The RICE study found that SBM helped drastically improve rural sanitation coverage in the four states—up from 37% in 2015-16 to 71%.
It has been clear for a while that judging the Swacch Bharat Mission’s (SBM’s) impact from the toilet coverage effected under the programme—99.43% for individual household latrines (IHHL)—alone could be flawed. Indeed, a study by the Research Institute for Compassionate Economics (RICE) shows that, while toilet coverage is significantly up, usage tells a different story. As per official SBM data, Madhya Pradesh (MP), Uttar Pradesh (UP) and Rajasthan have already achieved 100% IHHL coverage. Yet, 44% of the rural population in Bihar, UP, MP and Rajasthan, as per RICE data, still defecates in the open. The RICE study found that SBM helped drastically improve rural sanitation coverage in the four states—up from 37% in 2015-16 to 71%. But, behavioural change in favour of sanitation is, perhaps, still a concern. Against this backdrop, the Economic Survey examines an important metric of the SBM’s impact—the impact of improved sanitation on health—that may be used to nudge the behavioural change key to the programme’s vision.
Diarrhoea, whose prevalence is negatively correlated with the spread of sanitation, is a leading cause of death among children under the age of five. The Economic Survey looks at SBM’s impact on diseases like diarrhoea and malaria in children aged under five, and on incidence of still birth and low birth weight between 2015 and March 2019, in two groups of districts—one with a lower IHHL coverage than the 2014 national median of 33.5% and the other with a higher IHHL coverage than this median. Given how IHHL coverage would have shown drastically higher improvement in the first group after SBM’s implementation, the Survey notes, the impact on health was also expected to be larger for it than the second group. Diarrhoea cases fell from 6,968 and 5,262 in 2015 to 5,683 and 4,550 in 2019 in the first and the second group of districts, respectively. Malaria dropped from 761 and 273 to 222 and 113, still births from 540 and 403 to 456 and 368, and incidence of low birth weight from 3,890 and 3,230 to 3,686 and 3,198. The Survey acknowledges that other factors, like distribution of mosquito nets, increased fogging, etc, along with steps taken under the National Vector Borne Disease Control Programme, the Integrated Action Plan for Prevention of Pneumonia and Diarrhoea, and numerous state initiatives, could have played an important role in the decline of these diseases. A ministry of drinking water and sanitation study in five states shows that the prevalence of diarrhoea in non Open-Defecation-Free (non-ODF) areas was higher than that in ODF areas. Another study, by WHO, shows that while, in 2014, there were an estimated 140,000 diarrhoeal deaths attributable to lack of proper sanitation,this had declined to an estimated 50,000 in 2017-18. The positive for health from SBM should translate into economic gains for a household—a Unicef study shows, on average, every household in an ODF area saves about Rs 50,000 due to lower likelihood of disease due to using toilets and adopting sanitary habits. The poorest households benefit most from the spread of sanitation—the Unicef study, comparing costs and benefits of having a toilet over a 10-year period, found, financial savings exceed costs by 1.7 times on average, and 2.4 times for the poorest households under conditions of 100% IHHL coverage. While SBM must contend with challenges on effecting behavioural change, especially in the next phase where waste management is the focus, the gains of the programme are likely to soon become evident in the form of improved morbidity indicators across the country.