India’s Road To Universal Sanitation

Shashi Buluswar
January 2024

Of the various human senses, olfaction—the sense of smell—is known to have a particularly strong connection to memory. Once you smell something, you can never unsmell it. It stays with you as long as you live; and the stronger the smell, the more ingrained and evocative it becomes. When smell is combined with sight, the memory becomes permanently etched. And so it came to be that untold millions of us who grew up in India were scarred for life with remembrances that we tried so hard to Dettol® out. Fortunately, future generations of Indians will be spared the ordeal.

In the year 2000, only 14% of India’s population had access to what the World Health Organization calls at least “basic sanitation services,” that is, toilets as rudimentary as holes in the ground. The problem was particularly acute in rural areas where barely 1% of the population had anything resembling toilets. People without access to toilets live with the daily indignity of defecating in the open: in fields and vacant lots, next to waterways, on railway tracks, in the woods. The hardship is especially severe on women who—deprived of basic privacy, and at perpetual risk of sexual harassment if not outright assault—are forced to relieve themselves only outside of daylight hours to avoid preying voyeurs. Without plumbed toilets, people cleanse themselves with water they carry in little plastic jugs, grass and leaves, even mud. Soap, in such a context, is a luxury typically not available.

Human fecal waste contains many microbial pathogens which find their way back into human digestive systems via unwashed hands, contaminated water, etc., and can cause deadly diseases like dysentery, cholera, hepatitis A, and (more so in years past) polio. Accounting for over 1.2 million deaths in India in 2000, such diseases are among the largest killers of young children. Repeated infection at a young age can cause such severe corrosion of the intestines that many millions of children lose the ability to adequately absorb nutrients from food, causing chronic malnutrition for the rest of their lives.

The repeated references to the year 2000, above, are not coincidental: that was when the world adopted and rallied around the UN’s Millennium Development Goals (MDGs) which sought to make unprecedented advances towards improving conditions in developing countries. Many billions of dollars in aid were mobilized to achieve these goals, and there was a coordinated global effort to track standardized data to measure progress towards the Goals. Access to sanitation was one of the more visible areas of MDG-driven effort.

By the time the MDGs were launched, India had already been making strong progress along multiple fronts as a result of the regulatory reforms of the early 1990’s. Hence, it was well positioned to achieve its share of the MDGs without relying on external aid as much as other developing countries.

Since the launch of the MDGs, the share of India’s population with basic sanitation has steadily grown by about 3% every year: whereas in 2000 only 14% of the country had access to toilets, that number had grown to 43% by 2010, and to 73% by 2020; today, it exceeds 80%. Even rural areas have crossed the 70% mark. These indicators are consistent with India’s overall progress during the same period: the share of population living in extreme poverty (defined by the World Bank as earning less than $2.15/day) fell from 43% to 10%; adult literacy improved from 60% to 78%; and life expectancy improved from 62 to 70 years. In other words, India’s sanitation story is a part of its overall story of strong, steady progress over the past 2-3 decades: as people work their way out of poverty, their desire for—and ability to—have private toilets naturally increases. (See Exhibit 1.)

Exhibit 1: Since 2000 there has been a steady decrease in poverty in India, accompanied by an equally steady growth in the share of the population with access to sanitation.

Even as overall access to toilets had been growing steadily through the 2010’s, two major challenges remained: first, reaching increasingly remote rural communities still struggling with poverty; and second, ensuring everyone with toilets actually used them (particularly in communities that, for various reasons, were resistant to the idea of indoor toilets).

It was in this context that the Indian Government, in 2014, launched the Swacch Bharat (Clean India) program to achieve universal sanitation. The initiative used several mechanisms, notably:

  1. Cash incentives of up to 12,000 rupees (US$150) for each household that built a new toilet. To minimize fraud, tools like geo-tagged photographs were used to validate that toilets were indeed constructed as claimed.
  2. A massive influencing campaign to encourage people to stop open defecation and urination, use toilets, generally work towards a clean India. The campaign consisted of billboards, posters and murals all across the country featuring movie stars, Mahatma Gandhi, and Prime Minister Narendra Modi. Exhibit 2 shows examples of this campaign.
  3. Encouraging private companies to dedicate their corporate social responsibility (CSR) programs to complement the government’s investment, thereby leveraging a massive source of additional funds.
  4. Enlisting the help of hundreds of NGOs in building toilets, educating communities on the health benefits of toilet use, and helping community leaders drive behavior changes in their respective communities.
  5. Promoting technology innovations for new mechanisms of processing and decontaminating fecal waste.

Exhibit 2: A key part of the Swacch Bharat campaign involved blanketing the country with billboards, murals and posters featuring national icons.

The vast majority of toilets built during that period employed the twin-pit system which consisted of two holes in the ground connected to an outlet pipe from the commode. In this system, each pit takes about a year to fill up; after one pit fills up, the user diverts the outlet pipe to the other pit. As the second pit fills up over the course of another year, the waste in the first pit decomposes and becomes sterile. Thereafter, the user can (with modest effort) empty out the first pit and re-divert the outlet pipe. In principle, this process can continue indefinitely.

I myself got deeply involved in India’s broader sanitation initiative via my nonprofit organization, the Institute for Transformative Technologies. In collaboration with a Pune-based company called Primove, we developed a system that uses earthworms to process fecal waste. This system, called the Tiger Biofilter, treats the waste of hundreds of thousands of people across the country. You can read more about it here.

Under the auspices of Swacch Bharat, over 300 million people have gained access to sanitation. Combined with the previous 8-year window (from 2006-2014) which also crossed the 300 million threshold, the 16-year period between 2006 and 2022 marks the largest sanitation drive in human history. Thanks to the collective efforts of dedicated government agencies and civil society organizations over these years, deaths in India attributable to diarrheal diseases (according to the WHO) have fallen by over 50% since 2000 to about 650,000. As Exhibit 3 shows, the decline has been a steady 3% every single year, mirroring the 3% annual increase in access to toilets.

Behind the big numbers, of course, is a more powerful story of hearts-and-minds. As a nation, India decided that the quotidian ritual hopscotch to carefully elude those ubiquitous piles of human fecal waste, was no longer acceptable. As a nation, India decided that ambient cleanliness was no longer just aspirational, but achievable. (Critics legitimately argue that mere construction of toilets does not guarantee their consistent use. I, myself, am not overly worried about it: while there certainly are millions of laggards—mostly men—who still avoid using toilets, I believe that that it is only a matter of time before societal pressures force them to become more considerate of their communities. Certainly, the habit will not survive into the next generation of Indians who are growing up accustomed to toilets.)

Exhibit 3: Deaths in India from diarrheal diseases have dropped steadily by 3% each year since 2000, reflecting the 3% increase in access to sanitation.

One could argue that for any nation that aspires to be truly great, providing the dignity of basic sanitation to its people and reducing open defecation, is a pretty low bar. Unsurprisingly, much remains to be done before the Gandhian vision of true nationwide cleanliness is achieved. India’s rivers are inundated with massive levels of pollution from veritable tributaries of raw sewage; its air quality is consistently the worst in the world; trash piles up on streets with seemingly no one interested in removing it; and of course, there is the scourge of paan spit everywhere.

Still, a very important corner has been turned. This gives us something to build on.

About the author: Shashi Buluswar is the Founder & President of the Institute for Transformative Technologies and teaches at the University of California-Berkeley

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