One can easily enumerate the many milestones Community-Led Total Sanitation (CLTS) has contributed toward the goal of achieving a world free from open defecation (OD). The CLTS approach to sanitation has come far from its humble beginnings in Bangladesh in 2003. Since then, 50 million people now live in OD free (ODF) environments in 66 countries across Africa, Asia, Latin America, the Middle East, the Pacific Islands, and the Caribbean due to the adoption of CLTS by various governments and international agencies, bringing with it many positive outcomes for health and human dignity.

While it has enjoyed widespread success over a range of geographical and social contexts, a number of challenges and concerns have arisen concerning the efficacy of CLTS not only to galvanize communities into ending OD but also to remain ODF. Unfortunately, it is not uncommon for people who had built and used latrines to abandon them and resume the practice of OD. While poorly implemented CLTS has resulted in communities that have not become ODF, many factors play into a community’s failure to become ODF. However, it is chiefly the recidivism back to OD that is the most prevalent obstacle to sustained behaviour change. Why do communities recede back into the practice of OD? And what is responsible for this ‘backsliding’ of sanitation practices after communities? Further, how can these gaps be addressed and reflected in future CLTS planning and implementation exercises?

While a comprehensive analysis of sanitation recidivism is beyond the scope of this article, a combination of factors influences a society’s decision to collectively end the practice of OD and remain ODF. In 2013, a case study studying 4960 households in 116 African villages that had been declared ODF for two or more years found that 92% of the households had receded back to the practice of OD.¹ Physical factors include sandy soil, heavy floods or rains, and termite attacks, and can lead to the destruction or collapse of latrines that have been built. A host of cultural and socioeconomic factors include age, sex, education, income, household size, local leadership, and religious beliefs often act concomitantly to undermine sustained behaviour change concerning OD and determine whether communities will strive to remain ODF.

CLTS cannot change fixed physical factors that contribute to the decline in post-CLTS latrine usage. As mentioned previously, difficult soil conditions, excessively wet or dry climatic conditions, and pestilence all play an important part in determining whether individuals or communities rebuild their sanitation hardware or not. In this case, community living in an area with consistently heavy rain or floods might become discouraged and abandon their broken, full or overflowing latrines.² For instance, many ODF communities in the northern district of Nampula, Mozambique fell victim to heavy flooding in 2015 which destroyed 10,860 homes.³ A follow-up survey indicated that many latrines had collapsed, and so their sanitation status could not be defined.

A community’s morale (or lack thereof), as well as its perception concerning its abilities to rebuild latrines, the longevity of the latrines, and the material resources, required clearly influences the decision to remain ODF or slide back into the practice of defecating in the open. In many cases, poorly designed latrines that were used for a short period were eventually abandoned due to issues with poorly constructed doors, roofs, pans, and pits.⁴

Cultural and economic barriers to sustained behaviour change are, however, more readily addressed by the CLTS approach. In many communities, beliefs about ritual purity and pollution concerning latrines, education about sanitation and health issues, the size and income of a household, plays an important part in their use even after they have been constructed. In Northern Mozambique for example, a study shows that more years spent in school is associated with a higher likelihood of rebuilding a latrine.⁵ Some community members like farmers find it burdensome to use a latrine in the middle of a working day, while others such as the elderly are less likely to use a latrine due to the sanitation habits they have adopted for many decades.⁶ One notices that many of these are indeed the same factors that discourage latrine construction and use, to begin with.

Arguably, however, it is primarily a community’s social dynamic and environment that plays the largest role in its decision to become or remain ODF or continue the practice of OD. Changing the way community members interact with and relate to each other in the context of health and sanitation is central to the CLTS approach. Therefore, the concepts of social capital, social dilemma, and social identity need to be considered in order to delineate and relate the overarching social challenges with sanitation backsliding. While social dilemmas describe situations in which individuals are better off  not doing something which benefits the whole group, social capital encapsulates factors as trust, cooperation, communication, and social cohesion within a community.⁷ Lastly, social identity illustrates how well individuals are connected within a group and how strong intra-group ties are.⁸

It is here that CLTS can make the biggest difference in the behaviours and attitude of community members towards each other with respect to health, sanitation, and general social cohesion. Communities with higher collective ambitions to reduce or eliminate OD, as well as higher levels of solidarity, trust and cohesion between residents are more likely to make the required efforts to galvanize the community into shaping solutions to their specific sanitation situation. When conducting pre-triggering and triggering exercises, CLTS facilitators must accurately investigate the social capital of a community and emphasize its importance in the process of eliminating OD, capitalizing on it if it is strong, and seeking to augment it if it weak. In this context, issues such as feelings of vulnerability to disease, latrine ownership, cooperation in building sanitation hardware, and confidence in the ability of others should be emphasized to all community members to give a sense of a shared risk as well as a goal. Ultimately, it must be effectively demonstrated that building, owning, and maintaining a latrine poses little risk or cost to a household.

Health concerns are also big drivers for communities to strive towards eliminating OD. In Benin, a study demonstrated that latrine users felt safe from contact with harmful bacteria or viruses by using a latrine. They are also more likely to rebuild or repair a damaged latrine than to recede back into the practice of OD.⁹

The pre-triggering and triggering exercises could also extend to teaching communities how to evaluate their physical environment and advising them on how best to optimize resources towards the design and development of sanitation hardware, especially in areas where soil conditions are poor and communities are not likely to rebuild damaged latrines.¹⁰ Moreover, it would also be highly beneficial if organizations implementing CLTS provided communities with comprehensive guidance on how to maintain and empty existing latrines so they may be used again. This is especially important as several studies have demonstrated that latrines are often abandoned when they are full.¹¹

CLTS interventions must, therefore, be adjusted and customized to fit the needs and tackle the challenges unique to a community, and must also attempt to successfully change some of the conditions that facilitate the decision to reconstruct or continue using a latrine. If it is possible to ascertain how the success of CLTS in influencing sanitation behaviour is related to structural, social, and individual conditions, then CLTS can be improved and amended so that it encourages collective behaviour change within the community that not only supports the goal of becoming or remaining ODF but also equips community members to better assess the obstacles to that goal. The addition of data-based behaviour change strategies within the CLTS framework could improve its effectiveness even more. As such, such strategies could target and augment factors like education, social cohesion and trust, vulnerability to disease and community health concerns, perceptions towards latrine ownership, and confidence in latrine construction, rebuilding and repair.

While the responsibility of not sliding back to OD does lie upon the community, it would be beneficial for various implementers of CLTS around the globe to incorporate the above factors into all their triggering exercises. CLTS has indeed succeeded in transforming the mindsets of myriad communities to recognize the dangers of OD. However, an improved framework of behaviour change that not only empowers a community to accurately assess its sanitation goals, but also allows for the establishment of stronger social capital, would only hasten the achievement of Sustainable Development Goal 6.2.

Featured image source: https://www.hindustantimes.com/mumbai-news/here-s-proof-mumbai-isn-t-free-of-open-defecation/story-3qSgOZdv3rspFgpXQPe0JM.html

1,2 Tyndale-Biscoe P, Bond M, Kidd R. ODF Sustainability Study. FH Designs Australia: PLAN International. 2013:1±181.

3 Mozambique: Floods Emergency Appeal MDRMZ011 Final Report: International Federation of Red Cross and Red Crescent Societies, 2015

4,5, 10,11 Mosler, Hans-Joachim, et al. “Is Community-Led Total Sanitation Connected to the Rebuilding of Latrines? Quantitative Evidence from Mozambique.” Plos One, vol. 13, no. 5, 2018, doi:10.1371/journal.pone.0197483.

6 Routray, Parimita, et al. “Socio-Cultural and Behavioural Factors Constraining Latrine Adoption in Rural Coastal Odisha: an Exploratory Qualitative Study.” BMC Public Health, vol. 15, no. 1, 2015, doi:10.1186/s12889-015-2206-3.

7 Grootaert C. Measuring social capital: an integrated questionnaire: World Bank Publications; 2004.8 Cameron JE. A three-factor model of social identity. Self and identity. 2004; 3(3):239±62.
9 Jenkins MW, Curtis V. Achieving the ‘good life’: why some people want latrines in rural Benin. Soc SciMed. 2005; 61(11):2446±59.

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It is estimated that 0.12 million tonnes of faecal sludge is generated in India per day.³ With poor sewage networks in Indian cities, a large proportion of the urban poor still depend on public toilets. Public toilets often have no water supply while others are not connected to the public sewage system. The lack of public sanitation infrastructure also propagates crude septage handling practices like manual scavenging which require scavengers to collect human excreta from one household to the next. In contrast with the large proportion of on-site installations, limited attention has been accorded to proper construction, maintenance management and safe disposal of septage from septic tanks and pit latrines in Indian cities. Most of the latrines built under the Swachh Bharat Abhiyan will depend on on-site containment systems, augmenting the urgency of the rapid and widespread development of Fecal Sludge Management (FSM) solutions in the face of increased latrine access and generation of faecal sludge.

While large-scale networked sewage systems have their own financial, legal, administrative, and infrastructural barriers, there exist shorter-term solutions that are effective, efficient and environmentally sustainable precursors to the increasingly urgent problem of faecal sludge and wastewater management. In the face of massive deficits in urban sanitation and considerable investments required for the design and installation of sewage systems, small-scale on-site treatment systems offer a potential way to further close the sanitation deficit in India.

Among other things, FSM entails developing tools to assess the generation of faecal sludge, its pathways from containment to treatment, the constraints to establishing an effective chain of services to manage it. Developing new waste handling and treatment technologies is also essential.⁴

In the effort towards establishing an effective FSM network throughout India, the Consortium for DEWATS Dissemination (CDD) Society has been leading the charge and exploring novel ways in which to design and implement smaller-scale FSM systems in smaller Indian cities. The sanitation not-for-profit introduced its first dedicated faecal sludge treatment plant in Devanahalli, a town in Karnataka of 28,000 people. Since the beginning of its operation in 2015, it prevented about half a million litres of faecal sludge from polluting the environment in its first two years.⁵ It was eventually recognized by The Federation of Indian Chambers of Commerce and Industry and the India Sanitation Coalition and awarded the Best Innovation in Sanitation Award in 2017. The plant, no larger in area than a medium-sized bungalow, collects the faecal sludge of Devanahalli from desludging vehicles, which is then treated through anaerobic respiration. The treated sludge is then dried and distributed to local farmers as an organic soil conditioner.

The CDD society developed a multistage research and development process prior to the establishment of the plant. Firstly, it assessed the volume of faecal sludge generated in Devanahalli, the total number of toilets, pits and septic tanks, and the frequency and mode of desludging by residents. This led to the development of an operations model in which desludging operators do not have to travel large distances before emptying their truck, the location of the plant was close to the city.

Particularly beneficial in the development of such small-scale FSM projects is the collaboration and partnerships that form between the private/non-profit and public sector. In the case of Devanahalli, the town passed a series of resolutions pertaining to the regulation of new containment systems, licensing and regulation of private desludging operators, outsourcing the operations of the treatment plant to private operators, and property taxes to support the cost of the plant. It is worth noting that the cost of the Devanahalli treatment plant is also well within the budget of most towns of similar size, as it is operated by just one operator and runs on gravity, not electricity. Sales from faecal sludge compost, as well as desludging fees and property taxes also help to finance the operation.⁶ It is thus cheap, sustainable, and effective.

CDD is now working with governments and authorities in various towns in Rajasthan, Tamil Nadu, Orissa, Leh, and Bhutan to expand and scale up their affordable FSM operations throughout India.

A similar example of the private-public partnership model in FSM involves a faecal sludge treatment plant commissioned by the Jhansi Municipal Corporation in Jhansi, Uttar Pradesh, and built by Purna-Pro Enviro Engineers. As the town sits on the rocky terrain of India’s central plateau, it has been difficult to plan and build underground sewage. Consequently, about 80% of the population is dependent on on-site sanitation systems. The remaining 20% dispose of their untreated excreta openly into the environment. In Jhansi, additional desludging vehicles were commissioned in order to provide desludging services within the entire city, while a request-for-services and payment system was also established.

No more than an acre in size, the plant was built in 2018 with a capital investment of INR 2 crores. Its daily treatment capacity is 6000 liters and carries an annual maintenance and operation cost of INR 27.6 lakhs.⁷ Here, the treatment process entails many similar features as that of the Devanahalli plant: gravity-powered anaerobic filtration, gravel filters, and drying beds. The treated water is subsequently used for irrigation, and the treated sludge is used as organic manure.

The above FSM solutions are a much-needed innovation in a sector of development which does not receive adequate attention in India. To begin the heavy lifting of urban sanitation, authorities in India must further incentivize the design and innovation of cost-effective and reliable engineering solutions that are able to treat large volumes of waste, at least in smaller and medium-sized cities such as Devanahalli and Jhansi. Their establishment also sets up a precedent for and provides an understanding of the necessary aspects of construction, regulation, logistics, and financing of such sanitation projects. This will also allow for the effective and smooth scaling up of FSM in bigger cities such as Mumbai, Delhi, Bangalore, or Kolkata.

While the above FSM solutions are worthy and desirable investments in urban sanitation, they are not long-term solutions to India’s massive deficits in urban and peri-urban sanitation, as their treatment capacities over time will have to increase drastically. In the coming years, the Government of India will have to grapple with this fact. The consistent disposal of millions of litres of untreated septage continues to wreak havoc on India’s ecosystems and natural habitats, massively polluting its various water bodies and water supplies. This subsequently carries dire implications for public health, disease prevention, and quality of life in general. It is important then for India to begin to deploy a slew of strategies and projects that develop an effective regulatory and licensing framework, engage citizens and garner public support, use competition to improve the quality of planning and encourage innovative funding mechanisms, rapidly develop “quick-win” projects, and rapidly invest in public-private partnerships,  among other things. In this sense, the treatment plants of Jhansi and Devanahalli serve as effective pilot projects to developing sustainable and effective FSM solutions.

Featured image source: https://www.borda-sa.org/strengthening-the-operation-maintenance-sector-for-servicing-decentralised-urban-sanitation-infrastructure-in-karnataka-india/

1,2 Dobbs, Richard, and Shirish Sankhe. “India’s Urban Transformation.” McKinsey & Company, www.mckinsey.com/~/media/McKinsey/Featured Insights/Urbanization/Indias urbanization A closer look/Indias urbanization A closer look.ashx.

3,4 Luthra, Bhitush. “Faecal Sludge Management Gets World Attention.” Down To Earth, www.downtoearth.org.in/news/faecal-sludge-management-gets-world-attention-48293.

5 “Faecal Sludge Management.” CDD Society I Water and Waste Management Solutions I Faecal Sludge Management I Wastewater Treatment Systems I City Sanitation P, 18 Apr. 2018, cddindia.org/faecal-sludge-management.

6 India, Dasra. YouTube, CDD India, 18 May 2017, www.youtube.com/watch?v=WZgT2Vwfvwc.

7 Faecal Sludge Treatment Plant at Bijoli, Jhansi. Center for Science and Environment, www.cseindia.org/feacal-sludge-treatment-plant-at-bijoli-jhansi-9070.

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A wealth of reports and studies have described open defecation as one of the biggest public health concerns in developing nations. They elaborate upon the various health problems that arise from children’s chronic exposure to open defecation while emerging evidence has linked open defecation to a number of poor health outcomes the most prevalent of which is child stunting, particularly in South Asia. It is estimated that 159 million children worldwide under the age of five are stunted.¹ Inadequate access to latrines also has its consequences. In 2015, a joint report by UNICEF, USAID and the WHO compiled a list of case studies and scientific studies that demonstrated a link between poor sanitation and chronic malnutrition in children through the spread of diarrhoea and other intestinal parasites.

Child Stunting

Child stunting and wasting is observed to be one of the most widespread consequences of open defecation and poor sanitation around the world. A study published by Dean Spears and Arabinda Ghosh studies 112 districts in India demonstrated that child stunting statistics were significantly higher in areas where the practice of open defecation was more frequent.² In these districts, it was noted that “Over half of the children are stunted, and almost a third of children are severely stunted.” In another paper, Spears has stated that living with or near neighbours that continue to practice open defecation the negative health effects of open defecation are significantly more pronounced  owing to densely populated regions.³

This is especially common in many areas in India. He mentions “the difference in average height between Indian and African children can be explained entirely by differing concentrations of open defecation. There are far more people defecating outside in India more closely to one another’s children and homes than there are in Africa or anywhere else in the world.”⁴

Diarrhoea and Child Mortality

Diarrhoea accounts for 9% (800,000) of deaths of children under five years of age worldwide due to constant exposure and ingestion of germs from faecal matter.⁵ In Ethiopia for instance, diarrhoea is the leading cause of mortality for children under five, causing 23% of deaths. A study conducted in Ethiopia from the Journal of Environmental and Public Health demonstrated that “the overall prevalence of under-five diarrhoea among the individuals living in the ODF kebeles [neighbourhoods] was lower as compared with the OD kebeles.” ⁶ A similar result was observed in Kenya, where the only two sub-districts in the country that were ODF had significantly lower prevalence of diarrhoea than other areas.⁷

Similarly, it was reported in 2015 that 100,000 children in India died due to diarrhoea, with a combined 499,000 from India and Nigeria alone.⁸ While the study cited above also states that “71 out of every 1,000 babies born alive die before they are one year old”⁹, another report from the Lancet journal, however, has noted some encouraging news. While overall diarrhoea deaths in children under the age of five dropped by 34.3% globally between 2005 and 2015, in India the rate of reduction was at 43.2%. The number of under-five deaths in India declined from 3.33 million in 1990 to 1.34 million in 2013.¹⁰

Malnutrition

The WHO estimates that 50 percent of malnutrition is associated with repeated diarrhoea or intestinal worm infections from unsafe water or poor sanitation.¹¹ This is because children with diarrhoea eat significantly less food and are able to absorb fewer nutrients from their food, which perpetuates the cycle of catching bacteria-related illnesses. Diarrhoea is also caused by lack of clean water for handwashing. It is also exacerbated by the lack of functional toilets which adequately dispose of faecal matter, as faeces on the ground contribute to contaminated drinking water and water resources.

This means that millions of children are unable to attain a healthy body no matter how well they are fed, a classic sign of malnutrition. Jean Humphrey, a professor of human nutrition at Johns Hopkins Bloomberg School of Public Health mentions that the “children’s bodies divert energy and nutrients away from growth and brain development to prioritize infection-fighting survival.”¹² This eventually leads to stunting and inadequate childhood development. This phenomenon is, again, much more prevalent in India due to its dense population concentration in many areas of the country.

Gender-based violence

There are also strong and disproportionate gender-based impacts of open defecation and the lack of adequate sanitation hardware. For girls and young women, the lack of access to private latrines and toilets renders them vulnerable to sexual violence, which frustrates efforts for them to lead a healthy and productive life. This is a major public health concern as well as one of human rights.

This means that many girls and young women live in constant fear, as has been noted by the Sanitation and Hygiene Applied Research for Hygiene (SHARE) organization.¹³ As there are no private lavatory facilities for women, they are often forced to relieve themselves in public places during the early hours of the morning or late at night, when the likelihood of sexual assault or violence is higher. In India for example, the SHARE report notes various instances of rape as boys were observed to wander around women’s toilets at night. The report also mentions “boys shamelessly staring at them, making threats, throwing bricks and stabbing them.”

Moreover, the report also outlines that many women fear the water and public toilets that they can use to clean themselves is far from clean, which contributes to the fear of infection or sickness, further exacerbating the health problems that result from open defecation.

Featured image source: https://www.yashodafoundation.org/sanitation-for-children-in-rural-india/

1 “Without Toilets, Childhood Is Even Riskier Due to Malnutrition.” UNICEF, 19 Nov. 2015, www.unicef.org/media/media_86283.html.

2,9 Spears, Dean, and Arabinda Ghosh. “Open Defecation and Childhood Stunting in India: An Ecological Analysis of New Data from 112 Districts.” PLoS ONE, 2013.

3 “Open Defecation Linked to Stunting in Indian Children.” Down To Earth, www.downtoearth.org.in/news/open-defecation-linked-to-stunting-in-indian-children-42252.

4,12 Harris, Gardiner. “Poor Sanitation in India May Afflict Well-Fed Children With Malnutrition.” The New York Times, 13 July 2014, www.nytimes.com/2014/07/15/world/asia/poor-sanitation-in-india-may-afflict-well-fed-children-with-malnutrition.html?_r=0.

5,6 Ayalew, Abireham Misganaw, et al. “Assessment of Diarrhea and Its Associated Factors in Under-Five Children among Open Defecation and Open Defecation-Free Rural Settings of Dangla District, Northwest Ethiopia.” Journal of Environmental and Public Health, vol. 2018, 2018, pp. 1–8., doi:10.1155/2018/4271915.

7 Njuguna, John. “Effect of Eliminating Open Defecation on Diarrhoeal Morbidity: an Ecological Study of Nyando and Nambale Sub-Counties, Kenya.” BMC Public Health, vol. 16, no. 1, 2016, doi:10.1186/s12889-016-3421-2.

8,10 Livemint. “India Continues to Record High Child Mortality Rate Due to Diarrhoea: Study.” Https://Www.livemint.com, Livemint, 2 June 2017, www.livemint.com/Science/oWS5VjPoILlK0HG3TK3QSM/India-continues-to-record-high-child-mortality-rate-due-to-d.html.

11 “Water, Sanitation, Hygiene, and Malnutrition in India.” Population Reference Bureau, www.prb.org/india-sanitation-malnutrition/.

13 Lennon, Shirley. Fear and Anger: Perceptions of Risks Related to Sexual Violence against Women Linked to Water and Sanitation in Delhi, India. Sanitation and Hygiene Applied Research for Hygiene, Nov. 2011, www.susana.org/_resources/documents/default/2-1758-vawindia.pdf.

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In the last two decades, rural India’s healthcare system has witnessed increasing chronic shortages of medical professionals, from doctors and paramedics to lab technicians and surgeons. The decline in access to medical professionals is detrimental to the Indian rural healthcare system, as the quality and availability of care for rural communities significantly worsens. To add to this, India has the highest overall burden of disease globally, making reform of the healthcare system more urgent than it already is.¹ Improving the quality of medical care in rural communities, therefore, is a priority for policy makers, donors, development workers, and international agencies.

Within the health budget of India, a large proportion is spent on curative services, while staff salaries comprise the majority of public health expenditure. If salaries are used inefficiently because of poor motivation and performance of staff, this may mean that a large share of the overall health budget is wasted. While the number of health facilities in rural India has increased, many studies point to a major source of wastage of health-sector resources, namely the excessive of medical providers and professionals. This significantly weakens the relationship between health spending and positive health outcomes. For instance, as of March 31^st 2015, more than 8% of 25 300 primary health centres in India had no doctor, 38% had no laboratory technician, and 22% had no pharmacist.²

India’s rural health system is structured around a tiered system of care. The first tier comprises a system of sub-centres, which are manned by trained health workers and auxiliary nurse midwives and cater to 3000-5000 people per centre. Primary health centres (PHC) comprise the second tier of care and act as the first point of contact between rural communities and medical officers. They cater to about 30,000 people per centre and are supposed to have a doctor supported by fourteen paramedic staff. PHCs are also referral units for smaller sub-centres. Community health centres (CHC), the third tier of care, are meant to have four medical specialists supported by 21 paramedic staff and cater to about 120,000 people per centre.

It is essential then, to understand why this problem persists at a systems level, what the structural and administrative flaws in the system are, and how the skills gap and lack of resources can be remedied through training, increased health spending, policy reform, data and information sharing, and a better medical education framework.

Why the rampant absenteeism of healthcare providers?

While the above network of facilities looks impressive, the nationwide average absentee rate for doctors and other healthcare providers is around 40% and only 20% of those seeking outpatient services and 45% of those seeking indoor treatment are able to access public health services.³ Employees of such facilities are usually paid by the state, while local officials have no authority over them. Further, many medical officers visit the PHCs infrequently and run parallel private practices in nearby towns. Many are frequently unavailable for childbirths even if the mother is willing to come to a PHC. Though PHCs are supposed to be free, most of them charge an informal fee. Thus, many poverty-stricken rural communities choose to favour private practices.

While India has one of the largest medical education systems in the world, many educated and ‘city-bred’ doctors are not willing to serve in rural areas, many of which are still difficult to access and lack electricity. While the Indian medical education system produces some of the finest doctors and health professionals in the world, it still trains doctors to primarily work in tertiary care centres, specialized hospitals, or hospital in high-income areas.⁴ Working in the public sector is thus often seen as a humiliating and demoralizing experience as their professional lives lack occupational development opportunities, accountability, and access to basic medical resources to fulfil their roles as healthcare providers. As a result, there is gross neglect for primary health and family care within the professional development of doctors in India.

The dilapidated state of medical infrastructure and equipment, as well as the poor supply of medical equipment and drugs, is also to blame. While vastly increased expenditure in medical infrastructure and facilities is needed, it is unlikely to have a meaningful impact without a concomitant reform in rural health policy and administration.

Lack of Training, Motivation, and Accountability

The quality of health care services in rural India matters because it reflects the extent to which investments in its national health care systems are able to raise both human capital and individual welfare. Chronic absenteeism leads to low usage, because health care personnel are not available, and dissuades future use because of unreliable service.

Many rural medical practitioners, who provide 80% of outpatient care, have no formal qualifications for it.⁵ This is an alarming statistic for many communities who rely on their practitioners to provide safe and effective treatment. The absence of large-scale training measures to address skill gaps and staff shortages for nurses, doctors, paramedics, and support staff have also severely blunted the ability of India’s rural healthcare system to deliver timely and effective care to rural communities.

There is also little to no oversight or accountability for medical providers owing to the fact that, as mentioned before, payrolls are administered by the federal government. Monetary incentives are usually weak, which leads to healthcare employees taking unsanctioned absences of leave. According to Shrawan Nigam, a senior consultant at the Indian Council for Research on International Economic Relations, rural health workers have a tendency passing on the responsibility to the Panchayati Raj, the local council.⁶ The need for monitoring and accountability is therefore urgent.

What can be done?

The quality of health care services in rural India matters because it reflects the extent to which investments in national health care systems are able to raise both human capital and individual welfare. Efficient and accountable health care systems provide good returns on such investments. Moreover, in the long term, the quality of health care matters more to improving health outcomes than increases in health care spending.

It is abundantly clear then, that a variety of shortcomings play into the inefficacy of India’s rural public health infrastructure, policies, and management. These shortcomings require rapid remedy on the part of the central government, but also on state governments, NGOs, and the private sector.

The Global Monitoring Report 2008 published jointly by the World Bank and the IMF emphasize that increased spending on education and health programs alone is not the answer and that the quality and equity of spending are equally important.⁷ In this context, improved governance, more robust accountability mechanisms, and effective expenditure management are required to raise the quality of education and health services and improve health access of poor, underserved populations. Moreover, problems of physical accessibility and transportation for rural communities are also a major barrier to medical care, and so efforts to ensure greater accessibility by improving road or transport options to sub-centres, PHCs, or CHCs must be taken.

It must be recognized that, at least in the near and mid-term, the Indian government is of limited capacity in delivering health services. It should, therefore, devise a shift in strategy that allows for rural communities to choose between public and private providers. In this context, providing the poor with cash transfers for out-patient care and insurance for in-patient care would be a worthy preliminary step. Next, a competitive price for services provided at public facilities could be established in order to increase revenues and therefore the quality of care. The state should invest in public facilities only in difficult to access regions where private providers may not wish to do business.

Increased depth and breadth of training must also be instituted across the board, from doctors to support staff. In line with the National Health Policy Act 2002, the federal government could introduce one-year long training courses for practitioners engaged in treating routine illnesses, which would not only better equip paramedics and nurse practitioners to handle an increased number of illnesses and conditions, but also close the skill gap of myriad health practitioners nationally to provide better primary care.⁸

It would also be highly beneficial for all stakeholders if either state or central governments introduced workforce policies in which doctors are rotated between rural and non-rural postings, which would address workplace dissatisfaction and motivation between young doctors. In the last few decades, several state governments have experimented with various measures to increase the number of doctors posted in rural areas. These include mandatory rural postings, linking rural postings to admission into postgraduate courses, and offering monetary incentives. While there has also been much activity within the Indian Medical Council, the federal government, and the Delhi High Court, about shorter and more focused medical education courses (non MBBS), opinion is bitterly divided on the potential consequences on rural communities and the rural health system. The state of Chhattisgarh, for example, introduced a three-year diploma course for rural medical assistants in 2001, as did Assam in 2004.⁹

It is also possible to include the private sector and NGOs in training healthcare workers, as is happening in West Bengal. There, an NGO by the name of the Liver Foundation is training informal health providers to provide better health care.¹⁰

The task of administering adequate and functional health care to communities in rural India is a leviathan undertaking. Ex health minister Jagat Prakash Nadda stated in 2015 that “reaching out to a vast population in a country like India requires arrangements of midlevel care providers in the rural areas. My Ministry is working in consultation with IMA and MCI for provision of rural health-care providers like trained Indian medicine doctors, nurse practitioners, and BSc graduates in community health.”¹¹ Given the above considerations and complications, all stakeholders involved in rural India’s healthcare system will have to come to a consensus if an effective and sustainable solution is to be found.

___________________________________________________________________________

1 Muralidharan, Karthik, et al. “Is There a Doctor in the House? Medical Worker Absence in India.” 12 Apr. 2011.

2,4,11  Sharma, Dinesh C. “India Still Struggles with Rural Doctor Shortages.” The Lancet, vol. 386, no. 10011, 2015, pp. 2381–2382., doi:10.1016/s0140-6736(15)01231-3.

3,5 Panagariya, Arvind. India: The Crisis in Rural Health Care. Brookings Institution, 28 July 2016, www.brookings.edu/opinions/india-the-crisis-in-rural-health-care/.

6 “Absenteeism among Health Workers Highest in India: Report.” The Economic Times, 17 May 2008, economictimes.indiatimes.com/news/company/corporate-trends/absenteeism-among-health-workers-highest-in-india-report/articleshow/3047607.cms?from=mdr.

7 Global Monitoring Report 2008, World Bank

8,9 Sachan, Dinsa. “India Looks to a New Course to Fix Rural Doctor Shortage.” The Lancet, vol. 382, no. 9899, 2013, doi:10.1016/s0140-6736(13)62058-9.

10 Tnn. “Bengal Liver Foundation Gets Rs 2.96 Crore Grant | Kolkata News – Times of India.” The Times of India, 5 Nov. 2012, timesofindia.indiatimes.com/city/kolkata/Bengal-liver-foundation-gets-Rs-2-96-crore-grant/articleshow/17095706.cms.

Featured image source:

• https://www.governancenow.com/news/regular-story/india-faces-acute-shortage-of-doctors
• https://www.downtoearth.org.in/dte-infographics/61322-not_enough_doctors.html

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Air pollution is now a more serious global health issue than smoking, high blood pressure, child and maternal malnutrition. A walk down New Delhi’s ceremonial Rajpath boulevard will show you all you need to know about the state of air quality in India. While Delhi is significantly more polluted than most Indian cities, 22 out of the 30 most polluted cities in the world are in India, with Gurugram and Ghaziabad topping the list.¹ According to the State of Global Air 2019 report, India had an air pollution mortality burden of 1.2 million people in 2017.² That is 1.2 million people who died directly from air pollution, or from physiological complications arising from it. Though India’s per capita emission of greenhouse gas is low, a further 140 million people breathe air that is 10 times over the WHO safe limit. Chronic obstructive pulmonary disease is now India’s largest cause of death after heart disease.³

India faces a dilemma of choices when it comes to balancing the industrial, development, and transportation needs of the country and upholding air pollution standards which might affect the business and development environment of a rapidly expanding economy. There are other factors that compound the aggregate health effects of air pollution in India, with poverty being the overarching concern. It is usually the poor and marginalized that bear the brunt of the health burden of dirty air in India, and make up a sizeable chunk of the above mortality burden statistic.

It is important then to understand the causes of unbridled air pollution, what the Government of India has done over the years and potential policies for curbing persistent carbon emissions. These questions are especially pertinent given India’s national energy and development needs.

What causes so much pollution?

India is the third largest emitter of carbon emissions after China and the US. The biggest sources of air pollution in urban India are vehicular exhaust fumes, fossil fuel fired power plants, construction dust, industrial emissions, while the burning of stubble after crop harvests and household biomass cookstoves contribute to poor air quality in rural areas.

The Government of India has been pushing an ambitious renewable energy project to expand India’s capacity for renewable energy generation. While India has imposed tougher emissions standards for power plants and state utilities, which own many of India’s ageing coal power plants, they have failed to comply. 60% of India’s combined power output is still generated from 246 highly polluting and inefficient coal-fired power plants.⁴ The International Energy Agency has found that India’s thermal power plants (coal, oil, and natural gas) emit 50 to 120 percent more CO2 per kWh produced compared to the those in the European Union.⁵ This presents the Government of India as well as Indian power companies with the opportunity to significantly reduce CO₂ emissions through acquisition of better technology.

Traffic congestion in Indian cities also contributes heavily to India’s poor air quality. In the last few decades, the number of vehicles on India’s roads and transport systems has skyrocketed, resulting in an increase in the number of vehicles per kilometre of available road. This is exasperated by a lack of organized intra-city divided-lane highways and expressways networks, inter-city expressways, and chaos on the road stemming from poor enforcement of traffic laws. Poor traffic management also ensures that traffic moves slower, and that engine fuel is burned inefficiently, polluting more per journey.⁶

Household pollution from the combustion of biomass and wood is the main culprit for the persistent and dangerous haze that hangs over rural India. Cookstoves or chulhas are used by rural communities for food preparation and heating, and usually comprise burning wood fuel, coal, livestock excrement, and dried grass and leaves. The World Health Organization outlines the health risks involved in the use of household combustion of fuel, and states that 300,000 to 400,000 deaths result annually from indoor air pollution and carbon monoxide poisoning.⁷ While the government has provided cooking gas cylinders to more than 50 million households, the high cost of gas refills means that biomass burning remains a major source of pollution.

What are the health risks?

22 out of the 30 most polluted cities in the world, when measuring atmospheric fine particulate matter (PM2.5), are in India. A study published in the Lancet journal that studied the impact of PM2.5 concentration on death, disease burden, and life expectancy found that “in 2017, no state in India had an annual population weighted ambient particulate matter mean PM2·5 less than the WHO recommended level of 10 μg/m³, and 77% of India’s population was exposed to mean PM2·5 more than 40 μg/m³, which is the recommended limit set by the National Ambient Air Quality Standards of India.”⁸ Moreover, 56% of India’s population was still exposed to household air pollution from solid fuels, resulting in an estimated 0·67 million deaths to ambient particulate matter pollution and 0·48 million deaths to household air pollution. The authors also estimate that life expectancy would be increased by 1.7 years if levels of pollution had been lower than the minimum level associated with health loss. Another report by the Washington Post, life expectancy in India was cut short by an average of 5.3 years.⁹

It is also important to consider the effect of air pollution on younger generations. Reports indicate that,  unsurprisingly, the effect of air and particulate pollution on children is significantly more severe. Dr. Sai Kiran Chaudhuri, the pulmonary chief of the Delhi Heart & Lung Institute highlights that 2.2 million children in Delhi, about half of the city’s youth, have abnormalities in their lung function — asthma, bronchitis, spasmodic cough, and others.¹⁰ Air pollution also adversely impacted growth and weight indicators according to the Brookings Institution.¹¹ Persistent exposure to air pollution during the first trimester of gestation was linked to increased stunting and underweightedness in children, which in turn results in long lasting health complications such as poor mental development, cardiovascular disease, chronic respiratory failure and infections. Counted over millions of children, this also has a strongly detrimental effect on the human capital of India, and thus its GDP. The study states that an increase of 10% in GDP is a likely benefit of the complete elimination of stunting in India.

Policy Recommendations for the Indian Government

Over the last few decades, Indian authorities have been reluctant to address the problem of increased air pollution, especially throughout northern India, due to fear of reprisal by heavy industries, automakers, and other powerful vested interests. The government’s attempts to tackle the problem have traditionally been incremental in nature, as opposed to ambitious plans to ensure cleaner air.

In 2017, the Government in Delhi took steps to launch the Odd-Even rule policy, in which cars with number plates ending with odd and even number will be permitted to use the roads on alternating days. Many have claimed the policy is too little too late, and that more bold and decisive policies to tackle air pollution are needed. In 2016, the Government of India also committed itself to a 50% reduction in households using solid fuel for cooking and heating.¹² In late 2018, Delhi’s government installed 54 large air purifiers at large traffic intersections throughout the city in order to remove fine vehicular pollution from the air. Again, however, critics have been cautious about the efficacy or cost of the machines. Other measures include air filters have also been fitted atop public buses. The Central Pollution Control Board of India has other plans in the making, such as those to sprinkle hygroscopic magnesium chloride and cement powder on roads and construction sites to absorb water from the air, making the ground moist and keeping dust from becoming airborne, as well as a cloud-seeding project that generates artificial rain to wash away pollution.¹³ Other examples of programs that are being tested are Haryana’s ‘Happy Seeder’ program, in which the state government is providing farmers with a machine called a Happy Seeder, which converts agricultural residue to fertilizer.

However, such incremental efforts towards cleaning India’s air are eclipsed by the leviathan number of thermal power plants, construction sites, and combustion engines that operate every day. In the coming decades, the Government of India will need to commit, invest and modernize heavily in a number of areas relating to renewable energy generation, cleaner and more efficient technology in power plants, meaningful policies on vehicular pollution and manufacture and public transport systems.

It will also need to conduct a comprehensive fact-finding mission to understand which areas of the country contain the most pollution, and how much pollution each area generates. This could be done by the mandatory establishment of automatic emission-measurement stations in all highly polluting industrial plants, which would send pollution measurements to national pollution authorities and allow them to better enforce pollution rules, and develop new ones.

A concerted national effort aimed at turning agricultural residue into profitable products could reduce PM2.5 levels in North India in the winter. A robust supply of electricity would also allow for the phasing out of polluting diesel generators. Similarly, providing even more clean-burning liquefied petroleum gas cooking stoves to replace biomass burning would cut households pollution levels even further. Enforcing pollution standards for industries, and introducing legions of electric transport around the country would also help immensely.

The Government of India will soon have to reckon with its increasingly severe pollution problem and the myriad health costs that are associated with it. There are currently several pollution control laws and policies established on paper but are not being enforced in reality. India’s biggest problem is, therefore, implementation of pollution policies, as firework bans have not worked, vehicle emissions test centres falsify compliance data, and construction companies rarely take the required steps to ensure debris and dust is not spread. Lastly, a gargantuan amount of political will and public involvement must be generated. It is, after all, the public who is affected most. Garnering public assistance and trust, along with concrete measurable actions on the part of the government will ensure over time, that India’s air becomes cleaner and more breathable.

________________________________________________________________________________

1 Griffiths, James. 22 Of the Top 30 Most Polluted Cities in the World Are in India. CNN, 5 Mar. 2019, edition.cnn.com/2019/03/04/health/most-polluted-cities-india-china-intl/index.html

2 State of Global Air 2019. Economic Times, energy.economictimes.indiatimes.com/etanalytics/reports/coal/state-of-global-air-2019/640.

3,4 Bernard, Steven, and Amy Kazmin. “Dirty Air: How India Became the Most Polluted Country on Earth.”  , The Financial Times, 11 Dec. 2018, ig.ft.com/india-pollution/.

5 CO2 Emissions from Fuel Combustion. International Energy Agency, 2011, www.iea.org/media/statistics/CO2highlights.pdf.

6 Barth, Matthew, and Kanok Boriboonsomsin . Real-World CO2 Impacts of Traffic Congestion. UC Riverside, citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.367.5168&rep=rep1&type=pdf.

7 Stoves: Green Stoves to Replace Chullahs | India News – Times of India. The Times of India, timesofindia.indiatimes.com/india/Green-stoves-to-replace chullahs/articleshow/5293563.cms?referral=PM.

8 Dandona, Lalit. “The Impact of Air Pollution on Deaths, Disease Burden, and Life Expectancy across the States of India: the Global Burden of Disease Study 2017.” The Lancet, www.thelancet.com/journals/lanplh/article/PIIS2542-5196(18)30261-4/fulltext.

9 “How Many Years Do We Lose to the Air We Breathe?” The Washington Post, WP Company, 19 Nov. 2018, www.washingtonpost.com/graphics/2018/national/health-science/lost-years/?noredirect=on&utm_term=.5bf23000f734.

10 Webber, Tammy. “US Exporting Dirty Fuel to Already Pollution-Choked India.” AP NEWS, Associated Press, 1 Dec. 2017, www.apnews.com/77273861e393412a913fa332054ab2d7.

11 Singh, Prachi, et al. Early Life Exposure to Outdoor Air Pollution: Effect on Child Health in India. Brookings Institution, 19 Mar. 2019, www.brookings.edu/research/early-life-exposure-to-outdoor-air-pollution-effect-on-child-health-in-india/.

12 India Takes Steps to Curb Air Pollution. WHO, www.who.int/bulletin/volumes/94/7/16-020716.pdf.

13 Pelley, Janet. “Does Cloud Seeding Really Work?” CEN RSS, cen.acs.org/articles/94/i22/Does-cloud-seeding-really-work.html.

Featured image source: https://edition.cnn.com/2018/02/01/health/india-air-pollution-crop-burning-subsidy-intl/index.html

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The event was inaugurated and hosted by Mr. Sisir Pradhan, who is currently a Ph.D candidate at the School of Environment, Enterprise and Development, University of Waterloo. Pradhan has worked with Kar for several years and highlighted various instances of their work together and the emergence and importance of CLTS moving forward.

Following that, Dalbir Singh, Sarpanch of Bilaspur Village from Panipat, one of the natural leaders from Haryana
elucidated his experience with CLTS, how the state of sanitation had undergone a change in his community, and how the community benefitted from CLTS. He also stated proudly that his community was now open defecation free (ODF). The author of the book, Dr. Kamal Kar then took the stage and elaborated upon the history and development of the CLTS movement and how the approach came to be adopted by various governments, non-governmental organizations (NGOs), and international agencies, citing the successful transformation in Bangladesh to an ODF country using the CLTS approach.

Kar added some anecdotes from his experiences in Asia, Africa and Latin America on the strength of collective action to end open defecation. He also briefly outlined the important CLTS case studies which have been enumerated from around the world, as well as the need, obstacles and potential to scale-up the approach, taking the journey ‘From Village to Nation’.

Following the official launch, a panel discussion was held. The panel was moderated by Dr. Kar and the speakers included Mr. V.K. Madhavan of WaterAid India, Ms. Meena Narula of Water for People, and Mr. Jamie Myers of the Institute of Development Studies, University of Sussex. As the theme of the event was ‘Behaviour Change and Human Dignity’, panellists elaborated upon a wealth of topics including gender impacts, subsidies for sanitation hardware, access to latrines, the Swachh Bharat Abhiyan (SBA), and the ways forward for the CLTS movement.

While Madhavan applauded the national importance given to the SBA as a movement against open defecation, he stated that the program and the CLTS approach must be retrofitted to address the emerging challenges of inclusion, sanitation demands and post ODF sustainability in this journey towards total hygiene. He said “the CLTS approach is not only an effort to help people build toilets and use them. It is meant to help people transform towards hygiene behaviour”, thereby drawing attention to the next phase of WASH concerns.

Similarly, Kar praised the SBA but also stated that sanitation has turned from a people’s movement to the
government’s movement requiring more participation for sustainability. While Myers shared his experiences
from India and Africa to highlight the idea and impact of gender specific sanitation interventions, Narula
expanded on the need for an intermingling of local culture and practices towards bringing forth sustained
behaviour change for human dignity.

Members of the audience then posed a number of questions to the panellists, which focused on issues related to modifying CLTS in the future, CLTS solutions for women’s dignity and gender parity, institutional triggering, political factors, efficacy of subsidies, and others. The panellists shared their thoughts on making this a holistic movement with special focus on these emerging concerns.

After the panel discussion, Pradhan expanded upon the book, citing its various sections, case studies and
findings. He also described its various uses for the future of the CLTS program development and
implementation, as well as notable anecdotes from its writing and publishing. Mahesh Kumar, Sarpanch of
Basara from Haryana then took the podium to illustrate his experience with scaling up CLTS. He stated that
the momentum of the CLTS approach in Haryana was established because his village was involved in
helping neighbouring villages become ODF after becoming ODF itself. He emphasized that this strategy is
an effective way to build support and traction for CLTS.

The event was concluded with the closing address by Ms. Urvashi Asthana from Practical Action, India. She
thanked the various organizations, media and community members for attending the event and making their
presence felt. She also stated that this book marked the beginning of a new phase for CLTS.

About the Book

The book has been written by Dr. Kamal Kar, and is an extensive account of how the CLTS movement came about, got adopted/institutionalized by governments and other agencies, and spread across the world. It includes methodologies for influencing the sanitation policies at the national level as well as ‘triggering’ villages/regions/districts to initiate and sustain collective local action against open defecation. A major publication after more than a decade since the Handbook on CLTS was published in 2008, the book also encapsulates case studies from across the world with special emphasis on scaling up and institutionalization of the CLTS approach.

The book is available for purchase online at:-

1. https://developmentbookshop.com/scaling-up-community-led-total-sanitation?fbclid=IwAR3brsAlCqgxGAqrzVvOYuGqs6fgO5ueqsc75ahl0vCnQHLhUXZMd8rUvzc
2. https://www.amazon.in/Scaling-up-Community-Led-Total-Sanitation-village-ebook/dp/B07NNRYBQ3/ref=sr_1_1?keywords=scaling+up+CLTS&qid=1557120725&s=gateway&sr=8-1-spell

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