The battle for toilets and minds

The official sanitation policy has been uniquely focussed on building toilets. But the connection between good health and using toilets has not yet been made

When the road in front of his house is finally laid, in Fatehpur, Uttar Pradesh, Ramesh Kumar hopes he will get permission to set up a small shop in a corner of his compound. Another corner will have a temple, as his father wants. To make place for it, Mr. Kumar will have to pull down a structure built five years ago — a toilet that his joint family of 14 has never used.

“I had some money so I spent a few thousands and built it then, but none of us have used it. And now that my father will live with us, it has to go. The front of a house must have a temple, my father says,” Mr. Kumar grumbles.

One of the rare moments of agreement in the heated political campaign that preceded the general election this May was when both Narendra Modi and former Rural Development Minister Jairam Ramesh announced that toilets were more important than temples in a country where 70 per cent of rural households do not have a toilet (as the 2011 Census shows). Yet, despite the rhetoric, new data shows that Mr. Kumar is no exception — a substantial portion of households with access to toilets are not using them.

Survey findings

Sangita Vyas and Ashish Gupta of the Research Institute for Compassionate Economics (r.i.c.e.), led a Sanitation Quality Use Access and Trends (SQUAT) survey in 13 districts of the five States of Haryana, Rajasthan, Uttar Pradesh, Madhya Pradesh and Bihar. They chose districts whose change in levels of rural open defecation between the 2001 and 2011 census most closely matched that State’s overall change in that period. The villages were chosen randomly, and infield randomisation techniques were used to choose households. In all, they interviewed 3,613 adults from the same number of households, and collected latrine use data on 26,792 individuals in those households.

They found that a full 40 per cent of households in the sample that had a latrine had at least one person who was still defecating in the open. This number was the highest for Rajasthan (57 per cent) and the lowest for Haryana (35 per cent). In all, over a quarter of men with a toilet and 17 per cent of women with a toilet defecated in the open.

In Mr. Kumar’s village — Manawa in Haswa block of the fertile Fatehpur district, and one of those surveyed — these numbers are particularly believable. In 2008, the village was awarded the Nirmal Gram Puraskar for being completely open defecation free, former sarpanch Dhanno Devi, who collected the award from former President Pratibha Patil, told The Hindu. Yet, dozens of houses, particularly in the “Harijan basti” that lies on the north-western edge of the village, have never received toilets under the Nirmal Bharat Abhiyaan (NBA) scheme meant to deliver toilets to all rural households. “The rest of the village has electricity while the line hasn’t even come to us. It was the same with toilets,” says Jug Raj, a Dalit marginal farmer and labourer who built his family a toilet when his two daughters grew up some years ago. He doesn’t use the toilet himself; it’s for emergencies, he says.

Moreover, dozens of other households that have a toilet, either built through the NBA or from their own money, do not use the toilet. “It is much healthier to go in the open,” small farmer Ram Avatar told The Hindu at the village tea shop. “For the new daughter-in-law or for emergencies, you need a toilet. Otherwise, taking a walk in the fresh air is much better for health.”

His views are mirrored by the survey’s findings. Of those who had a toilet but defecated in the open, 74 per cent gave “pleasure, comfort, and convenience” as the reason for this, and another 14 per cent said it was because of “habit, tradition, and because they have always done so.”

Undoubtedly, the majority of people who defecate in the open are not doing it for pleasure; in the survey, of the persons defecating the open, 86 per cent did not have toilets. However, the findings also show that just building toilets without focussing on behaviour change is not going to be enough, the researchers say.

Since India’s sanitation problem has been diagnosed as a lack of access to toilets, the official sanitation policy has been uniquely focussed on building toilets. However, the survey findings also show that the lack of money to build a toilet is not the only thing that is holding rural households back from building toilets; large parts of the population do not seem to have as yet made the association between good health and using toilets.

Stunting in children

This connection between sanitation and child health — stunting in particular — has been forcefully made in the last few years by a significant body of research from Dean Spears and Diane Coffey at r.i.c.e. Mr. Spears, a visiting economist at the Delhi School of Economics, showed for instance that almost all of the difference in the heights of Indian and African children could be explained by nutrient loss on account of open defecation.

Yet, less than a quarter of households with a toilet in the survey said that they had constructed it for health reasons. In Manawa, The Hindu found that “protecting” the “modesty” of their daughters-in-law was the most common reason cited for need for a toilet. Less than half of all households in the survey which did not have a toilet believed that children would be a lot healthier in a village where no one defecated in the open.

As a result, families are unlikely to build a basic toilet that they can afford at their stage of development; across two blocks of Fatehpur, households did not consider building a toilet a priority until they had built themselves a bigger and better house and taken care of other expenses.

This is not true for other developing countries. Bangladesh’s Demographic and Health Survey (DHS) shows that sanitation in Bangladesh has been taken up by the rich and the poor alike, Ms. Vyas said. “In India’s DHS, 21 per cent of households had a dirt floor and no electricity, compared with 52 per cent in Bangladesh in the next year. Clearly, Bangladeshis are poorer,” she said. “But poor Bangladeshis are more likely to use latrines than poor Indians. Of these impoverished Indians (21 per cent of the whole), 84 per cent defecate in the open. In contrast, a mere 28 per cent of the Bangladeshis living in homes with dirt floors and no electricity similarly defecate in the open,” she said.

Building on his “toilets over temples” statement, Mr. Modi had promised during his successful campaign to build a toilet in every Indian house. “People throughout India and around the world are watching optimistically for Mr. Modi to achieve his goal of eliminating open defecation, but to succeed he will have to focus on behaviour change — not construction — and commit to learning and tinkering with new behavioural solutions,” Mr. Spears said