A recently-published paper in Lancet has an important lesson for Swachh Bharat: Sanitation goals hinge as much, if not more, on changing the attitude of people towards hygiene and sanitary practices as on improving coverage of sanitation facilities. The authors of the paper examined the implementation of the erstwhile Total Sanitation Campaign (TSC)—aimed at improving access to sanitary toilets in rural India to end open-defecation—in Puri district in Odisha, and found that the programme had no effect in reducing exposure to faecal matter with the result that the toilets did not bring down the incidence of diseases like diarrhoea.
TSC was implemented by NGOs and community-based organisations with funds from the Centre. It focussed on constructing sanitary toilets for rural households that didn’t have one. In a period of 13 months (January 2011-January 2012), the Puri villages where the programme was implemented saw a marked improvement in toilet coverage—from 9% to 63%—but only 38% of the toilets were functional. A key reason for this is that the programme heavily leaned on coverage as a performance indicator while motivating behavioural change (habitual use of sanitary toilets) has been neglected. As a result, the implementation has been marked by quick building of toilets before moving on to the next village. Even so, coverage has typically plateaued at around 60% (somehow, that’s unofficial threshold for declaring programme success). The study further found that between February 2012 and March 2013, some of the “covered” villages saw a decline in coverage, indicating poor construction. Those handling Swachh Bharat must remember that sanitation programmes, in order to achieve desired health outcomes (like reduction in exposure to faecal matter), needs to ensure both 100% coverage—without this, open defecation doesn’t end and neither does contamination by faecal matter—and complete attitudinal transformation.