Evidence-based sanitation advocacy in India to promote latrine use (r.i.c.e. India)

  • SangitaVyas
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Evidence-based sanitation advocacy in India to promote latrine use (r.i.c.e. India)

Dear all,

Today I would like to tell you about a sanitation grant by the Bill & Melinda Gates Foundation that I am involved with at the r.i.c.e. (Research Institute for Compassionate Economics):

Title of grant: SQUAT (Sanitation Quality, Use, Access, and Trends): Evidence based sanitation advocacy for India
Subtitle (more descriptive title): To promote evidence-based sanitation policy-making in India that can reduce open defecation and improve children’s health by promoting latrine use
Name of lead organization: Research Institute for Compassionate Economics (r.i.c.e.)
Primary contact at lead organization: Sangita Vyas
Grantee location: Amston, CT (Connecticut, USA)
Developing country where the research is being or will be tested: India
Start and end date: February 2013 – July 2015
Grant type: Global Development (e.g. Global Challenges Explorations, Reinvent the Toilet Challenge, Other)
Grant size in USD: $262,340 (as per grant database: www.gatesfoundation.org/How-We-Work/Quic...n%2C%20and%20Hygiene )

Short description of the project:

Open defecation imposes enormous costs on children’s health and human capital, and is exceptionally widespread in India. We believe that there is convincing evidence of the benefits for health and human capital of safe latrine use. What is needed now is (1) to convince policy-makers of this, and (2) a better understanding of the local political economy, social forces, and economic factors that constrain or promote latrine use.

Ultimately, our goal is to influence Indian policy, such that the government – at its various levels – might better pursue an end to open defecation, especially in rural India, which is r.i.c.e.’s focus. We note that we can only be a small part of this large process. However, many policy-makers still do not recognize sanitation as a top priority; others are missing opportunities to make programs more effective; and nobody fully understands, including we ourselves, how rural communities can be best encouraged to use latrines. Thus, there is a need for basic persuasion of the urgency of safe excreta disposal; for advocacy of more effective policies, based on latrine use, not construction; and for research into the social, institutional, and political mechanisms that might successfully promote latrine use.


Policy advocacy goals:

1. Sanitation as a policy priority. Although the Total Sanitation Campaign (TSC) has been a “flagship program” of the Indian government, there is still much scope for increasing the prominence of sanitation as a policy priority. A key part of this will be emphasizing the link between sanitation and stunting, commonly called “malnutrition.” Many activists who worry about children’s health advocate a “right to food;” others seek to promote medical care, or even access to water (rather than safe excreta disposal in particular); none of these promote the crucial public good of ending open defecation. Among those who do, there is debate over whether negative externalities imply that eradication of open defecation is necessary for a locality to see health effects.

2. Focus on latrine use, not construction. Too much of the policy discussion centers on building latrines, however building latrines has not significantly reduced open defecation over the past 15 years in India. Information, education, and latrine use promotion need to be the cornerstones of any successful program to end open defecation.

3. Central measurement of latrine use. Recognizing that any goal that is not measured is not achieved, the government should establish an independent, accountable mechanism of monitoring latrine use, not latrine construction.

4. Latrine use requires a ground staff. Rural sanitation teams at the block and district level require a new, dedicated staff responsible only for behavior change and promotion of latrine use, not for latrine construction.

o Conducting a new survey on sanitation attitudes and behaviors in rural north India
• SQUAT report based on findings
• Short contributions from many stakeholders
• “Launch party” conferences in Delhi and two state capitals (probably UP and Bihar, or maybe MP, three very poor Indian states where we have experience and connections)

o Conference jointly produced with the Delhi School of Economics and World Bank Water and Sanitation Programme about stunting of Indian children
o Newspaper articles authored by and not authored by rice staff, in English and Hindi press
o Continuing to meet with policy-makers in Delhi to advocate policy goals and report findings
o Meeting with 15-25 District Magistrates or District Panchayati Raj Officers (or similar local officers) note that this will work towards both research and advocacy goals
o Meeting with relevant state officials in at least two states
o Presentation at LBNAA (IAS academy)
o Encouraging other advocates (e.g. World Bank WSP, UNICEF) to cite our research and to promote our messages
o Offering to help the government design systems for useful monitoring data collection

Research or implementation partners: Delhi School of Economics

Links, further readings – results to date:

A policy brief summarizing the findings of the SQUAT Study can be found here: squatreport.in/wp-content/uploads/2014/0...UAT-policy-brief.pdf
SQUAT Study’s website: www.squatreport.in
r.i.c.e.’s website, the home of our blog: www.riceinstitute.org
NY Times article covering our research: www.nytimes.com/2014/07/15/world/asia/po...th-malnutrition.html
The Economist article covering our research: www.economist.com/news/asia/21607837-fix...tories-also-changing

Current state of affairs:

In August 2013, we organized a conference on stunting. Leading scholars of child height—economists, epidemiologists, nutritionists, and pediatricians—and government officials came together to discuss why children in India are so short? Height is an important indicator of overall health and human development because the same good health that helps a child grow tall can also help her grow smart. In presentation after presentation at the conference, sanitation stood out as an important part of this puzzle.

We have completed the data collection and entry for the SQUAT Study. Our working paper is available on the SQUAT Study’s website and is forthcoming in Economic and Political Weekly. The data was collected in villages in five states in India: Bihar, Haryana, Madhya Pradesh, Rajasthan, and Uttar Pradesh. We found that rural households do not build inexpensive latrines of the sort that commonly reduce open defecation and save lives in Bangladesh, Southeast Asia, and sub-Saharan Africa. Many survey respondents‘ behavior revealed a preference for open defecation: over 40% of households with a working latrine had at least one member who defecated in the open. In the sample from the four largest states, more than half of people in households which owned a government latrine defecated in the open. We applied a demographic model of latrine use which predicted that if the government were to build a latrine for every rural household that lacked one, without changing sanitation preferences, most people in our sample in these states would nevertheless defecate in the open. Further evidence supports a preference for open defecation: many survey respondents reported that open defecation is more pleasurable and desirable than latrine use. Among people who defecated in the open, a majority report that widespread open defecation would be at least as good for child health as latrine use by everyone in the village.

Numerous publications have covered our research including the New York Times, The Economist, The Hindu, among others. Additionally, numerous opinion pieces authored by us have appeared in a number of Indian newspapers.

In June and July of 2014, we sent the findings of our research and policy proposals to promote latrine use to 230 members of parliament, 377 ministry officials, and 389 district collectors by mail and email.

Biggest successes so far:

Sanitation has become a policy priority under the new government. We completed quantitative and qualitative research that explores sanitation attitudes and behaviors in north India perhaps more than any other study has. Our research and messages have been well-covered in the media.

Main challenges / frustration:

Convincing politicians who make policy decisions on sanitation to emphasize latrine use, rather than construction, in India’s sanitation policy.

We are happy to answer any questions you may have here on the forum.


Sangita Vyas
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  • ggalli
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Re: Evidence-based sanitation advocacy in India to promote latrine use

Hi Sangita,
Thanks, for this. Had already followed your great work and the SQUAT report, and shared it internally within my organisation.

I have a question for you or your colleagues. The topic is named 'evidence-based sanitation advocacy' yet you end your post by saying that the biggest challenge is 'convincing politicians to emphasize latrine use, rather than construction'. Can you explain me what the reasons are why it is so difficult to convince politicians in India even though you have produced good evidence to back up your claim?

I am asking because more and more I am wondering whether we are wasting our time in generating more data and evidence. Political decisions are not made on basis of data, but on pressure, money and power. Maybe it is time to switch our strategy and start to get more 'dirty' (pun intended).

Giacomo Galli
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  • SangitaVyas
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Re: Evidence-based sanitation advocacy in India to promote latrine use

Hi Giacomo,

You pose an interesting question. The government doesn't focus on latrine use simply because all incentives point towards focusing on construction.

Local level bureaucrats prefer construction projects to behavior change campaigns because they are more profitable. It is easier to skim money off construction projects. Politicians prefer construction projects because they are very visible, and they can easily claim responsibility. Many local level politicians actually get their names written on the latrines that are built during their time in office. And to people who don't know much about sanitation in India, construction sounds like the obvious solution. Finally, construction is the status quo. And inertia gets in the way of changing it.

Only a politician or bureaucrat who really cares about eliminating open defecation would emphasize latrine use.

Sangita Vyas
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  • pkjha
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Re: Evidence-based sanitation advocacy in India to promote latrine use

Hi Sangeeta

As per the guidelines of NBA (earlier TSC) financial incentive will be provided after the construction and use of latrines. At policy level there is no problem in this regard. Main problem is almost complete lacking of monitoring (of construction and use of toilets) at the state and centre levels. Lack of awareness in rural areas is the most important issue. In such areas sanitation is not regarded as a felt need problem due to lack of knowledge, awareness and motivation. In some states like Haryana, in a short period, there has been appreciable sanitation coverage due to involvement of Women Self Help Groups. Many households constructed toilets without taking any financial support from the Government.
Lack of sanitation is mainly a social issue- not financial or technical. One can easily see several households having good houses and personal vehicles but without toilet. Increasing rate of cash subsidy of construction of toilets is also one of the deterrents of the programme. Such subsidy has made the program a supply driven approach. In 2011 rural sanitation coverage, as per the IMS data of the Ministry (as provided by the States) was over 70%. However, Census 2011 data showed only 31-32% coverage. Obviously there were considerable no. of missing/ unfinished construction/ wrongly located toilets, constructed under subsidy, not fit for use. Therefore, proper construction of toilets is equally important. Without having a toilet there is no question of its use. The IEC program of the Ministry needs to be monitored by the States with measurable deliverables.

Pawan Jha
Foundation for Environment and Sanitation
Mahavir Enclave
New Delhi 110045, India
Web: www.foundation4es.org
Linked: linkedin.com/in/drpkjha
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Re: Evidence-based sanitation advocacy in India to promote latrine use

Hi Pawan,

You are right. In India, very few people have inexpensive, simple latrines. These types of latrines are much more common to find in other parts of the developing world, even in South Asia. In Bangladesh, it's very common to find simple pit latrines, the kinds that UNICEF/WHO classifies as "unimproved." It's virtually impossible to find these in India. In India, people either build expensive latrines which often have septic tanks. And if they can't afford that, then they build nothing at all. There is no such thing as the sanitation ladder here.

Yes, there needs to be much more focus on IEC*. In the past financial year, very little of the IEC budget was spent. We need to be spending all of it.


* IEC stands for Information, Education, Communication (note added by moderator)

Sangita Vyas
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  • neilpw
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Re: Evidence-based sanitation advocacy in India to promote latrine use

Pawan Jha wrote on 29 August: "Lack of awareness in rural areas is the most important issue. In such areas sanitation is not regarded as a felt need problem due to lack of knowledge, awareness and motivation."

Thank you for this comment. I would be interested to hear what works (and what doesn't) with regards to IEC*. Below are some possible methods, but I am not sure where and how they have been tried, and with what results:
- Community Health Workers (or ASHAs in India) explain importance of sanitation as part of routing health education (one-to-one, or in groups)
- Health education / sanitation posters (at health facilities and/or in public places)
- Health education / sanitation leaflets (at health facilities and/or in public places)
- SMS text messaging (health education "behavior change" messages)
- short videos on feature phones (basic mobile phones with SD cards)

Women's learning groups have been successful in reducing maternal and child mortality in many countries, through learning and preparedness for childbirth and child diseases. I am sure they have an important potential role in sanitation also.

Best wishes,
Neil Pakenham-Walsh, HIFA moderator ( www.hifa.org )

* IEC stands for Information, Education, Communication (note added by moderator)

Neil Pakenham-Walsh is the coordinator of the HIFA campaign (Healthcare Information For All) and co-director of the Global Healthcare Information Network. He is also currently chair of the Dgroups Foundation ( www.dgroups.info ), a partnership of 18 international development organisations promoting dialogue for international health and development. He started...
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Re: Evidence-based sanitation advocacy in India to promote latrine use

Here is a useful 1-page summary about the current status of this project called "Evidence based sanitation advocacy for India" in a recent report by the BMGF called "Building Demand for Sanitation - A 2015 Portfolio Update and Overview" (available here in the SuSanA library; Roshan has made a post about this report here )

The grant is officially coming to an end today (31 August 2015), so this is a nice summary of the outcomes.

I copy a section from this pdf file (file attached below):


Discussion of Findings:

India with its very high OD rate is an outlier compared to other
Asian and South Asian countries. Simple latrines are unpopular
in India, especially in the northern plains states, though they
have gained popularity in many other countries in the region
and in Africa. Comparing India to other countries, India’s higher
OD rate does not appear to be correlated with income, poverty,
education, or access to water. Importantly, access to sanitation is
not really the answer—even households with latrines still have
members which practice OD—as many as 40% or more of rural
household members with latrines may still OD.
Another important finding is that Government-constructed or
supported latrines are less likely to be used than private latrines.
One reason is that private latrines typically have much largercapacity
pits which require much less frequent emptying.

OD practices and low preference for latrines appears linked
to cultural beliefs about ‘purity’ and ‘pollution’. The presence
of a latrine in the home is seen as ‘polluting’, whereas OD is
seen as pleasant, invigorating, and a healthy lifestyle practice.
Latrine use is also associated with weakness—they are built for
the convenience of sick people, the elderly, young children, and
women who recently delivered a baby; i.e., people who would
have a hard time walking long distances to defecate. Relatively
few interviewees expressed interest in having a latrine, when
given a choice of other consumer goods.

Moreover, higher-caste members do not prefer simple pit latrines
because they require more frequent emptying (and contact
with pit emptiers, who are seen as polluting). At the same time,
lower-caste members want to distance themselves from manual
scavenging and pit emptying as symbols of the past and of

These findings help explain the high rate of OD, the preference
for private over Government latrines, and the difficulty of
promoting latrines in areas with limited space around the
household. Therefore, solving the OD problem in India will
require much stronger attention to drivers of behavior, which
include religious and cultural values, among other challenges.

Next steps:

The preference for very large latrine pits and related cultural
preferences will be key issues to address in any sanitation
campaign. These policy issues should be discussed with local,
state and national government.
New questions being considered in ongoing research include
analysis of cultural links to the Infant Mortality Rate, and
possible links between sanitation and anemia.

Previous research:
R.i.c.e. has carried out a number of studies on the correlation
between stunting and OD—starting with the Indian question
(why are children in India shorter, on average, than children
in sub-Saharan Africa who are poorer, on average?) as well as
performing similar analyses on other country data sets. The
findings demonstrate strong correlations between stunting and
the percent of households who engage in OD. These results,
and numerous related research studies, can be found on the
r.i.c.e. website.


I thought this could be interesting for those following the progress of this project.

Note that a related topic where Sangita from r.i.c.e. also posted in was this one:
"Article in the WIRE in India - The chief reason why open defecation is so rampant in India... "rural Indians do not want pit latrines""

In that thread, Sangita had written, which sums up the research quite nicely:

This rejection of latrines with internationally recommended pit sizes is unique to India because of caste and untouchability. India's problem is unique, and so the solutions are also likely to be unique, and we need to be experimenting as much as possible with solutions that address people's real concerns.


Dr. Elisabeth von Muench
Independent consultant
Community manager of this forum via SEI
(see: www.susana.org/en/resources/projects/details/127 )
Wikipedian, co-founder of WikiProject Sanitation: en.wikipedia.org/wiki/Wikipedia:WikiProject_Sanitation

Location: Frankfurt, Germany
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