The worship of a broom during Deepawali or Dhanteras all over Bharat shows the significance that has been accorded to sanitation in our culture since time immemorial. Sanitation is also directly connected to health and wealth. No wonder, even the World Health Organisation has recently given a thumbs-up to the success of Swachh Bharat Abhiyan and its impact on the health indicators. While celebrating Deepawali and worshipping Lakshmi, it is also time to learn from the best practices of cleanliness to be healthy and wealthy
Dr Shamika Ravi
This article highlights the shifting cultural foundations of modern Indian growth story through the lens of Swachh Bharat Mission. Emerging evidence that linked open defecation to health outcomes, particularly child health, made sanitation policy priority for the Modi government, which launched a massive public campaign to make the country Open Defecation Free (ODF). Since its inception, there have been some scepticism about the impact of this programme in India, but they have been largely limited to anecdotes and poorly designed confounding studies. Systematic rigorous research across multiple independent institutions over the last 2 years has shown compelling evidence that Swachh Bharat Mission has made a remarkable transformation to quality of hygiene and health in India. I list some of these findings below.
Since October 2014, when the programme was launched, SBM has equipped 75 million households with toilets. In 2014, at the time of its launch, fewer than 40% of households had toilets at home. Today that figure is up to over 85%. The number of open defecation-free (ODF) villages has gone up from 47,000 to 384,000 over the same period—about 65% of all villages in the country. Then came the criticism that while many toilets were being constructed across the country, few were indeed being utilised by people and therefore this massive programme was a wasted and inefficient effort. An independent survey of over 92,000 households across the country, guided by a group of international experts and representatives of Unicef and World Bank, verified that 96% of the villages declared ODF were indeed ODF, and 77% of the households surveyed had toilets. This was consistent with the official estimate of 76% at the time of the survey.
Volunteers of ‘Pahal Ek Prayas’ generating awareness about sanitation in Meerut, Uttar Pradesh
If we consider the country level data in a state-wise disaggregation, then the picture is consistent. Seventeen States and Union Territories (UTs) are now ODF. Of the remaining 16, another three are almost ODF (greater than 90%) and six are more than 85% ODF. Only seven States/UTs are lagging behind. Odisha is the worst with only 56% sanitation coverage, followed by Bihar (57%), Puducherry (68%), Uttar Pradesh (72%), Tripura (75%) and Goa (76%). The survey showed that of the people who had access to toilets, 93% were found to use them regularly, which is very close to an even higher estimate of 95% revealed by a separate survey conducted by the National Sample Survey Office.
Does this evidence amount to better health and nutritional outcomes for citizens? A more robust measure of the health impact of the SBM is its impact on malnutrition. There is a large body of scholarly research available now to show that poor hygiene may be as important a factor contributing towards malnutrition as poverty of households. To address this question, another independent study was commissioned (by the Gates Foundation) which conducted an independent survey across several states of India using a stratified random sample design to compare the incidence of diarrhoea and malnutrition in ODF and non-ODF villages. The results from this survey revealed that the incidence of diarrhoea was significantly less in ODF villages compared to non-ODF villages and that measures of undernutrition (stunting and wasting), were also significantly better in the ODF villages. These differences between ODF and non-ODF villages are all statistically significant and therefore important evidence supporting the SBM. There are several pathways to explain these significant gains, but the results are consistent. For instance, one study revealed that 70% of the villages surveyed also had minimum litter or stagnant water. These are usually the focal points for carriers of several diseases in the villages.
Research has also shown that there are significant financial gains to households from SBM. A survey of over 10,000 households last year, sponsored by Unicef, estimated that, on average, a household in an ODF village could be gaining as much as Rs.50,000 per year from savings in medical expenditure because of lower incidence of illness and less income loss due to fewer days of unpaid sick leave. This is a very significant gain, especially for poor households.
It is true that emphasis of SBM has largely been felt in rural parts of India, while people living in urban India may not be aware of the achievements cited above because all of it relates to rural areas covered under the Grameen component of SBM (SBM-G). This is, however, not a concern because the problem of open defecation is primarily a rural problem. However, sanitation is also a major challenge in urban India so SBM also has an urban component. It is important to note that Indian cities are now rated in terms of their sanitation status. In her book, Survive or Sink, Ms. Naina Lal Kidwai reports that 22% of Indian cities are now ODF and 50% of all urban wards have 100% door-to-door solid waste collection. These may seem like marginal steps, but in fact they are a giant leap ahead for India and can unequivocally be termed remarkable transformations.
Swachh Bharat Mission has become a success story not only in our country but in the whole world and everyone is talking about this movement —PM Narendra Modi
It is rightly said that problem of sanitation in India has essentially been a gender concern. It is girls who drop out from schools and women who wait for the dark when there are no toilets available. Data show that a million schools (91%) now have separate toilets for girls, up from 37% when the SBM was launched, though there is no statistics on how many are actually functional.
Data tell us that in the last four years, India has made major strides towards a cleaner and healthier future. So what is the way forward now? SBM cannot be only about toilets at homes and schools but must be extended to toilets and water points everywhere. This would include public spaces, bus stations, train stations, airports and highways fuel stops and all tourist destinations. India has made major gains in sanitation behaviour of ordinary citizens in the last few years and the focus should now be to sustain this momentum. In an innovative move, the government has appointed 450,000 grass-roots motivators, called Swachhagrahis, who are tasked with maintaining this momentum. One remarkable feature of the SBM is that all states – whether governed by BJP or non-BJP—have shown progress through this mission over the last several years. This healthy bipartisan tradition must be encouraged and fostered over time for all fundamental programmes that affect our culture and future wellbeing. And in doing that, programmes like Swachh Bharat are laying the foundation of future robust growth of our nation.
(The writer is a Sr Brookings India Fellow and Member of PM Eco Advisory Council)