programme. Unfounded criticism notwithstanding, a question worth asking is: What next? The country has, in the past, experienced the pitfalls of considering sanitation a one-time exercise. Many villages in the country were handed Nirmal Gram Puraskars with great fanfare a few years back. A few years down the line, however, it was found that many households in these villages had slipped back into old habits like open defecation. The country was littered with dysfunctional toilets which the Government had built but the people had not used.
This is because while behaviour can be modified even in a short period of time, evidence suggests that in order to produce a sustained change, behaviour-change campaigns need to be implemented on a regular basis. To safeguard against the possibility of families reverting to old habits, the SBM guidelines incentivize on-ground swachhagrahis to continue their door-to-door messaging, regular verifications and early morning nigrani visits to open-defecation hotspots in the village long after it has been declared ODF.
In order to be effective, behaviour-change communication campaigns need to be tailored to local cultures and contexts. For instance, applying positive peer pressure, creating associations between toilet construction and an aspirational lifestyle, reinforcing the association between shame and open defection on the one hand, and pride and clean toilets on the other, are all strong communication levers used under SBM.
Incentives and benefits need to be designed for promoting the use of infrastructure. For example, a teacher or student who champions the cause of sanitation in school or plays a vital role in maintaining facilities could be rewarded appropriately. The personal habits of children are in the process of being shaped and they can also act as change agents for their communities. Messages pertaining to health and hygiene have been integrated into the school curriculum under SBM.
Going forward, the focus must shift towards encouraging the adoption of basic hygiene practices such as handwashing with soap. It is estimated that handwashing can reduce the incidence of diarrhoea and acute respiratory infections by 40 per cent and 20 per cent respectively. Also, we constantly need to innovate and develop ecologically robust and cost-effective technology options in the sanitation sector that are better suited to local conditions and resource availability. Technologies that have been successfully piloted in different parts of India or in other countries need to be scaled up, following the necessary adaptations.
The quality, pace and scale of progress made under SBM is undeniable and reflected in the ground realities. At the time of its independence, Singapore faced many of the challenges we are grappling with today, including poor sanitation, disease and poverty. Realizing that prevention is far better than cure, national campaigns such as ‘Keep Singapore Clean’ were launched soon after the country became independent. In a relatively short span of time, the philosophy of cleanliness extended beyond sanitation to various aspects of people’s lives, including water, food, cooking practices, the environment, and even corruption.
All told, India has a similar opportunity to make history. SBM has provided a solid foundation. The Government obviously has a big role to play, and so does every citizen of the country, to ensure that we realize Mahatma Gandhi’s dream of a Clean India.