India’s toilet troubles

Sikkim’s achievement in becoming the country’s first state with 100 per cent sanitation coverage is significant. It is also unsurprising. Despite their high poverty levels, the Northeastern states have always been outliers when it comes to sanitation. Seen in that context, what Sikkim has managed — commendable as it is — only throws the problem facing the rest of the country into sharper relief. Granted, there has been a distinct improvement over the past decade or so; in 1990, rural sanitation coverage was only about 1 per cent and overall sanitation access was 18 per cent. Set against that, the current situation of 45 per cent sanitation access as per 2009 figures shows that the country is at least trending in the right direction. But it still leaves about 600 million people with no access to toilets.
This has concrete human and economic costs. Poor sanitation is at the root of widespread medical problems, and economists have argued that it is as much a factor as malnutrition in Indian children suffering from high levels of stunted growth. And according to a study published in the Lancet medical journal, about 200,000 children below the age of four die of water-borne diarrhoeal diseases annually in the country. The hit to the country’s GDP, according to World Bank estimates, is about 6.4 per cent at purchasing power parity.
At least some in the political fraternity have begun to realise the severity of these deleterious consequences. Jairam Ramesh and, more recently, Narendra Modi have both spoken about the importance of access to toilets; the former has taken concrete action in this regard, as with his ‘no toilet, no bride’ campaign. But such campaigns can ultimately do little in a country where the public health system has a curative approach, addressing specific diseases, rather than a holistic, preventative one that incorporates sanitation in the larger architecture of public health. The Alma Ata declaration of 1978 made specific recommendations in this regard, but the first national health policy in 1983 and the second in 2002 have both failed to follow through in any significant fashion.
In lieu of this, the various government programmes such as the Nirmal Gram Puraskar started in 2003 — in aid of 1999’s Total Sanitation Campaign — and more localised efforts such as the Slum Sanitation Program in Mumbai have shown some results. But if government efforts have to be successful on a wide scale in rural areas, they must view the problem in a granular fashion where different caste, culture, resources and other socio-economic factors can necessitate different approaches. There is a bureaucratic tendency to cite these factors as an insurmountable problem. That is a misperception. They are hurdles, certainly, but approaches that emphasise economic feasibility have been shown to overcome them.  An Asian Development Bank study on Assam and Kerala with Gujarat and Maharashtra highlights this. The latter two richer states have a higher percentage of population with access to high-cost solutions, but also a higher percentage with no access to toilets. The former two states, meanwhile, have utilised lower cost solutions such as pit latrines to achieve much higher coverage. 
Community-led approaches that take local factors into account, upgrading ancillary infrastructure such as sewage lines and wastewater treatment plants in urban areas, innovative solutions such as composting toilets —the central and state governments must work on multiple fronts. If not, Sikkim will remain an outlier.