Document Type : Original Article

Authors

1 National Health Mission, Department of Health and Family Welfare, Government of Odisha, Odisha, Bhubaneswar, India

2 School of Rural Management, KIIT Deemed to be University, Bhubaneswar, Odisha, India

Abstract

Universal access to safe sanitation is yet to be accomplished in India. Although Clean India
Mission (named as “Swachh Bharat Mission (Gramin)” for rural India) claims that the sanitation
coverage in rural India has increased from 39% to 100% of households from 2014 and 2019, yet
open defaecation continues in India in large numbers. This article discusses the achievements on
Swachh Bharat Mission (Gramin) and identifies the existing challenges that need to be acted on to
achieve the success of India’s Swachh Bharat Mission. We searched international database mainly
Google scholar, Pubmed, Medline, Scopus, and Science direct using “Clean India,” “Swachh Bharat,”
“Sanitation,” “Open defecation,” “Environmental heath,” and “India” as search keywords in different
combinations. In addition, websites of relevant United Nations (UN) agencies, Government of India
and leading newspaper and national agencies were also searched manually for related publications
and reports. In the last 5 years (2014‑2019), significant efforts have been made for the Swachh Bharat
Mission by creating various social movements and awareness program to improve toilet coverage
throughout India. Over 100 million, latrines have been built as of the end of the first phase of Swachh
Bharat Mission (Gramin) as on October 2, 2019 and all villages across the districts of India have
been declared Open Defaecation Free. Still, nearly half of the rural population (52.1%) defecate in
the open. Lack of piped water supply, poor construction of toilet substructures and misconception
among people about toilet use remain as key challenges in the achievement of India’s sanitation
mission. Sanitation‑related behavioral change and improvement in toilet facilities must be prioritized
to ensure usage of built toilets and eventually can accelerate the universal access to sanitation and
meet Sustainable Development Goals.

Keywords

  1. Development Initiatives. Global Nutrition Report: Shining
    a Light to Spur Action on Nutrition; 2018. Available
    from: https://globalnutritionreport.org/reports/
    global‑nutrition‑report‑2018/. [Last accessed on 2020 Nov 13].
    2. International Institute for Population Sciences, ORC Macro.
    National Family Health Survey (NFHS‑4), 2015–16. Mumbai:
    IIPS; 2020. Available from: https://dhsprogram.com/data/.[Last
    accessed on 2020 Nov 17].
    3. Liu L, Oza S, Hogan D, Perin J, Rudan I, Lawn JE, et al. Global,
    regional, and national causes of child mortality in 2000‑13, with
    projections to inform post‑2015 priorities: An updated systematic
    analysis. Lancet 2015;385:430‑40.
    4. Liu L, Johnson HL, Cousens S, Perin J, Scott S, Lawn JE, et al.
    Global, regional, and national causes of child mortality: An
    updated systematic analysis for 2010 with time trends since 2000.
    Lancet 2012;379:2151‑61.
    5. Humphrey JH. Child under‑nutrition, tropical enteropathy,
    toilets, and hand washing. Lancet 2009;374:1032‑5.
    6. Briend A. Is diarrhoea a major cause of malnutrition among
    the under‑fives in developing countries? A review of available
    evidence. Eur J Clin Nutr 1990;44:611‑28.
    7. Pruss‑Ustun A, Corvalan C. Preventing Disease through Healthy
    Environments. Towards an Estimate of the Environmental Burden
    of Disease. Geneva: World Health Organization; 2006.
    8. Lunn PG, Northrop‑Clewes CA, Downes RM. Intestinal
    permeability, mucosal injury, and growth faltering in Gambian
    infants. Lancet 1991;338:907‑10.
    9. Lunn PG, Northrop‑Clewes CA, Downes RM. Recent
    developments in the nutritional management of diarrhoea. 2.
    Chronic diarrhoea and malnutrition in The Gambia: Studies on
    intestinal permeability. Trans R Soc Trop Med Hyg 1991;85:8‑11.
    10. Curtis V, Cairncross S, Yonli R. Domestic hygiene and
    diarrhoea – Pinpointing the problem. Trop Med Int Health
    2000;5:22‑32.
    11. Clasen TF, Bostoen K, Schmidt WP, Boisson S, Fung IC, Jenkins
    MW, et al. Interventions to improve disposal of human excreta for
    preventing diarrhoea. Cochrane Database Syst Rev 2010;6:1‑30.
    12. O’Lorcain P, Holland CV. The public health importance of Ascaris
    lumbricoides. Parasitology 2000;121 Suppl: S51‑71.
    13. Strunz EC, Addiss DG, Stocks ME, Ogden S, Utzinger J,
    Freeman MC. Water, sanitation, hygiene, and soil‑transmitted
    helminth infection: A systematic review and meta‑analysis. PLoS
    Med 2014;11:1-38.
    14. Ziegelbauer K, Speich B, Mäusezahl D, Bos R, KeiserJ, UtzingerJ.
    Effect of sanitation on soil‑transmitted helminth infection:
    Systematic review and meta‑analysis. PLoS Med 2012;9:1-17.
    15. Wolfe M, Kaur M, Yates T, Woodin M, Lantagne D. A systematic
    review and meta‑analysis of the association between water,
    sanitation, and hygiene exposures and cholera in case‑control
    studies. Am J Trop Med Hyg 2018;99:534‑45.
    16. Pickering AJ, Djebbari H, Lopez C, Coulibaly M, Alzua ML. Effect
    of a community‑led sanitation intervention on child diarrhoea
    and child growth in rural Mali: A cluster‑randomised controlled
    trial. Lancet Glob Health 2015;3:e701‑11.
    17. Hammer J, Spears D. Village sanitation and child health: Effects
    and external validity in a randomized field experiment in rural
    India. J Health Econ 2016;48:135‑48.
    18. Prüss-Ustün A, Bartram J, Clasen T, Colford JM Jr., Cumming O,
    Curtis V, et al. Burden of disease from inadequate water, sanitation
    and hygiene in low‑and middle‑income settings: A retrospective
    analysis of data from 145 countries. Trop Med Int Health
    2014;19:894‑905.
    19. Sumpter C, Torondel B. A systematic review of the health and
    social effects of menstrual hygiene management. PLoS One
    2013;8:1-15.
    20. Kjellén M, Pensulo C, Nordqvist P, Fogde M. Global Review
    of Sanitation Systems Trends and Interactions with Menstrual
    Management Practices – Report for the Menstrual Management
    and Sanitation Systems Project. Stockholm, Sweden: Stockholm
    Environment Institute (SEI); 2012.
    21. Sahoo KC, Hulland KR, Caruso BA, Swain R, Freemen MC,
    Panigrahi P, et al. Sanitation‑related psychosocial stress:
    A grounded theory study of women across the life‑course in
    Odisha, India. Soc Sci Med 2015;139:80‑9.
    22. Routray P, Torondel B, Clasen T, Schmidt WP. Women’s role in
    sanitation decision making in rural coastal Odisha, India. PLoS
    One 2017;12:1-17.
    23. UNICEF. Gender‑Responsive Water, Sanitation and Hygiene:
    Key Elements for Effective Wash Programming. UNICEF; 2017.
    24. UNICEF/WHO. Progress on Household Drinking Water,
    Sanitation and Hygiene 2000‑2017. Special Focus on Inequalities.
    New York: United Nations Children’s Fund (UNICEF) and World
    Health Organization (WHO); 2019.
    25. Spears D, Ghosh A, Cumming O. Open defecation and childhood
    stunting in India: An ecological analysis of new data from 112
    districts. PLoS One 2013;8:1-9.
    26. Chambers R, Von Medeazza G. Sanitation and stunting in India.
    Econ Polit Wkly 2013;48:15.
    27. Coffey D, Deaton A, Dreze J, Spears D, Tarozzi, A. Stunting among
    children. Econ Polit Wkly 2013;48:68‑9.
    28. Panagariya A. Does India really suffer from worse child
    malnutrition than sub‑Saharan Africa? Eco Polit Wkly
    2013;48:98‑111.
    29. UNICEF. The Financial and Economic Impact of Swachh Bharat
    Mission in India – Summary Report. New Delhi: United Nations
    Children’s Emergency Fund; 2018. Available from: http://www.
    indiaenvironmentportal.org.in/files/file/UNICEF_Economic_
    impact_study.pdf. [Last accessed on 2020 Oct 19].
  2. 30. Routray P, Schmidt WP, Boisson S, Clasen T, Jenkins MW.
    Socio‑cultural and behavioural factors constraining latrine
    adoption in rural coastal Odisha: An exploratory qualitative
    study. BMC Public Health 2015;15:880.
    31. Gupta A, Khalid N, Hathi P, Srivastav N, Vyas S, Coffey D.
    Coercion, construction, and ’ODF paper pe’: The Swachh Bharat
    Mission, according to local government officials. India Forum
    2019;4:5.
    32. Abraham M, Bharadwaj S, Chambers R, Dheeraj Hueso A,
    Joseph MJ, Mukerjee R, et al. Using Immersive Research to
    Understand Rural Sanitation: Lessons from the Swachh Bharat
    mission in India. In Proceedings of the Transform. Sustain.
    Resilient WASH Serv. 41st WEDC International Conference;
    Egerton University, Nakuru, Kenya, 9‑13 July 2018.
    33. Ministry of Drinking Water and Sanitation. Swachh Bharat
    Mission – Gramin; 2020. https://swachhbharatmission.gov.in/
    sbmcms/index.htm. [Last accessed on 2020 Oct 03].
    34. Bharat GK, Dkhar NB, Abraham M. Aligning India’s Sanitation
    Policies with Sustainable Development Goals (SDGs). The Energy
    and Resources Institute (TERI) Discussion Paper; 2020. Available
    from: https://www.teriin.org/sites/default/files/2020‑01/
    aligning‑Indias‑sanitation‑policy‑with‑the‑SDGs.pdf. [Last
    accessed on 2020 Aug 23].
    35. Ministry of Drinking Water and Sanitation. Swachh Bharat
    Mission – Gramin (All India); 2020. Available from: https://sbm.
    gov.in/sbmReport/home.aspx. [Last accessed on 2020 Aug 21].
    36. Curtis V. Explaining the outcomes of the ‘Clean India’ campaign:
    Institutional behavior and sanitation transformation in India. BMJ
    Glob Health 2019;4:1-11.
    37. Kantar Public, IPE Global. National Annual Rural Sanitation
    Survey (NARSS) 2018–19. New Delhi: Ministry of Drinking Water
    and Sanitation; 2018. Available from: https://jalshakti‑ddws.
    gov.in/sites/default/files/NARSS‑2018‑19.pdf. [Last accessed
    on 2020 Nov 19].
    38. Gupta A, Khalid N, Deshpande D, Hathi P, Kapur A,
    Srivastav N, et al. Changes in Open Defecation in Rural
    North India: 2014–2018. New Delhi: Research Institute for
    Compassionate Economics; 2018. Available from: https://
    riceinstitute.org/research/changes‑in‑open‑defecation‑inrural-north-india-2014‑2018‑2/. [Last accessed on 2020 Sep
    23].
    39. Kantar Public. Review of Health Data in Selected ODF and
    Non‑ODF Districts Under the SBM. New Delhi: Ministry of
    Drinking Water and Sanitation; 2017. Available from: https://
    jalshakti‑ddws.gov.in/sites/default/files/BMGF_Health_
    Impact_Study_final.pdf. [Last accessed on 2020 Sep 23].
    40. WHO. Summary of Preliminary Estimations of Potential Health
    Impacts from Increased Sanitation Coverage through the Swachh
    Bharat Mission. New Delhi: World Health Organization; 2018.
    Available from: http://origin.searo.who.int/india/mediacentre/
    events/2018/swachh‑bharat‑ report‑web.pdf. [Last accessed on
    2020 Oct 19].
    41. Water Aid India. Quality and Sustainability of Toilets:
    A Rapid Assessment of Technologies under Swachh Bharat
    Mission. New Delhi: Water Aid India; 2017. Available from:
    https://www.wateraidindia.in/sites/g/files/jkxoof336/files/
    quality‑and‑sustainability‑of‑toilets.pdf. [Last accessed on 2020
    Sep 13].
    42. Biswas D, Jamwal P. Swachh Bharat Mission: Groundwater
    contamination in peri‑urban India. Econ Polit Wkly 2017;52:18‑20.
    43. Verhagen J, Scott P. Safely Managed Sanitation in High‑Density
    Rural Areas: Turning Fecal Sludge into a Resource through
    Innovative Waste Management. Washington, DC 20433: The
    World Bank; 2019.
    44. Coffey D, Spears D. Where India Goes: Abandoned Toilets,
    Stunted Development and the Costs of Caste. New Delhi:
    HarperCollins Publishers India; 2017.
    45. National Sample Survey Organization (NSSO). Swachhata Status
    Report. Ministry of Statistics and Programme Implementation
    2016, Govt. of India.
    46. 2018 National Sample Survey Organization (NSSO) Report No.
    584: Drinking Water, Sanitation, Hygiene and Housing Condition
    in India. NSS 76th round (July‑December 2018), National Statistical
    Office. Ministry of Statistics and Programme Implementation
    2019, Govt. of India.
    47. Dwivedi LK, Banerjee K, Jain N, Ranjan M, Dixit P. Child health
    and unhealthy sanitary practices in India: Evidence from recent
    round of national family health survey‑IV. SSM Popul Health
    2019;7:1-9.
    48. Bawankule R, Singh A, Kumat K, Pedgaonkar S. Disposal of
    child’s stools and its association with diarrhoea in India. BMC
    Public Health 2017;17:12.
    49. O’Reilly K, Louis E. The toilet tripod: Understanding successful
    sanitation in rural India. Health Place 2014;29:43‑51.
    50. Greenland K, Cairncross S, Cumming O, Curtis V. Can we
    afford to overlook hand hygiene again? Trop Med Int Health
    2013;18:246‑9.
    51. Water Aid India. Spotlight on Hand Washing in Rural India. Water
    Aid India; 2017. Available from: https://www.wateraidindia.
    in/publications/spotlight‑on‑handwashing‑in‑rural‑india. [Last
    accessed on 2020 Nov 07].
    52. Institute of Development Studies, Praxis, Water Aid. Swachh
    Bharat Mission (Gramin) Immersive Research – Main Report.
    Water Aid India; 2017. Available from: http://wateraidindia.
    in/wp‑content/themes/wateraid/immersion‑sbm/images/
    SBM‑immersive‑research‑findings‑online.pdf. [Last accessed on
    2020 Aug 19].
    53. National Health Profile 2019, 14th Issue. Central Bureau of Health
    Intelligence, Directorate General of Health Servies, Ministry of
    Health and Fmaily Welfare, Government of India. Available from:
    https://www.issuelab.org/resources/29151/29151.pdf. [Last
    accessed on 2020 Dec 19].
    54. Hueso A, Bell B. An untold story of policy failure: The Total
    Sanitation campaign in India. Water Policy 2013;15:1001‑17.
    55. Programme Evaluation Organisation. Evaluation Study on Total
    Sanitation Campaign, Planning Commission Government of India;
    2013. Available from: https://niti.gov.in/planningcommission.
    gov.in/docs/reports/peoreport/peo/rep_tscv1_2205.pdf. [Last
    accessed on 2020 Jun 19].
    56. CrockerJ, Saywell D, Bartram J. Sustainability of community‑led
    total sanitation outcomes: Evidence from Ethiopia and Ghana. Int
    J Hyg Environ Health 2017;220:551‑7.
    57. Chambers R, Kar K. Handbook on Community‑Led Total
    Sanitation. Brighton: IDS; 2008.
    58. VenkataramananV, CrockerJ, KaronA, BartramJ. Community‑led
    total sanitation: A mixed‑methods systematic review of evidence
    and its quality. Environ Health Perspect 2018;126:1-17.
    59. Jenkins MW, Curtis V. Achieving the ‘good life’: Why some people
    want latrines in rural Benin. Soc Sci Med 2005;61:2446‑59.
    60. Novotný J, Hasman J, Lepič M. Contextual factors and motivations
    affecting rural community sanitation in low‑ and middle‑income
    countries: A systematic review. Int J Hyg Environ Health
    2018;221:121‑33.
    61. Chunga RM, Ensink JH, Jenkins MW, Brown J. Adopt or adapt:
    Sanitation technology choices in urbanizing malawi. PLoS One
    2016;11:1-16.
    62. Pattanayak SK, Yang JC, Dickinson KL, Poulos C, Patil SR,
    Mallick RK, et al. Shame or subsidy revisited: Social mobilization
    for sanitation in Orissa, India. Bull World Health Organ
    2009;87:580‑7.
    63. Guiteras R, Levinsohn J, Mobarak AM. Sanitation subsidies.
    Encouraging sanitation investment in the developing world:
    A cluster‑randomized trial. Science 2015;348:903‑6.
    64. Clasen T, Boisson S, Routray P, Cumming O, Jenkins M, Ensink JH, et al. The effect of improved rural sanitation on diarrhoea and
    helminth infection: Design of a cluster‑randomized trial in Orissa,
    India. Emerg Themes Epidemiol 2012;9:7.
    65. Humphrey JH, Mbuya MNN, Ntozini R, Moulton LH,
    Stoltzfus RJ, Tavengwa NV, et al. Independent and combined
    effects of improved water, sanitation, and hygiene, and improved
    complementary feeding, on child stunting and anaemia in rural
    Zimbabwe: A cluster‑randomised trial. Lancet Glob Health
    2019;7:e132‑47.
    66. Tofail F, Fernald LC, Das KK, Rahman M, Ahmed T, Jannat KK,
    et al. Effect of water quality, sanitation, hand washing, and
    nutritional interventions on child development in rural
    Bangladesh (WASH Benefits Bangladesh): A cluster‑randomised
    controlled trial. Lancet Child Adolesc Health 2018;2:255‑68.
    67. Ministry of Drinking Water and Sanitation. Swachh Bharat
    Mission (Grameen), Phase II. Operational Guideline; 2020.
    Avaailable from: https://swachhbharatmission.gov.in/
    SBMCMS/guidelines.htm. [Last accessed on 2020 Dec 22].