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Published on: 12/08/2014

Various news stories have come out in the recent months on the low level of sanitation coverage in India and the consequences this has, particularly on the country's most vulnerable residents. Last May the world was shocked by the appalling case of two girls being gang-raped and killed in Uttar Pradesh when they had gone to the fields outside their village at dark to relieve themselves. The international attention for this case immediately sparked pleas to increase efforts in constructing toilets in every home, schools and public place in order to end open defecation. A recent article featured in the NY Times (see below for link) describes how the terrible state of sanitation in India is closely linked to high malnutrition levels, even of children who are well-fed. Research has shown that there is a difference in the under-five mortality rate between Hindus and Muslims in India. It appears that what matters most for child survival, is the open defecation of one's neighbours rather than that of the household's own practice.

As the NY Times article rightly points out, together with other recent articles from the Economist  and Bloomberg, merely building toilets will not solve India's sanitation problem (nor curb its rape culture for that matter). Research has shown that there is a preference for open defecation over the use of a latrine and that this has not changed despite the large subsidy-driven Total Sanitation Campaign devised to enable India's poor to build subsidised toilets. As a conclusion, many of these articles plea for large-scale behaviour change campaigns to make sure that those defecating in the open switch towards the use of a latrine.

Behaviour change campaigns are certainly necessary, but unfortunately it is not only the 'poor villagers' that need to be guided in a turnaround of their practices. A research on the Total Sanitation Campaign has found that it has been an enormous policy failure, as it became clear from the 2011 Census that the large reported achievements previously reported by the Ministry of Drinking Water and Sanitation have never materialised, accruing to more than 37 million 'missing toilets'. The reasons cited by the authors behind the failure of the Total Sanitation Campaign include low political priority; flawed monitoring; distorting accountability and career incentives; technocratic and paternalistic inertia; and corruption. It becomes clear that a shift in practices also needs to occur within the ranks of state functionaries, at all levels from the Gram Panchayats to the Ministry.

How interesting this all may be, it is nothing new under the sun. The widespread practice for open defecation among Indians is widely known, and it would be naive to deny the fact that this is linked to some degree of cultural acceptance or preference. The widespread corruption linked to large-scale government programs need not shock us either, however sad this may be. What strikes me the most, aside from the high level of bigotry of some commentators on the webpages of the newspapers mentioned above, is the stalemate that we have reached. From the comments on these articles, and from the discussions that these articles have provoked on some Linkedin groups and professional fora, it seems that there is a genuine lack of ideas on how to move forward at scale. Sure there are some ideas on projects that can be carried out, and there are also some clues on what the drivers are for construction and use of latrines (recurring themes are issues of status, peer pressure, political will and exposure to toilets in cities, see for more information the resources below). But with the daunting task of a much needed sector reform, and almost 600 million Indians that practice open defecation (WHO/UNICEF, 2014), it seems that there are very few ideas on how to take these initial leads forward and make sure that these result in meaningful change at (very large) scale. 

At least the political will at the highest level seems to be present. The recently elected Prime Minister Narendra Modi made a plea in his very first post-election speech to clean up Varanasi and the rest of India by 2019, the 150th birth anniversary of Mahatma Gandhi. This will not be an easy task by any means. To achieve this ambitious target in such a short period, there is a serious need to quickly find, and act upon the drivers that lead people to start using latrines. Most likely one of the biggest challenges for Modi will be to make sure that this high-level political will actually leads to change in the attitudes and practices of the public officials under his command.


Barnard, S., Routray, P., Majorin, F., Peletz, R., Boisson, S., Sinha, A., & Clasen, T. (2013). Impact of Indian Total Sanitation Campaign on Latrine Coverage and Use: A Cross-Sectional Study in Orissa Three Years following Programme Implementation. PloS one, 8(8), e71438.

Bhalotra, S., Valente, C., & Van Soest, A. (2010). The puzzle of Muslim advantage in child survival in India. Journal of Health Economics, 29(2), 191-204.

Coffey, D., Gupta, A., Hathi, P., Khurana, N., Spears, D., Srivastav, N., & Vyas, S. Revealed preference for open defecation. SQUAT Working Paper No.1 

Geruso, M., & Spears, D. (2013). Sanitation and health externalities: Resolving the Muslim mortality paradox. University of Texas at Austin Working Paper.

Harris, G. (2014) Poor Sanitation in India May Afflict Well-Fed Children With Malnutrition. New York Times 13 July 2014 

Hueso, A., & Bell, B. (2013). An untold story of policy failure: the Total Sanitation Campaign in India. Water Policy, 15(6), 1001-1017.

O'Reilly, K. & Louis, E. (2014). The toilet tripod: Understanding successful sanitation in rural India. Health & place, 29, 43-51.

WHO/UNICEF, 2014. Progress on sanitation and drinking-water - 2014 update, Geneva. Available at:


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