1. Cover Letter to the MOH of the Country (10 lines)
To the Ministry of Health:
We, the consultant team, have prepared a report to combat the health issues stemming from India's practice of open defecation. The immense pressure of this cultural tradition is taking a toll on the health status of millions of citizens and the ever-growing population is an added incentive to take control of the problem. While open defecation is practiced throughout urban and rural communities within India; it is very common in the impoverished communities because of the lack of restrooms in their dwellings and poor infrastructure. This practice endangers the public drinking and bathing water, which leads to chronic illnesses like diarrhea, which is the leading cause of death in children under five years old. In our report, we have developed cost-effective incentives to elevate the financial burden from families and also the government. To achieve the most success in regards to sanitation and ending open defecation, our plan will involve multiple stakeholders including health agencies, the government and the community. The end of open defecation will only happen with the total change of behavior and attitude of the Indian community. In our report, we discuss our support of organizations who are educating the community about how personal hygiene and health are linked. Our plan is to completely change the way Indian citizens think about this cultural practice and have them begin to truly see how their actions are detrimental to their health.
2. Consultant’s Report (Add a Title for the Report)
Recommendations for Improving Sanitation Related to Open Defecation in India
3. Primary Consultant:
Colin R. Jones
Secondary Consultant (If there are more than 2 consultants add a third consultant name below this one):
Isabelle E Michel
4. Problem Description (20 lines)
A larger portion of India's growing health issues can be attributed to open defecation. Most of the families living below the poverty line do not have proper access to restrooms because their homes are not equipped with one. Individuals have the option of using the facilities at their workplace or school grounds. When left with no other option they turn to near by rivers and fields. From 1993-2011, the poverty line has been lowered tremendously from 45.3 percent to 21.9 percent because of initiatives like the National Health Insurance Scheme (World Bank, 2011). This allows for "around 75% of the financing for this scheme to be provided by the national government, with the remainder by state governments" (WHO, 2010). This give families living under the poverty line a sense of relief when it comes to healthcare costs and allows them to have to chance to save the little income they do earn. However, even with these programs in place and India's growing prosperity, open defecation is very much prevalent and a recurring problem throughout the country, especially in rural communities. About half of India's population openly defecates (Bakshi, 2015). We are learning it is a problem that has little to do with access to restrooms and more to do with the lifestyle of the Indian people.
Open defecation is a traditional practice that is learned from a very young age. Like any other cultural practice, open defecation is mimicked by children and thus the cycle is continued. This is not the only reason as to why this cultural practice continues to grow. Sanitation is not widely spoken of and is considered a taboo topic. Open defecation can also be viewed as "wholesome, healthy and social" (Economist, 2014). This is the wide spread thinking of most individuals in India, even when they are aware of the health risks that come with open defecation. Twenty-five percent of children under five years old die from diarrhea, forty percent of children suffer from stunting, and fifty percent of malnutrition is attributed to sanitation and hygiene (UNICEF, 2012).
Open defecation is a cultural issue that is practiced in both urban and rural areas, yet rural areas have the highest rates. It was thought to be believed the occurrence is higher in rural communities because of the lack of access to restrooms in their homes. However, even with the implementation of more toilets open defecation continues. With the implementation of more toilets the census has reported the proportion of families living without proper restrooms has fallen from sixty-three to fifty-three percent (Nathoo, 2015). In some cases, even when the government has built additional restrooms some citizens still refuse to use them because they believe open defecation is much more convenient, completely dismissing health concerns. To truly end this problem, there must be a movement within the Indian community to want to change. The attitudes towards open defecation need to change and not be taken as lightly as it has in the past.
5. Conclusion-Recommendations (25 lines)
Ending open defecation in India is a significant challenge due to long-standing cultural beliefs, an extremely large rural population and a lack of toilet infrastructure. With absolute certainty, open defecation has a negative impact on both the environment and sanitation levels of the surrounding area. It is estimated that 626 million Indian citizens still practice open defecation, nearly half of the population (WHO, 2015). This statistic illustrates the dire need for health initiatives geared to end open defecation while also improving sanitation. As Consultants to the Indian Ministry of Health, this report recommends some solutions for combating this issue at both the community and national levels.
The primary recommendation for the Ministry of Health is to increase the number of Village Health and Sanitation Committees (VHSC). Village Committees are responsible for the overall health of a village and play a huge role in monitoring health activities. VHSC also educate the local public about new health programs, encourage safe and progressive hygiene practices, and develop health plans based on the situational needs of each village. Each village committee will also have the responsibility of instituting and maintaining accountability mechanisms for community-level health and nutrition services provided by the Government. Annual health reports from the VHSC to the Gram Sabh would be an effective way for governments to obtain data at the village level for enacting health services and initiatives. Annual grants of 10,000 Rupees are recommended to be distributed by state governments to help fund these committees.
Secondly, additional toilet infrastructure will need to be built. Flushing systems are not feasible in many rural areas, therefore Ecological Sanitation (EcoSan) toilets are the preferred recommendation because they manage human waste through decomposition, requiring less water. The benefit of this type of toilet is that they are cost effective and the waste is composted into usable fertilizer. Each EcoSan toilet will cost around 10,747 Rupees and it is recommended that government subsidies be offered by State Governments to help citizens fund and build a toilet per household. A similar model being used in the state of Tamil Nadu should be modeled, where subsidies of up to 4,7000 Rupees are offered for each EcoSan toilet being built.
In many cases, access to a toilet facility does not ensure it will be used, as some Indians choose open defecation over using a bathroom. This implies building more toilet infrastructure alone will not suffice. A multi-dimensional campaign will also be needed to educate and bring awareness about the dangers of open defecation and poor sanitation. The campaign should utilize all outlets of social media including the internet, radio, television and phone applications. The four main messages of the campaign to be emphasized are the construction and use of toilets, safe disposal of child feces, hand washing with soap after defecation and safe storage and handling of drinking water. A national school campaign would be at the forefront of this initiative to teach students in grade school the importance of healthy hygiene. This initiative would prove to be extremely effective in both educating young students who can relay the information to their parents at home, while also reshaping certain cultural beliefs for the betterment of society. Lastly, it is recommended national SMS reminders be sent out monthly and on April 7 (National Health Day) reminding citizens of the dangers of open defecation while also providing new health updates and encouraging safe hygiene.
6. Background Information (20 lines)
Having a population of 1.3 billion creates an extremely difficult burden for the Indian government in relation to health and healthcare. Currently, one of the most important health initiatives taking place in India is ending open defecation and its negative impact on sanitation. India accounts for nearly 626 million of the estimated 1.1 billion people in the world who practice open defecation, more than twice the number of the next 18 countries combined (WHO, 2015). At the Global Citizen Festival in 2014, Prime Minister Modi emphasized the importance of this issue with one of his campaign slogans "Toilets before Temples" (Cuming & Sheldrick, 2014).
Open defecation, or going to the bathroom outside without using a toilet is one of the most important threats to child health and human capital (Spears & So, 2013). Going to the restroom outdoors fills the surrounding environment with fecal matter and germs, which could then be spread into the water supply. Adding to this problem, many citizens including groups of young women prefer to relieve themselves in the fields after sun down. This creates a dangerous situation because in some cases women have been robbed, raped and even killed.
The implication of defecating in open water is that other individuals may use this same water for drinking and bathing. Fecal germs cause diarrhea and now research points to the greater importance of chronic intestinal disease making it harder for the body to use the nutrients that children eat, even without necessarily manifesting as diarrhea (Spears & So, 2013). This attributes to the death of infants and could also stunt the growth of young bodies and minds (Spears & So, 2013). Ingested bacteria and worms spread disease, especially those pertaining to the intestine. Infectious diseases may also potentially negatively impact one's ability to work or continue their education.
Roughly half the population of India still practices open defecation and in many of these cases there is sufficient access to a toilet (Bakshi, 2015). The government has built toilets that often exceed international standards, averaging Rs 12,000 per latrine while neighboring Bangladesh spends only Rs 2,000 (Bakshi, 2015). This signifies a major problem that even when there is access to a toilet, many Indians choose open defecation. One major problem preventing modern bathroom practices are that latrine usage in India is often regarded as limited to the elderly, disabled or weak (Bakshi, 2015). Culturally, emptying latrines is inconceivable by high-caste Hindus and 'untouchable' castes who want to distance themselves from such work (Bakshi, 2015). Also, cultural beliefs about purity and not accumulating waste near or around the home have long been entrenched in the Indian people. Despite the addition of toilets, open defecation practices still remain and this signifies that building toilets alone will not effectively end this problem.
7. Proposed Solution(s) (60 lines)
The primary recommendation for improving sanitation related to open defecation is to implement a greater frequency of Village Health and Sanitation Committees (VHSC). This type of committee is one of the nine institutional mechanisms developed under the NRHM initiated by the Government of India in 2005 (Ganesh et al., 2013). These committees will be designated with the responsibly for the overall health of a village. Comprised of village health workers, Panchayat Raj Institution representatives, members of Community Based Organizations and special groups who are marginalized, these committees have the capacity and competency to do a situational analysis of the local health status (Ganesh et al., 2013). VHSC's will have control over finances and budgets with built in systems of transparency to the public to ensure against corruption. The committees will be designated with monitoring all the health activities that are conducted in the village such as Village Health & Nutrition Day and mother's meetings. Also, it will be the responsibility of the VHSC to develop a village health plan based on an assessment of the village situation and priorities identified by the village community.
An additional objective of the Village Health and Sanitation Committees is to educate the local public on the essentials of health programs, proper hygiene and safe bathroom practices. Education and training programs to oversee the disposal system for solid waste, wastewater management and disposal, drain maintenance and disinfection of stagnant water are recommended. This initiative has the goals of engaging the community and local populations in planning and monitoring health service delivery, especially in rural areas. Waste disposal management will be essential to help reduce mosquito-breeding breeding sites to lower the rates of malaria, dengue and Japanese encephalitis (Ganesh et al, 2013). Established community toilets are not being maintained well enough so it will be the responsibility of VHSC to oversee, clean and maintain them.
To fund this initiative it is recommended an annual grant of 10,000 Rupees be available to each committee for village level activities. The committee should only utilize the funds after taking resolution in the VHSC monthly meetings and should not utilize all of the grant at one time. It is recommended that each VSHC be required to share the information of fund utilization with the villagers during village meetings or public dialogue. The VHSC should also be required to maintain a register of funds received and expenditures incurred relating to activities undertaken.
An additional solution to the open defecation problem in India is the construction of toilets. There is no plumbing or running water in a majority of rural areas therefore standard flush toilets are not feasible. Ecological Sanitation (EcoSan) toilets are the preferred recommendation because they manage human waste through decomposition, requiring less water and no flushing system. The EcoSan toilets consist of two constructed pits, one for use and one for composting. Each pit is designed to sustain bathroom use for a five member family for around six months, after which the second pit is used and the first pit is left to decompose (Shah, 2014). After every toilet use, a handful of ash has to be thrown over the waste to create the optimum conditions for decomposition into nutrient rich fertilizer (Shah, 2014). Urine and waste water that is rich in ammonia is collected in a separate chamber, to be diluted and used for vegetable and flower beds (Shah, 2014).
Each EcoSan toilet will cost roughly 10,747 Rupees or $164.77 USD (Ayala, 2014). It is recommended that government subsidies be offered by State Governments to help citizens fund and build the aforementioned toilet infrastructure. Models can similarly be structured after the system currently being used in Tamil Nadu where the Tamil Nadu State Government provides subsidies of 4,700 Rupees for each household building a toilet. Application forms to receive subsidy can be obtained from Village Administrative Officers, Block Development Officers, District Rural Development Agencies and District Collectorates.
The construction of toilets will be monitored by poverty reduction committees, self-help groups, and panchayat level federations. The construction should be completed within three months from the date of obtaining consent from village panchayat presidents. The subsidy amount will be given in two installments. The first installment will be released after laying of the foundation and base structure and second installment will be given on completion of the toilet.
The last recommendation for the Ministry of Health in India is a multi-dimensional media campaign designed to educate and bring awareness about the dangers of open defecation and poor sanitation. One of the major determinants of open defecation is a lack of awareness, with many rural residents and children remaining unaware of the risks associated with poor sanitation and germs. Additionally, emphasizing safe hygienic practices and the importance of hand washing after going to the bathroom will also improve sanitation by reducing the rates of germs and infections.
The four key messages that will need to be emphasized in the campaign include: construction and use of toilets, safe disposal of child feces, hand washing with soap after defecation and safe storage and handling of drinking water. EcoSan toilets are a cheap and effective measure that could effectively replace open defecation while also providing fertilizer for crops. In many rural areas, child feces is still disposed of in the streets or in the yard and this unsafe practice needs to be eliminated.
To achieve the most coverage and effectiveness, all media outlets will need to be utilized including television, radio, smartphone applications and the internet. India has the second-largest number of mobile phone users in the world with over 900 million subscribers while also accounting for 10% of the world’s online population in 2011 (PIB, 2012). This creates the potential to reach out to huge amounts people with SMS messages, especially those living in remote areas. It is imperative that a country rich enough to have almost a billion cell-phone users eliminates the millions of people who don’t use toilets due to a lack of access or awareness. National reminders should be sent out monthly and on April 7 (National Health Day) reminding citizens of the dangers of open defecation while also providing new health updates. One example of effective use of mobile technology is using SMS to communicate with the 3.2 million Central Government Health Services (CGHS) beneficiaries spread across India (PIB, 2012). These beneficiaries are patients who come to the CGHS Wellness Centers for consultation and receiving medicines for treatment and have benefited greatly from the increased access and information allowed by cellphones.
The biggest challenge in ending open defecation is triggering behavioral changes in the population to accept the need for building and using toilets. For major changes to take place, the campaign will need to be respective of traditional cultures yet still be educational and informative of modern and progressive health behaviors. In particular, Muslims are generally less averse to owning and using affordable latrines, which need to have their pits emptied every few years, than Hindus, who tend to view such latrines as ritually impure and are extremely concerned about emptying pits, or having them emptied (Coffee, 2014). To many Indians, open defecation is associated with rising early, and being industrious, as well as with strength and exposure to healthy fresh air. Many people who defecate in the open despite having access to their own latrine explain that they do so because they find it enjoyable and healthy. These notions must be expelled and more safe hygienic practices must be taught and ingrained into Indian culture.
Ganesh, S. R., Kumar, S. G., Sarkar, S., Kar, S. S., Roy, G., Premarajan, K. C. (2013). Assessment of village water and sanitation committee in a district of Tamil Nadu, India. Indian Journal of Public Health. 57(1), 43-46. DOI: 10.4103/0019-557X.111376
1. Cover Letter to the MOH of the Country (10 lines)
To the Ministry of Health:
We, the consultant team, have prepared a report to combat the health issues stemming from India's practice of open defecation. The immense pressure of this cultural tradition is taking a toll on the health status of millions of citizens and the ever-growing population is an added incentive to take control of the problem. While open defecation is practiced throughout urban and rural communities within India; it is very common in the impoverished communities because of the lack of restrooms in their dwellings and poor infrastructure. This practice endangers the public drinking and bathing water, which leads to chronic illnesses like diarrhea, which is the leading cause of death in children under five years old. In our report, we have developed cost-effective incentives to elevate the financial burden from families and also the government. To achieve the most success in regards to sanitation and ending open defecation, our plan will involve multiple stakeholders including health agencies, the government and the community. The end of open defecation will only happen with the total change of behavior and attitude of the Indian community. In our report, we discuss our support of organizations who are educating the community about how personal hygiene and health are linked. Our plan is to completely change the way Indian citizens think about this cultural practice and have them begin to truly see how their actions are detrimental to their health.
2. Consultant’s Report (Add a Title for the Report)
Recommendations for Improving Sanitation Related to Open Defecation in India
3. Primary Consultant:
Colin R. JonesSecondary Consultant (If there are more than 2 consultants add a third consultant name below this one):
Isabelle E Michel4. Problem Description (20 lines)
A larger portion of India's growing health issues can be attributed to open defecation. Most of the families living below the poverty line do not have proper access to restrooms because their homes are not equipped with one. Individuals have the option of using the facilities at their workplace or school grounds. When left with no other option they turn to near by rivers and fields. From 1993-2011, the poverty line has been lowered tremendously from 45.3 percent to 21.9 percent because of initiatives like the National Health Insurance Scheme (World Bank, 2011). This allows for "around 75% of the financing for this scheme to be provided by the national government, with the remainder by state governments" (WHO, 2010). This give families living under the poverty line a sense of relief when it comes to healthcare costs and allows them to have to chance to save the little income they do earn. However, even with these programs in place and India's growing prosperity, open defecation is very much prevalent and a recurring problem throughout the country, especially in rural communities. About half of India's population openly defecates (Bakshi, 2015). We are learning it is a problem that has little to do with access to restrooms and more to do with the lifestyle of the Indian people.
Open defecation is a traditional practice that is learned from a very young age. Like any other cultural practice, open defecation is mimicked by children and thus the cycle is continued. This is not the only reason as to why this cultural practice continues to grow. Sanitation is not widely spoken of and is considered a taboo topic. Open defecation can also be viewed as "wholesome, healthy and social" (Economist, 2014). This is the wide spread thinking of most individuals in India, even when they are aware of the health risks that come with open defecation. Twenty-five percent of children under five years old die from diarrhea, forty percent of children suffer from stunting, and fifty percent of malnutrition is attributed to sanitation and hygiene (UNICEF, 2012).
Open defecation is a cultural issue that is practiced in both urban and rural areas, yet rural areas have the highest rates. It was thought to be believed the occurrence is higher in rural communities because of the lack of access to restrooms in their homes. However, even with the implementation of more toilets open defecation continues. With the implementation of more toilets the census has reported the proportion of families living without proper restrooms has fallen from sixty-three to fifty-three percent (Nathoo, 2015). In some cases, even when the government has built additional restrooms some citizens still refuse to use them because they believe open defecation is much more convenient, completely dismissing health concerns. To truly end this problem, there must be a movement within the Indian community to want to change. The attitudes towards open defecation need to change and not be taken as lightly as it has in the past.
5. Conclusion-Recommendations (25 lines)
Ending open defecation in India is a significant challenge due to long-standing cultural beliefs, an extremely large rural population and a lack of toilet infrastructure. With absolute certainty, open defecation has a negative impact on both the environment and sanitation levels of the surrounding area. It is estimated that 626 million Indian citizens still practice open defecation, nearly half of the population (WHO, 2015). This statistic illustrates the dire need for health initiatives geared to end open defecation while also improving sanitation. As Consultants to the Indian Ministry of Health, this report recommends some solutions for combating this issue at both the community and national levels.The primary recommendation for the Ministry of Health is to increase the number of Village Health and Sanitation Committees (VHSC). Village Committees are responsible for the overall health of a village and play a huge role in monitoring health activities. VHSC also educate the local public about new health programs, encourage safe and progressive hygiene practices, and develop health plans based on the situational needs of each village. Each village committee will also have the responsibility of instituting and maintaining accountability mechanisms for community-level health and nutrition services provided by the Government. Annual health reports from the VHSC to the Gram Sabh would be an effective way for governments to obtain data at the village level for enacting health services and initiatives. Annual grants of 10,000 Rupees are recommended to be distributed by state governments to help fund these committees.
Secondly, additional toilet infrastructure will need to be built. Flushing systems are not feasible in many rural areas, therefore Ecological Sanitation (EcoSan) toilets are the preferred recommendation because they manage human waste through decomposition, requiring less water. The benefit of this type of toilet is that they are cost effective and the waste is composted into usable fertilizer. Each EcoSan toilet will cost around 10,747 Rupees and it is recommended that government subsidies be offered by State Governments to help citizens fund and build a toilet per household. A similar model being used in the state of Tamil Nadu should be modeled, where subsidies of up to 4,7000 Rupees are offered for each EcoSan toilet being built.
In many cases, access to a toilet facility does not ensure it will be used, as some Indians choose open defecation over using a bathroom. This implies building more toilet infrastructure alone will not suffice. A multi-dimensional campaign will also be needed to educate and bring awareness about the dangers of open defecation and poor sanitation. The campaign should utilize all outlets of social media including the internet, radio, television and phone applications. The four main messages of the campaign to be emphasized are the construction and use of toilets, safe disposal of child feces, hand washing with soap after defecation and safe storage and handling of drinking water. A national school campaign would be at the forefront of this initiative to teach students in grade school the importance of healthy hygiene. This initiative would prove to be extremely effective in both educating young students who can relay the information to their parents at home, while also reshaping certain cultural beliefs for the betterment of society. Lastly, it is recommended national SMS reminders be sent out monthly and on April 7 (National Health Day) reminding citizens of the dangers of open defecation while also providing new health updates and encouraging safe hygiene.
6. Background Information (20 lines)
Having a population of 1.3 billion creates an extremely difficult burden for the Indian government in relation to health and healthcare. Currently, one of the most important health initiatives taking place in India is ending open defecation and its negative impact on sanitation. India accounts for nearly 626 million of the estimated 1.1 billion people in the world who practice open defecation, more than twice the number of the next 18 countries combined (WHO, 2015). At the Global Citizen Festival in 2014, Prime Minister Modi emphasized the importance of this issue with one of his campaign slogans "Toilets before Temples" (Cuming & Sheldrick, 2014).Open defecation, or going to the bathroom outside without using a toilet is one of the most important threats to child health and human capital (Spears & So, 2013). Going to the restroom outdoors fills the surrounding environment with fecal matter and germs, which could then be spread into the water supply. Adding to this problem, many citizens including groups of young women prefer to relieve themselves in the fields after sun down. This creates a dangerous situation because in some cases women have been robbed, raped and even killed.
The implication of defecating in open water is that other individuals may use this same water for drinking and bathing. Fecal germs cause diarrhea and now research points to the greater importance of chronic intestinal disease making it harder for the body to use the nutrients that children eat, even without necessarily manifesting as diarrhea (Spears & So, 2013). This attributes to the death of infants and could also stunt the growth of young bodies and minds (Spears & So, 2013). Ingested bacteria and worms spread disease, especially those pertaining to the intestine. Infectious diseases may also potentially negatively impact one's ability to work or continue their education.
Roughly half the population of India still practices open defecation and in many of these cases there is sufficient access to a toilet (Bakshi, 2015). The government has built toilets that often exceed international standards, averaging Rs 12,000 per latrine while neighboring Bangladesh spends only Rs 2,000 (Bakshi, 2015). This signifies a major problem that even when there is access to a toilet, many Indians choose open defecation. One major problem preventing modern bathroom practices are that latrine usage in India is often regarded as limited to the elderly, disabled or weak (Bakshi, 2015). Culturally, emptying latrines is inconceivable by high-caste Hindus and 'untouchable' castes who want to distance themselves from such work (Bakshi, 2015). Also, cultural beliefs about purity and not accumulating waste near or around the home have long been entrenched in the Indian people. Despite the addition of toilets, open defecation practices still remain and this signifies that building toilets alone will not effectively end this problem.
7. Proposed Solution(s) (60 lines)
The primary recommendation for improving sanitation related to open defecation is to implement a greater frequency of Village Health and Sanitation Committees (VHSC). This type of committee is one of the nine institutional mechanisms developed under the NRHM initiated by the Government of India in 2005 (Ganesh et al., 2013). These committees will be designated with the responsibly for the overall health of a village. Comprised of village health workers, Panchayat Raj Institution representatives, members of Community Based Organizations and special groups who are marginalized, these committees have the capacity and competency to do a situational analysis of the local health status (Ganesh et al., 2013). VHSC's will have control over finances and budgets with built in systems of transparency to the public to ensure against corruption. The committees will be designated with monitoring all the health activities that are conducted in the village such as Village Health & Nutrition Day and mother's meetings. Also, it will be the responsibility of the VHSC to develop a village health plan based on an assessment of the village situation and priorities identified by the village community.An additional objective of the Village Health and Sanitation Committees is to educate the local public on the essentials of health programs, proper hygiene and safe bathroom practices. Education and training programs to oversee the disposal system for solid waste, wastewater management and disposal, drain maintenance and disinfection of stagnant water are recommended. This initiative has the goals of engaging the community and local populations in planning and monitoring health service delivery, especially in rural areas. Waste disposal management will be essential to help reduce mosquito-breeding breeding sites to lower the rates of malaria, dengue and Japanese encephalitis (Ganesh et al, 2013). Established community toilets are not being maintained well enough so it will be the responsibility of VHSC to oversee, clean and maintain them.
To fund this initiative it is recommended an annual grant of 10,000 Rupees be available to each committee for village level activities. The committee should only utilize the funds after taking resolution in the VHSC monthly meetings and should not utilize all of the grant at one time. It is recommended that each VSHC be required to share the information of fund utilization with the villagers during village meetings or public dialogue. The VHSC should also be required to maintain a register of funds received and expenditures incurred relating to activities undertaken.
An additional solution to the open defecation problem in India is the construction of toilets. There is no plumbing or running water in a majority of rural areas therefore standard flush toilets are not feasible. Ecological Sanitation (EcoSan) toilets are the preferred recommendation because they manage human waste through decomposition, requiring less water and no flushing system. The EcoSan toilets consist of two constructed pits, one for use and one for composting. Each pit is designed to sustain bathroom use for a five member family for around six months, after which the second pit is used and the first pit is left to decompose (Shah, 2014). After every toilet use, a handful of ash has to be thrown over the waste to create the optimum conditions for decomposition into nutrient rich fertilizer (Shah, 2014). Urine and waste water that is rich in ammonia is collected in a separate chamber, to be diluted and used for vegetable and flower beds (Shah, 2014).
Each EcoSan toilet will cost roughly 10,747 Rupees or $164.77 USD (Ayala, 2014). It is recommended that government subsidies be offered by State Governments to help citizens fund and build the aforementioned toilet infrastructure. Models can similarly be structured after the system currently being used in Tamil Nadu where the Tamil Nadu State Government provides subsidies of 4,700 Rupees for each household building a toilet. Application forms to receive subsidy can be obtained from Village Administrative Officers, Block Development Officers, District Rural Development Agencies and District Collectorates.
The construction of toilets will be monitored by poverty reduction committees, self-help groups, and panchayat level federations. The construction should be completed within three months from the date of obtaining consent from village panchayat presidents. The subsidy amount will be given in two installments. The first installment will be released after laying of the foundation and base structure and second installment will be given on completion of the toilet.
The last recommendation for the Ministry of Health in India is a multi-dimensional media campaign designed to educate and bring awareness about the dangers of open defecation and poor sanitation. One of the major determinants of open defecation is a lack of awareness, with many rural residents and children remaining unaware of the risks associated with poor sanitation and germs. Additionally, emphasizing safe hygienic practices and the importance of hand washing after going to the bathroom will also improve sanitation by reducing the rates of germs and infections.
The four key messages that will need to be emphasized in the campaign include: construction and use of toilets, safe disposal of child feces, hand washing with soap after defecation and safe storage and handling of drinking water. EcoSan toilets are a cheap and effective measure that could effectively replace open defecation while also providing fertilizer for crops. In many rural areas, child feces is still disposed of in the streets or in the yard and this unsafe practice needs to be eliminated.
To achieve the most coverage and effectiveness, all media outlets will need to be utilized including television, radio, smartphone applications and the internet. India has the second-largest number of mobile phone users in the world with over 900 million subscribers while also accounting for 10% of the world’s online population in 2011 (PIB, 2012). This creates the potential to reach out to huge amounts people with SMS messages, especially those living in remote areas. It is imperative that a country rich enough to have almost a billion cell-phone users eliminates the millions of people who don’t use toilets due to a lack of access or awareness. National reminders should be sent out monthly and on April 7 (National Health Day) reminding citizens of the dangers of open defecation while also providing new health updates. One example of effective use of mobile technology is using SMS to communicate with the 3.2 million Central Government Health Services (CGHS) beneficiaries spread across India (PIB, 2012). These beneficiaries are patients who come to the CGHS Wellness Centers for consultation and receiving medicines for treatment and have benefited greatly from the increased access and information allowed by cellphones.
The biggest challenge in ending open defecation is triggering behavioral changes in the population to accept the need for building and using toilets. For major changes to take place, the campaign will need to be respective of traditional cultures yet still be educational and informative of modern and progressive health behaviors. In particular, Muslims are generally less averse to owning and using affordable latrines, which need to have their pits emptied every few years, than Hindus, who tend to view such latrines as ritually impure and are extremely concerned about emptying pits, or having them emptied (Coffee, 2014). To many Indians, open defecation is associated with rising early, and being industrious, as well as with strength and exposure to healthy fresh air. Many people who defecate in the open despite having access to their own latrine explain that they do so because they find it enjoyable and healthy. These notions must be expelled and more safe hygienic practices must be taught and ingrained into Indian culture.
8. References
Aitken, M. (2013). Understanding healthcare access in India. IMS Institute for Healthcare Informatics. Retrieved on 10/11/2015 from http://www.imshealth.com/deployedfiles/imshealth/Global/Content/Corporate/IMS%20Institute/India/Understanding_Healthcare_Access_in_India.pdf
Ayala, P. N. (2014). 10 toilet designs that can actually work in rural India. The Alternative. Retrieved on 10/12/2015 from http://www.thealternative.in/business/10-toilet-designs-for-rural-india/
Bakshi, I. (2015). Building toilets not enough to end open defecation. Business Standard. Retrieved on 10/20/2015 from http://www.business-standard.com/article/economy-policy/building-toilets-not-enough-to-end-open-defecation-115032501279_1.html
Coffee, D. (2014). Culture, religion and open defecation in rural north India. International Growth Center- Ideas for Indi. Retrieved on 10/18/2015 from http://ideasforindia.in/article.aspx?article_id=329#sthash.nwkZ76FY.dpuf
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