At over 620 million, India has the most number of people in the world defecating in the open. Open defecation and lack of sanitation are the leading causes for water-borne diseases like diarrhoea and stunted growth in children. Over 300,000 children aged below five years in India die each year due to diarrhoeal diseases.
Hence, curbing open defecation is central to cutting the number of child deaths. But increasing the number of households with toilets and reducing the practice of open defecation to bring about any significant improvement in health outcomes in children aged below five years appears quite challenging according to a study published recently in PLOS Medicine .
The results of the first of its kind, large-scale, randomised, control study involving about 5,200 children below five years of age from 3,039 households amply demonstrates that the government has to revisit its current strategy of increasing the number of households that have toilets to reduce open defecation and thereby improve the health outcomes in young children. The study took place between May 2009 and April 2011 in 80 rural villages from two districts of Madhya Pradesh.
The households were divided into an intervention arm and a control arm. The households that were below the poverty line were provided Rs.4,200 to construct toilets. The funds were provided by the Total Sanitation Campaign (Rs.2,200) and Nirmal Vatika (Rs.2,000). The households in the intervention arm received messages on open defecation and the need to end it. There were community follow-ups and personal visits, as well. Toilets were also constructed in these households.
Despite all these, the intervention led to only 19 per cent increase in households that went in for toilets; there was just 10 per cent decrease in open defecation. Finally, there was insignificant improvement in child health outcomes (diarrhoea, anaemia, parasite infection and growth).
“We caution the readers that we are not saying that sanitation does not work but may be much high level of toilet coverage and their use are needed for health impacts,” Sumeet R. Patil, the corresponding author from the Network for Engineering and Economics Research and Management (NEERMAN), Mumbai, and School of Public Health, University of California, Berkeley, told this Correspondent in an email.
Can the modest decline (10 per cent) in open defecation in a matter of 21 months not be considered significant? “That should be a matter of interpretation. We report that among households [that] had a toilet, approximately 40 per cent reported daily open defecation by men or women. You can interpret this also as 60 per cent did not defecate in the open regularly when they had a toilet. One may say the glass is half full! Therefore, my inference would be that large reductions in open defecation in such a short amount of time were “conditional” on having a toilet. When toilets were increased by 20 per cent, open defecation decreased by 10 per cent,” he said.
The debriefing of people who did not have toilets helped in understanding why people did not construct toilets. The key reason was the lack of money/affordability. Lack of water supply and other constraints followed affordability. “As some quasi-experimental evidence to this, we find that the BPL households who got more subsidy built more toilets than non-BPL households (about 30 per cent effect), which suggests the effect of higher subsidy. We do believe (based on our analysis) that subsidy is needed and more subsidies do result in higher toilet coverage/more reductions in open defecation,” Dr. Patil said.
Besides subsidy, a big factor is addressing the habit, cultural, and mindset of people to bring about a real effect. “Household debriefing identified habit-related reasons for continuing with open defecation despite having a toilet,” Dr. Patil noted. “Whether the behaviour change would be sustained or slowly taper off over time remains an open question.”
But can health indicators, particularly diarrhoea, be seen within a short period of 21 months, especially when the entire community has not become free of open defecation? “There are two questions here. First, can diarrhoea be reduced in short amount of exposure to improved sanitation at household level or at village level? Yes! Diarrhoea is expected to be a sensitive disease and we can see reduction in a matter of a few months. The more distal outcomes such as [reduction in] parasite infections and [improvement in] child growth may take several months or even years,” he said.
“Second, can we see diarrhoea impacts when the entire community is not free of open defecation? There is a consensus that level of diarrhoea (infectious diseases) should go down in the entire community so that community-household-community transmission of diseases is reduced. With only few households using a toilet, the pathogenic load in the environment may not go down enough for even the toilet-using household to realise health effects. This is the externality of communicable diseases.”
The study has several limitations — the duration of the study was short, it relied totally on recall of details by participants, relying on them on toilet usage etc.
Despite these limitations, the study highlights the compulsion to take a hard look at the strategy of fighting open defecation.
Trials with intense awareness programmes bring about the most positive changes. In spite of this, the current study did not register significant improvements.
From a public health perspective, the strategy adopted has been unable to improve child health. “We recommended that first efficacy of approaches should be proven at the pilot scale to know what works, and then scale up the intervention to the entire country,” he stressed.
“Governments and international donors need to know whether large-scale rural sanitation programs improve child health before expending further resources on these interventions or to identify an urgency to improve the existing program design or implementation so that they deliver the health impact,” the Editor’s summary notes.
PLOS Medicine:>The Effect of India's Total Sanitation Campaign