Does Construction of Toilets Improve Sanitation? (even when toilets are constructed, people do not use them - example of India, comparison with the Philippines)

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Does Construction of Toilets Improve Sanitation? (even when toilets are constructed, people do not use them - example of India, comparison with the Philippines)

Does Construction of Toilets Alone Improve Sanitation?

Quite often, discussions occur whether construction of toilets alone improve sanitation. Some says that even when toilets are constructed, people do not use them. Others say that toilets become non-functional over a short period of time.

India launched Total Sanitation Campaign (TSC) in 1999.

The main objectives of the TSC were:

• Bring about an improvement in the general quality of life in the rural areas.
• Accelerate sanitation coverage in rural areas.
• Generate felt demand for sanitation facilities through awareness creation and health education.
• Cover schools/ Anganwadis in rural areas with sanitation facilities and promote hygiene education and sanitary habits among students.
• Encourage cost effective and appropriate technologies in sanitation.
• Eliminate open defecation to minimize risk of contamination of drinking water sources and food.
• Convert dry latrines to pour flush latrines, and eliminate manual scavenging practice, wherever in existence in rural areas.
rural.nic.in/sites/downloads/our-schemes...lientFeaturesTSC.pdf

Thomas Clasen, et al. (2014), assessed the effectiveness of a rural sanitation intervention, within the context of the Government of India’s Total Sanitation Campaign, to prevent diarrhoea, soil-transmitted helminth infection, and child malnutrition.

Effectiveness of a rural sanitation programme on diarrhoea, soil-transmitted helminth infection, and child malnutrition in Odisha, India: a cluster-randomised trial - Thomas Clasen, Sophie Boisson, Parimita Routray, Belen Torondel, Melissa Bell, Oliver Cumming, Jeroen Ensink, Matthew Freeman, Marion Jenkins, Mitsunori Odagiri, Subhajyoti Ray, Antara Sinha, Mrutyunjay Suar, Wolf-Peter Schmidt
www.thelancet.com/pdfs/journals/langlo/P...-109X(14)70307-9.pdf

(added by moderator: this paper has been discussed in some depth here in this thread on the forum: forum.susana.org/forum/categories/26-hea...-by-emory-university )

This is their interpretation (conclusion):

Our findings raise questions about the health effect of sanitation initiatives that focus on increasing latrine construction but do not end open defecation or mitigate other possible sources of exposure.

Although latrine coverage increased substantially in the study villages to levels targeted by the underlying campaign, many households did not build latrines and others were not functional at follow-up. Even householders with access to latrines did not always use them.

Combined with other possible exposures, such as no hand washing with soap or safe disposal of child faeces, suboptimum coverage and use may have vitiated the potential health effect generally reported from improved sanitation. These results are consistent with those from another trial.

Although the sanitation campaign in India has been modified to address some of these challenges, the programme still focuses mainly on the building of latrines—the main metric for showing progress towards sanitation targets. Although these efforts should continue, sanitation strategies can optimize health gains by ensuring full latrine coverage and use, ending open defecation, and minimizing other sources of exposure.


All this goes to show that simply constructing latrines in a village or town is not enough. Behavioral change is required to improve people’s outlook towards improved sanitation.

F H Mughal

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Re: Does Construction of Toilets Improve Sanitation?

Maybe you should start you own sanitation blog, or ask at sanitationupdates.wordpress.com if you can become an editor? :)

On the topic:
I think we need to be careful in drawing general conclusions from Indian case studies. Yes building toilets is not enough, but the specific case of India has several distorting co-factors both in governance and due to cultural reasons.

Here in the Philippines building household toilets seems to work for the most part. General hygiene practice is not too bad, but in the rural areas most people lack the resources to build good toilets that withstand the regular storms (and other issues like flooding, termites and ground water pollution). Thus building better toilets is probably hitting a fertile ground. Of course in the medium term the fecal sludge management issues will become more and more pressing, but that is already a step above in the evolution of a good sanitation system.

Krischan Makowka
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Re: Does Construction of Toilets Improve Sanitation? (even when toilets are constructed, people do not use them - example of India, comparison with the Philippines)

As we work at the grassroot level, the construction of toilets will not alone improve the sanitation in India.Because, firstly we need to focus more on the behaviorial change of communities rather than construction. Secondly, the quality of toilet is very poor. As per our survey, the quality of materials used by the contractors for the construction of toilets are very poor quality.Thirdly, community participation is very less. Fourthly, CLTS model is not a universal model to apply everywhere.
However, it is a very good initiative by the Govt. Of India towards sanitation.
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Re: Effect of Sanitation Programs on Individual Household Latrines, Defecation Behaviors and Diarrheal Diseases

Effect of Sanitation Programs on Individual Household Latrines, Defecation Behaviors and Diarrheal Diseases

The 2014 paper of Patil et al. titled The Effect of India’s Total Sanitation Campaign on Defecation Behaviors and Child Health in Rural Madhya Pradesh: A Cluster Randomized Controlled Trial, shed light on the efficacy of the sanitation programs in India. The researchers assessed the India’s Total Sanitation Campaign (TSC), a major sanitation program, and analyzed TSC’s impact specifically on individual household latrines, defecation behaviors and diarrheal diseases (child health).

At the outset, one would assume the positive impact of TSC on sanitation. India’s TSC is a good program, and appears to undo improper sanitation. However, research of Patil and his colleagues gives a different perspective.

In the study, the researchers investigated the effect of India’s TSC, initiated in 1999, on the availability of individual household latrines, defecation behaviors, and child health in rural Madhya Pradesh, one of India’s less developed states. Sixty percent of people who practice open defection live in India and a quarter of global child deaths from diarrheal diseases occur in the country. TSC components include change in social norms and behaviors and provides technical and financial support for latrine building (what is called in sanitation jargon as brick and mortar).

Patil and his colleagues enrolled 5,209 children aged under 5 years old living in 3,039 households in 80 rural villages in Madhya Pradesh. Half of the villages (40), chosen at random, were included in the TSC.

Mindful of the fact that the study may have some limitations (underestimation and possible bias), the study’s findings show that the TSC increased the percentage of households in a village with improved
sanitation facilities by 19 per cent on average. 41 per cent of households in the intervention villages had improved latrines on average compared to 22 per cent of households in the control villages.

TSC decreased the proportion of adults who self-reported open defecation from 84 per cent to 73 per cent. TSC did not improve child health measured on the basis of multiple health outcomes, including the prevalence of gastrointestinal illnesses and intestinal parasite infections, and growth.

The study can be seen at:
www.ncbi.nlm.nih.gov/pmc/articles/PMC4144850/


Clarissa Brocklehurst of Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America; and Sanitation and Water for All Secretariat, New York, New York, United States of America, responded to the study
( journals.plos.org/plosmedicine/article?i...journal.pmed.1001710 ) - Scaling up Rural Sanitation in India

Clarissa says (I admire her balanced comments):

It is disappointing that the authors find that the program resulted in very limited increases in adoption of improved sanitation and had even less impact on the practice of open defecation. The findings suggest that a significant number of families that constructed latrines under the program, incentivized by hardware subsidies, actually continued to practice open defecation. Furthermore, the modest increases in the use of improved sanitation did not result in improvements in child health.

It might be tempting to conclude from these findings that sanitation is not a good investment and that interventions at this scale are doomed to fail. That would be a mistake—the study shows simply that sanitation in rural areas is hard to get right. There are passionate debates in the water and sanitation sector about the best way to approach sanitation, which is, after all, more a question of behavior than of bricks and mortar. This study certainly illustrates this reality, and it shows that open defecation is a persistent behavior, practiced even by those with latrines at home. It suggests that, no matter how generous, subsidies designed to pay for the construction costs of latrines will not, of themselves, result in significantly increased use of latrines. It also implies that small, incremental improvements in sanitation are not enough—conventional wisdom in the sanitation sector has it that a ‘‘tipping point’’ is needed before latrine use becomes a social norm in a community.


Commenting on the publication: Linking Service Delivery Processes and Outcomes in Rural Sanitation:
Findings from 56 Districts in India
(available at: www.wsp.org/sites/wsp.org/files/publicat...-Districts-India.pdf ), Clarissa says:

A detailed examination of the actions of 51 districts in 12 Indian states implementing the Total Sanitation Campaign has been carried out by the World Bank Water and Sanitation Program. Although the researchers did not have access to the detailed and robust outcome data that an RCT produces, and they did not examine health impacts, the researchers scored actions undertaken by district governments and compared them with available government data on toilet usage. Their report concluded that districts in which the focus was on changing collective behavior, creation of demand for sanitation, and the development of technological solutions tailored to consumer preferences had the most success in increasing use of toilets.

While this forum’s users, perhaps, may have different views, the question is: what lessons should, a new entrant in the field of sanitation, take home, on the impacts of the sanitation programs?

F H Mughal

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Re: Does Construction of Toilets Improve Sanitation? (even when toilets are constructed, people do not use them - example of India, comparison with the Philippines)

We all agree that the Government’s goal to make India open defecation free is ambitious, but necessary. There is no doubt that lack of sanitation is a double-triple burden on people, especially women. The question is what needs to be done. Government has accepted that its goal is not only to build toilets, but to increase usage. In other words, people have to change their behavior so that they use the toilet. It is also important that this usage is now being measured in field surveys so design of programmes can be improved ( www.downtoearth.org.in/blog/the-behaviour-puzzle-58349 ).

The question is how do we bring this behavior change. As we ask in our recent article what will make people change behavior. Will it be education? Availability of options? Societal pressure? Fear of penalties? Or will it be all of the above.

We have found that state governments, pushed by the ambitious and much-needed targets set to make India open-defecation-free, are using name-and-shame as one way to bring about this change. They are pushing towards making open defecation socially unacceptable. Haryana (a successful state in terms of toilet usage), Uttar Pradesh (a dismal failure), Madhya Pradesh, Chhattisgarh and a few other states have passed bills making it compulsory for anyone contesting panchayat elections to have a functional toilet at home. Many districts are taking this approach forward by blowing whistles at people defecating in the open, publishing their photographs in village billboards, cancelling their ration cards or taking away other government benefits ( www.downtoearth.org.in/coverage/mission-madness-58328 )

All this can be an extremely dangerous method as it could backfire (we have detailed the one case, where it led to tragic end). It may also not build the kind of community pressure that is necessary to make sanitation a sustained need for people. It is for this reason that we have detailed out the current practices in the country. We believe we need to discuss these approaches, learn what is working and based on this, suggest what should not be done.

SUSHMITA SENGUPTA
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Re: Does Construction of Toilets Improve Sanitation? (even when toilets are constructed, people do not use them - example of India, comparison with the Philippines)

Does construction of toilets improve sanitation?
In the context of India, and the present scenario, the answer is a big NO.
There are incidences, where it has even worsened the situation. An example is the district of Barabanki in UP, which is largely a water logged area and presently the villages are submerged under ankle deep water. The water level has come up to the ground surface almost or at max 30-50 cm lower. Wide spread construction of twin leach pit latrines in such areas can only lead to disaster in a short time. As houses are built closure to each other, so are the leach pits and also the hand pumps.
People do complain of the foul smell from hand pump water but the government machinery, in order to meet the targets, are continuing to construct the twin leach pit latrines, without application of mind.
Barabanki is not the lone high water table district in India and the result is that public in general says " open defecation is much better than this".
Unless the government machinery really engages itself to improve sanitation, instead of just construction of latrines to meet the targets, situation will only get irreversibly frightening.
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