More than eight per cent of deaths in India are due to water and
sanitation-related causes. The Third South Asian Conference on
Sanitation (SACOSAN), opening in Delhi today, is an opportunity to
raise awareness and take vital steps on this crucial issue.

The South Asian Conference on Sanitation (SACOSAN) is taking place in
New Delhi (November 16-21) against the backdrop of two important
reports released recently by the WHO, which bring out the importance
of sanitation and its impact on health, particularly that of children.
These are: the Report of the WHO Commission on Social Determinants on
Health and a multi-country study report on the relationship between
drinking water, sanitation and health under the title: Safe Water,
Better Health.

The Report of the WHO Commission on Social Determinants of Health
(2008) emphasises that access to clean water and sanitation should be
considered as part of human rights. The report calls for improved
living conditions, including basic services and also for “a public
sector strong, capable, committed and adequately funded” to tackle the
inequities in health. It also throws light on the fact that one
billion people the world over live in slums with poor basic services.

Preventable causes

The other report; Safe Water, Better Health (2008), released a few
months ago, brings out that 7.5 per cent of deaths in India, 10 per
cent in Bangladesh, 13.6 per cent in Pakistan and 10.6 per cent in
Nepal are due to water and sanitation related causes. As the data
seems to be based only on reported deaths, this percentage would
increase if the causes of the vast majority of unreported deaths were
included. Yet, the report is significant, as it points out that the
percentage would jump by 20 per cent in the case of deaths of
children. It brings out further that 88 per cent of the cases of
diarrhoea worldwide are attributable to unsafe water, inadequate
sanitation or insufficient hygiene. The report reiterates the causal
link between under-five mortality, malnutrition and diarrhoeal
diseases. Half of all malnutrition cases among under-five children are
caused by repeated incidence of diarrhoeal and other intestinal
infections.

The Dhaka Declaration of SACOSAN in 2003 had called for an urgent
elimination of open defecation which is prevalent in most parts of the
Indian sub-continent consisting of countries such as Pakistan,
Bangladesh, Afghanistan, Nepal, Myanmar, Srilanka and Maldives from
where ministerial delegates had attended the conference. This
practice, which spreads germs causing various communicable diseases,
prevails in rural as well as urban areas of the sub-continent due to
inadequate provision of sanitation facilities, poor availability of
water and cultural habituation promoting it. In order to highlight the
need for healthy and dignified sanitation facilities for all, this
article does not dwell on other aspects of sanitation such as solid
waste disposal, sewage and sewerage.

Ambitious campaign

The target 10 of goal 7 of the Millennium Development Goal (MDG)
envisages to reduce by half the number of people without sustainable
access to safe drinking water and basic sanitation by 2015. Government
of India’s Total Sanitation Campaign (TSC) aims at providing toilets
to all rural households by the end of the Eleventh plan i.e. 2012. The
Jawaharlal Nehru National Urban Renewal Mission and other programmes
are aimed at 100 per cent sanitation coverage in the urban areas. TSC
also aims at providing information, education and communication to the
rural poor in sustainable use of the toilets. However, the current
percentage of households with toilets is only 49 as per 2006 figures
quoted in the Eleventh Plan. World Bank’s World Development Indicators
(2008) and the UNDP’s Human Development Report 2007-08 are mentioning
2004 figures which show only 33 per cent households with improved
sanitation facilities. The figures in this regard could have possibly
risen to 49 per cent; but there still remains a wide field to be
covered, in terms of eliminating open defecation by providing
household toilets and building awareness to use and maintain them.
Considering the severe competition for urban space, the provision of
sanitation facilities to the increasing population of slum dwellers in
India’s cities and towns is an issue which demands special attention.

Household toilets are also a matter of human dignity. An advertisement
issued by the Ministry of Rural Development with the title: “Don’t
wake up into darkness; Awake into sunlight”, sums it up. The ad shows
a woman holding a bucket in her hand and on the way from her house to
find a suitable place which gives her some semblance of privacy to
defecate. To bring out the contrast the ad also shows another woman
going into the toilet in her house with the morning sun’s rays very
much on. The privacy concerns of the second woman are met by the
household toilet, and therefore she doesn’t have to carry a bucket and
move around before the sunrise to find a place for defecation. While
there is no denying the links with open defecation and community ill
health, the rather unrecognised human dignity concerns of the poor
need to be acted upon urgently. Perhaps the latter would be a more
receptive communication angle for popularising household toilets as
well.

The Eleventh Five Year plan (2007-12) of India targets to achieve
universal sanitation coverage in the country by 2012. This target in
fact is obviously far more ambitious than the MDG stipulation to halve
by 2015 the number of people without sustainable access to basic
sanitation. The Eleventh Plan has also recognised the gender dimension
of sanitation by highlighting the need for women in particular to have
privacy in defecation. In this connection it needs to be noted that
covered toilets, which ensures privacy, began to be funded only from
2006. The Plan targets to build 7.29 crore household toilets in rural
areas for achieving universal sanitation, under the Total Sanitation
Campaign. The TSC also has a component for School sanitation under
which more than three lakh toilets were built in schools during the
10th Plan. It is, however, equally important to make sure that these
toilets do function. Children have also supported the TSC in spreading
the message of sanitation to their families.

Not quite enough

N.C. Saxena, former Secretary of the Planning Commission of India,
notes that there is a remarkable increase in the number of toilets
constructed in India, which has risen from 1.3 million in 1997-98 to 9
million in 2006-07 and was expected to touch one core in 2007-08.
Still, all this put together, would cover only 40 million households
leaving out 70 million households without toilets in the rural areas
alone. It is, however, encouraging to note that according to an
evaluation study, 80 per cent of the toilets built under TSC were
used, which signifies a welcome change in attitudes. This shows an
effective demand for household toilets which needs to be attended to.
There is also a steep increase in the number of Nirmal Gram Puraskars
(NGP) awarded in recent years. The NGPs are awarded to Gram Panchayats
which have achieved 100 per cent coverage of household sanitation, 100
per cent school sanitation and have eliminated open defecation in
their area. Five thousand Gram Panchayats were awarded NGP in 2006-07,
while in 2007-08 this number rose to 11,000, more than double. This
further underlines the increasing demand for household toilets, which
needs to be satisfied by not only supplying them but ensuring the
availability of water and awareness building for their clean and
sustainable use.

The third SACOSAN conference in New Delhi presents an opportunity to
raise the profile of the sanitation sub-sector in India to highlight
its importance.

The author works with Save the Children, New Delhi. The views
expressed here are not necessarily that of the organisation.