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The high costs of poor sanitation

Despite the Total Sanitation Campaign launched since 1991, just 30,000 of 600,000 villages are free of open defecation today. The economic impact of poor sanitation in India is Rs 2.46 trillion or 6.5% of the GDP, writes Darryl D’Monte

A young bride’s refusal to live in her husband’s home in Madhya Pradesh for lack of a toilet has shot her into limelight and made her richer by half a million rupees.

When Jairam Ramesh was divested of the environment portfolio, due no doubt to his proactive stand against various vested interests, it was widely assumed that he would go into some sort of political hibernation.  His successor, Jayanthi Natarajan, has certainly been far more pliant, notwithstanding the brave noises she made about global equity in the build-up to the Durban climate change conference last December. However, as recent actions show, it is difficult to keep Ramesh down even as rural development minister, with additional charge of the ministry of drinking water and sanitation, given his characteristic  ebullience.

Only recently, he has sought to virtually double the allocation of funds for water supply and sanitation from Rs 11,005 crore in the current year to Rs 20,000 crore in the forthcoming budget.  While the finance ministry has so far agreed to raise the funding to Rs 12,000 crore, Ramesh has indicated, if the media reports are accurate, that he is prepared to accept “anything short of Rs 16,000 crore”.

This sector, abbreviated to ‘watsan’ by experts in the field, has for far too many decades been sorely neglected, even though Gandhi, with enormous prescience, had said that sanitation was more important than independence. Indeed, sanitation is something of a taboo, which is reinforced by the fact that it affects women and children far more than adult males.

It is for this reason that Ramesh is quoted as being amenable to  a freeze on funds for other rural development schemes  under his ministry, so long as the allocations for watsan is substantially increased. The fact is that poor supply of potable water and lack of toilets are responsible for a huge toll of health and lives, particularly of children under five, due to diarrhoea.  The problem is that this link is not commonly perceived, with many villagers believing that open defecation is an age-old and harmless practice.

According to a World Health Organisation document in 2007, as many as 354 million people in the world will not be covered by the UN’s Millennium Goal of halving those without drinking water by 2015. What is more, 564 million will miss the bus so far as sanitation is concerned. The WHO estimated, at the time, that unsafe drinking water, sanitation and hygiene accounted for 1.7 million deaths every year. Some estimate that in India alone, diarrhoea accounts for the lives of a thousand children every day. The tragedy is that these basic amenities can be provided at a relatively moderate cost, especially if – as is often seen in this country – villagers are prepared to bear some of it themselves.

The Planning Commission has recently documented how nearly half the total population in India lacks access to decent lavatories. A Total Sanitation Campaign was launched in 1991 to provide access to all villages by 2012, but nothing of the kind has happened. Villages which had declared themselves free of open defecation were awarded a Nirmal Gram Puruskar, instituted in 2005, with up to Rs 5 lakh for a gram panchayat, Rs 20 lakhs for a block and Rs 50 lakhs for a zilla parishad.  An additional incentive was that the awards would be given away by the President in New Delhi. After an initial flurry of enthusiasm, some rural areas which have received these awards have lapsed, somewhat mirroring the total literacy campaign. The awards too have lost their lustre.

This year’s deadline, according to estimates, will be missed by no fewer than 22 states.  The five that may possibly make it are Kerala, Haryana (where women have played a leading role in many areas), Himachal Pradesh, Mizoram and Tripura.  There can be no greater ignominy than the finding that only 30,000 out of a total of some 600,000 villages are free of open defecation.  Experts have been arguing that while funds are sorely needed for taps and toilets, what is as important is a change in mindset. Particularly when sanitation is linked to hygiene and the concept of cleanliness, not to mention the vital issue of privacy, change can and does take place. International experts point to six ‘F’ words in this ‘faecal attraction’: faeces, fingers, flies, fields, fluids and foods, all of which factors are only accentuated when there is an acute shortage of water to wash hands with.

To cite just one instance, a woman in a village in Betul district, Madhya Pradesh, left her in-laws’ house just two days after her marriage in May 2011 because they did not have a toilet. She refused to return till one was built. The panchayat persuaded her husband to build one, and gave him Rs 2,200 to do so; the National Rural Employment Guarantee authorities chipped in with another Rs 3,400 and she was back in eight days. Since then, another 80 toilets have been built and there are another hundred applications in her village.  Very recently, the Delhi-based Sulabh International, which has created a unique network of pay toilets throughout the country and even in neighbouring nations, gave the woman a Rs 5 lakh award.

Apart from women, school children are another section of society that can galvanise action by pressurising their parents. Rather like the free lunch programme in many states, the provision of toilets can make a huge difference to attendance. As a matter of fact, children, especially girls, who lack such amenities at home, look forward to going to school for this singular reason and rue the weekends. NGOs in several states have also started schemes for poor women to make sanitary napkins which cost only a couple of rupees, since branded versions are way out of their reach. This, once again, highlights the close connection between sanitation and hygiene.  

One of the most innovative campaigns in many developing countries is known as Community-led Total Sanitation or more often by its acronym, CLTS. This employs ‘conscientisers’ who ask women to outline maps of their villages on the mud, then identify their homes with a coloured powder and where they defecate  with turmeric powder. This ‘shames’ villagers who realise that by permitting open defecation, their water sources are getting contaminated every day, exposing them to diarrhoea and other dreaded diseases.  An indefatigable exponent of this approach, who has been consulted in several neighbouring and developing countries, is an Indian, Kamal Kar.

The argument that a country like India cannot provide sufficient funds for sanitation does not take into account the high cost that the absence of such facilities imposes on society. The most exhaustive study of these costs in this country has been conducted, as part of an international initiative, by the Water & Sanitation Programme (WSP) of the World Bank in 2010. The astounding finding is that the economic impact of poor sanitation in India is Rs 2.46 trillion or $54 billion per year at exchange rates prevailing at that time. Taken on an annual per capita basis, this is Rs 2,200 for every person in the country. This amounts to nothing less than 6.5% of the GDP.

The costs are broken up under five heads. By far the greatest is the health impact, as much as 72%, which should be self-evident since it is estimated that 80% of all illnesses here are water-borne.  Illness and premature immortality are a consequence, and the total health impact adds up to Rs 1,763 billion. The time taken to access facilities comes next, at Rs 489 billion or 20% of the overall cost. One should spare a thought for the ordeal that women have to face in villages daily, when they have to wait until darkness to relieve themselves. In cities, the chronic shortage of public toilets results in long queues and hence the waste of productive time.  The shortage of water accounts for Rs 191 billion or nearly 8%. There is also a small cost of the loss of tourism due to the abysmal lack of toilets throughout the country. These costs together comprise a full 6.5% of the GDP, which should be a wake-up call to all concerned about development.

To all those who believe that the country cannot afford to provide sanitation to every citizen, these statistics ought to prove that the poor are already paying a heavy cost for it. Indeed, precisely the opposite can be argued: that the country cannot afford not to provide this most basic amenity. However, the WSP has calculated the economic benefits of proper sanitation. It cites how previous research in developing countries shows that the benefits of providing sanitation are five times the expenditure.  One has only to recall studies by the American sociologist Myron Weiner on the very high spinoffs in money terms of investment in education in this country.

Ramesh’s ministry has an overall allocation of Rs 90,000 crore, which is the next highest after defence expenditure. If the Centre jacks up the funding for sanitation to Rs 20,000 crore, it will be a very welcome move.  But even if it finds it difficult to do so, given the current economic crisis, there is no reason to give up hope. There have been any number of innovative projects initiated in the sanitation sector by NGOs here which are eminently replicable elsewhere in the country.  We have already referred to the path-breaking campaign by Dr Bindeshwar Pathak with his Sulabh International which, incidentally, is self-sustaining and has never received a single rupee from the government.

In rural areas of Orissa, Joe Madiath has worked wonders with his NGO, Gram Vikas, which relies heavily on full participation by beneficiaries. On the west coast, Nafisa Barot has done likewise with Utthan, which functions in the parched districts of Gujarat. Last year, its work was comprehensively documented by Ashoke Chatterjee in his Rising/Utthan: An Indian Quest for Dignity and Hope, published by Business Standard books. There is an overwhelming need for such initiatives to be widely disseminated in the country which will demonstrate that cooperation can achieve results even with a paucity of financial resources.

Infochange News & Features, February 2012