Sanitation & Behavior Change in India

As is well known and well covered in the media, there is a sanitation crisis in India, with over half the population (roughly 600 million people) forced toopen-defecateevery day due to a lack of adequate facilities, infrastructure, and even a basic understanding of the importance of healthy sanitation habits. This makes India the world's biggest culprit in terms of open-defecation, with more than double the amount of the next11 countries combined.

Additionally, the country loses overUS$50 billiondollars per year (roughly 6% of GDP) due to sanitation-related illnesses,one child under the age of 5 dies every 20-seconds from diarrheastemming from water-borne illnesses, safety of women and girls remains one of the primary concerns in settings where they are forced into the fields due to lack of access to toilets, generations of Indians havestuntedmental and physical development from nutrient deficiency stemming from persistent diarrhea related to inadequate sanitation, and on and on; there is no degree of hyperbole to overstate the dire state of sanitation in India, and the impact this has on the country.

Presently, there is cause for at least mild optimism in the sector. Prime Minister Narendra Modi'sSwachh Bharat(Clean India) Mission seeks to completely eradicate open defecation in India by 2019, and has committedthousands of croresin support of it. Efforts have also been made to free up tens of thousands of crores in additional funding throughCSR initiatives, an estimated half of which will go directly towards sanitation programs. Perhaps most encouraging, though, is the shift in focus on how the effectiveness of the campaign is gauged: in tracking actualtoilet userather than simply by the number of toilets purportedly built. (The latter metric is particularly flawed given the unfortunate reality that what isreportedis oftentimes not reflective ofground realities.)

There is clearly a demand for improvements in the sanitation space, an understanding of this reality in the public and private sectors, and an appreciation for the complex challenge that solving this crisis presents. The announcement of such a massive infusion of capital in addressing the sanitation crisis through infrastructural interventions, even if actual toilet use is closely monitored, has rightfully caused concern amongst sanitation practitioners in India and beyond. Without addressing the perceptions and attitudes that drive people away from using toilets, adding more toilets will simply not move the needle. Collectively, then, there is push for "behavior change" activities to accompany the Swachh Bharat mission.

Behavior change is certainly not a new concept, and is a key component in theCommunity Led Total Sanitationapproach popularized by Kolkata-based consultant Kamal Kar, and currently employed in over 60 countries worldwide. The issue that arises when talking about such a change is the lens in which it is viewed through: it is far too often that behavior change is looked at only as the responsibility of the end-users that are forced to open-defecate due to inadequate, dysfunctional or simply nonexistent sanitation options.

Disturbingly, a popular view is that those open-defecating are doing so purely as a function of preference, that they willfully snub their noses at available facilities. While there is certainly a portion of the more than half-billion people in India open-defecating that do cite OD as a preference, they are a minority. Further to this, opting to open defecate versus using a toilet is oftentimes driven by the quality of the facility available. The belief that there are pristine, well-maintained facilities being ignored and unused because people prefer using fields, train tracks, and other open spaces to answer nature's call is not only fallacious, it's dangerous: people do not empathize with the plight of so many because they discount their struggle as "it's their choice".

This is especially true when taken to the halls of the various national, state, and local government agencies tasked with providing adequate, safe, and sustainable sanitation to all of India's citizenry. And no group benefits more from the focus of behavior change on the end-user than these government officials.

Over the past three years, I have worked on a innovative sanitation initiative seeking to holistically reimagine the community sanitation experience for India's urban slums. The intent is to improve the infrastructural design, operations and maintenance approach, pricing models, community outreach and education, end-mile waste management, and other aspects of the ecosystem to provide a sustainable solution that community members value, and use. The plan is to build over 100 of these facilities, then rigorously evaluate the impact they have on increasing toilet usage and, by extension, reducing instances of open-defecation. By all estimates, over 60,000 people would directly benefit from the project.

One of the most exciting aspects of the project, at least initially, was the inclusion of the local municipal corporations as stakeholders in the project. They are to contribute not only the land and a majority of the funding to construct the facilities, but also establish what will effectively be help desks to address any issues community members may have that affect the functioning of the facilities. This was viewed as a coup to be held up as a prime example of an effective Private Public Partnership in India. Unfortunately, what was planned versus what has been experienced stand in stark contrast.

The initial timeline for the project was 20-months for all activities including the rigorous post-construction evaluation, which was agreed upon by all partners. Again, it's been three years now and we've yet to build even a single facility. While there have certainly been learnings and necessary course-corrections along the way, it would be accurate to say that a lot of the delays stem from a largely labyrinthine, intentionally opaque government run by officials that can act with impunity and devoid of fear of reproach. That is not to say all officials exploit this, but it is fair to say that a majority of those we have worked with do.

As a foreigner newly exposed to working with the Indian government, I approached my charge with an embarrassing level of naïveté. I genuinely believed that, with the local governments as partners, our project would be immediately successful and free from many of the challenges that have plagued other initiatives. I was therefore unprepared for such questions from our government partners like, "Why should I care about sanitation?", "How do Ibenefit from this project?", and on and on. Surprisingly, It's remarkably challenging to try and sell through the importance of empathy or, short of that, just doing the job one is tasked with.

A huge issue that we have fought diligently to push through is the need for innovation in the sanitation space to solve the problem, and save lives. Oftentimes, we have encountered government officials hesitant to sign off on our project based on the fact that there are aspects of it that are new, and therefore lacking any sort of baseline for comparison, an example of this being the inclusion of menstrual waste incinerators in our facilities. One engineer said outright that he would never approve our project with these incinerators included, and without any sense of shame supported this by saying that he was risk-averse and unwilling to put his neck on the line. Carrying that logic out with him, we asked if he would approve plans for a facility he knew was destined to fail because plans for such had previously been approved. Without hesitating, he said yes.

Beyond this, an omnipresent challenge is just getting in to meet with our government partners. Interactions with them are rarely done over the phone, never via email, and we oftentimes have to resort to communicate via letters in hopes that such dialogues make their way into our project file and, therefore, part of some permanent record. Any visitor to a government office here can attest that there are literally rooms with files stacked floor-to-ceiling, so whether or not anyone will ever give our initiative some ex post facto review is a longshot. No matter, though, it is certainly much better than doing nothing, and being reactive with the government will only lead to greater delays.

Following years of effort, we successfully established enough of a rapport to ensure that some of our meeting requests are granted, but if I'm being honest, the meetings we do get are on an ad hoc basis and are largely contingent upon our willingness to wait, for hours at times, outside an official's office in hopes of getting a few minutes of their time. Oftentimes, weeks can go by between meetings, irrespective of our daily attempts at scheduling such interactions. To further reinforce how challenging this is, our project has a dedicated, and well compensated, company solely responsible for interacting with the government. In spite of this, we have absolutely no leverage when it comes to government interactions. What makes this an even harsher reality is the fact that they are more than aware of this dynamic as well.

These challenges are when the officials are actually at work, which is certainly not a regularity. Governmenttruancyis so endemic that Prime Minister Modi launched awebsiteto track attendance of officials in various offices. It is truly an incredible challenge. How do you accomplish something when you require the active participation of individuals that are either unavailable outright, or unwilling to so much as speak to you even if they are in their offices?

One incident that stands out as the most distressing in my personal experience, and which is the impetus behind writing this, occurred when our government partners decided to reduce the number of facilities we were to build by more than half, citing vague "budget concerns" as the cause. Mere hours after being told this, I sat in a press conference and listened to these same officials proudly announce that sanitation is their top priority. When asked how one could drastically cut budgets on a sanitation project while simultaneously announce that sanitation is the top priority, I was told simply that, "We say what we have to, but do what we want."

As long as this attitude, and the environment that fosters it, persists, no amount of infrastructure or behavioral change achieved by end-users will make a bit of difference.