9 min read.Updated: 19 Aug 2014, 03:20 PM ISTDean Spears
Instead of focusing on toilet construction, promoting toilet use should be the policy priority
Sanitation policy makes strange political bedfellows. Most people in India defecate in the open. Most people worldwide who defecate in the open live in India. The diseases spread by open defecation kill hundreds of thousands of Indian children each year and stunt the physical and cognitive development of those who survive. So, it is no surprise that sanitation was a prominent part of the recent election, advocated by both sides.
It is also no surprise that economists are quick to recommend improving sanitation as an obvious policy necessity. Open defecation would be the textbook example of a negative externality if the people who write textbooks knew that a billion people still do it. According to Mike Geruso’s recent column on I4I (Ideas for India), even children living in households that use latrines are profoundly impacted by whether or not those living nearby defecate in the open.
The importance of removing faecal germs from children’s environments follows clearly from economists’ growing understanding of early-life human capital accumulation. Study after study is showing that exposure to disease and other health insults in the critical first months of life translate into quantitatively important lost productivity as adults (for a recent review, see Currie and Vogl, 2013). If children exposed to more open defecation grow up to be adults who earn less and pay less tax, open defecation is not only a health disaster but an economic one too.
In the President’s speech to Parliament, and again in the budget speech, the government committed to ending open defecation by 2019, through a new Swachh Bharat Mission. The debate, therefore, is over on whether ending open defecation and promoting latrine use must be a policy priority for India. It is. But how?
Building latrines is not enough
The worst mistake we can make about sanitation policy for India is to believe that it will be easy. If the new government hopes that they will easily succeed by intensifying the same programmes that have existed for decades, then India will not eliminate open defecation by 2019. Open defecation has been declining by only about one percentage point per year for a very long time. Intensifying business as usual is not enough.
The second worst mistake would be to believe that rural sanitation in India is principally an infrastructure or construction problem. I am part of a research team that recently completed a survey of over 3,000 rural households in five states of the northern Indian plains (Bihar, Haryana, Madhya Pradesh (MP), Rajasthan, and Uttar Pradesh (UP)) (Coffey et al., 2014). These states are certainly not representative of all of India—there is much less open defecation, for example, in Kerala, Himachal Pradesh and some northeastern states—but the states that we study are especially important for sanitation policy because they are where about one-third of all people worldwide who defecate in the open live.
India’s national data sources on sanitation—the Census and the National Family Health Survey (NFHS)—only ask about sanitation at the household level. This makes two mistakes. First, latrines are something households own, but open defecation is something people do. Therefore, surveys that do not separate latrine ownership from latrine use have built a blind spot into the data: they are guaranteed to miss open defecation among latrine owners. Second, not all the people in a household always do the same thing. In fact, we found many households in which some people use a latrine and some people defecate in the open—despite owning a working latrine in most cases.
In fact, our results suggest the dominant narrative of open defecation in Delhi, that hundreds of millions of Indians are forced to defecate in the open because they lack access to a latrine, overlooks two important ways in which many rural people could have access to and use latrines, if they sought to.
First, even without our survey, it is clear that there are many developing countries that are much poorer than India where open defecation rates are low and falling fast. Only 4% of people in Bangladesh and a small fraction of people in sub-Saharan African countries such as Rwanda, Burundi, Malawi, Kenya and the Democratic Republic of Congo (DRC) defecate in the open. People in these countries do not buy the expensive latrines with enormous pits that people in India insist on. Instead, these other countries are eliminating open defecation by switching first to using simple pit latrines that most people in India could already afford to make—affordable latrines which would save infant lives and prevent the spread of disease.
Second, we found that many people defecate in the open even though they live in a household with a working latrine—and we know the latrine is working because somebody is using it. Over 40% of households with a working latrine have at least one person who defecates in the open. This figure includes both privately constructed and government latrines, which are much less likely to be used. Most people living in households with a fully government constructed latrine defecate in the open—indeed, even most young women in their 20s do. In these cases, the problem is clearly not latrine access.
This isn’t about blaming the victim—or blaming the parents or neighbours of the victims, in the case of babies who die early deaths or become stunted by the diseases spread by open defecation. This is about designing a Swachh Bharat Mission that will work. If many of the people who have latrines do not want to use them—and presumably latrine owners are more interested in latrine use, on average, than latrine non-owners—then merely building latrines will not be enough to significantly reduce open defecation.
We apply a simple statistical model to our survey data, in order to make this intuitive conclusion more precise. Our framework effectively matches people who don’t have a latrine with demographically similar people who do have a latrine (for example, latrine owners are younger and richer, on average) to predict open defecation among current non-owners if the government hypothetically were to build a latrine for everyone in our sample.
We find that two-thirds of new latrine recipients would defecate in the open, and that even if the government were to build a latrine for every rural household in these states, without changing anybody’s preferences, a majority of people would still be defecating in the open.
In fact, this result reflects two optimistic assumptions—that existing latrine owners are not more likely to be latrine users for unobservable reasons, and that the government’s attempt to build a latrine for every household indeed translates into a latrine on the ground for every household. So, it is clear that mere latrine construction is simply not enough. Instead, the Swachh Bharat Mission must be built on promoting latrine use: building demand for latrines.
Politics of open defecation
Reducing open defecation in rural India does not map well on to the ordinary political spectrum of left and right. There may be other important sanitary goals for India, such as improving waste water management or cleaning up trash—and it may have value for people to have the option to use a latrine that they in fact never do use—but given the terrible externality costs for health and human capital, the effect on open defecation in particular should be the critical test by which a proposed sanitation policy is measured.
All of this is true, to some degree or another, but that quantitative degree turns out to matter a great deal. In joint work in progress with Nicholas Lawson of the Aix-Marseille School of Economics, we compute that the early-life human capital effects of poor sanitation are so large that any government scheme that reduced open defecation for less than about $400 per household would essentially pay for itself, in the net present value of higher future tax revenues.
This computation ignores all other benefits, such as better health, cognition, and take-home earnings. So, reducing open defecation turns out to be too good of an economic deal to be vulnerable to these standard arguments.
I am also sympathetic to those in the upper-left box who want the government to distribute free or highly subsidised latrines. There are surely some very, very poor or otherwise excluded people who would like to use a latrine but cannot otherwise get one, and targeting subsidised latrines to such people would be a great idea, if targeting were not itself so difficult and distortionary.
Unfortunately however, our survey and qualitative research results are clear: on average, mere public provision of latrines is not enough, because too many of them simply won’t be used. Providing access to rural sanitation is not enough because it is not the principal constraint in the rural places where open defecation is most constant. It accomplishes little to solve the wrong problem.
So, we are left with the green box: economically, open defecation is well worth ending. Nevertheless, attempting to distribute free latrines that often will not be built, and even if built, often will not be used, has not worked well yet—and probably will not work well going forward either. India must find ways to also build demand for latrine use.
Construction is not enough
Of course, written sanitation policies acknowledged years ago the importance of behavioural change and promoting latrine use. In fact, the 58 pages of the guidelines of the Nirmal Bharat Abhiyan detail a wide range of ideal activities. In practice, however, rural sanitation policy in the states where open defecation is most concentrated has been focused on latrine construction.
Right now, the new government is designing a Swachh Bharat Mission. I am optimistic that they will take the opportunity to change this focus to behaviour change. I do not have all the answers: indeed, because nobody quite knows how we will encourage hundreds of millions of rural Indians to switch to latrine use, learning and admitting what we do not know must be part of the solution.
But—whatever political box you may fall into—it is clear that a serious campaign to promote latrine use must be the centrepiece of India’s new Mission. Obviously, this requires measuring latrine use; we cannot claim to be trying to eliminate open defecation if we are making no effort to monitor how much there is—or, worse still, if we merely ask local implementers to report their own latrine construction.
There would be no special challenge to creating useable latrine-use data: high-quality sample surveys are conducted all the time in India, and it would be a quite straightforward signal of commitment for the ministry of drinking water and sanitation to commission its own from survey experts, dedicated to tracking latrine use. Because, as they say, you manage what you measure—credibly measuring latrine use and open defecation will become its own incentive for local governments to create change.
Beyond measuring open defecation, I hope the government will learn from marketing experts, local leaders, ethnographers, non-governmental organisations, and above all, from experience and evidence about what is succeeding and failing. A massive campaign with political leadership and broad participation changed behaviour and ended polio in India; may the Swachh Bharat Mission similarly lead the way to eradicating open defecation.
Published with permission from Ideas for India , a public policy portal.
This is the third and final part of the three-part series on sanitation.
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