Recent Changes

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.
Consultants' Report-5. Conclusion-Recommendations (25 lines)5. Conclusion-Recommendations (25 lines)
626 million IndiansIndian citizens still practice both the villagecommunity and national 10,000 Rupees shouldare recommended to be distributed
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.
recommended national SMS reminders be
Consultants' Report-6. Background Information (20 lines)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.
international standards, spendingaveraging Rs 12,000 on one pitper latrine on an average, while neighboring
Consultants' Report-7. Proposed Solution(s) (60 lines)7. Proposed Solution(s) (60 lines)
al., 2013). VHSCVHSC's will have and training programs to oversee stagnant water isare recommended. This health service deliverydelivery, especially in utilize the fundfunds after taking
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 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.
huge amounts people,people with SMS messages, especially those
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.
Consultants' Report-8. References8. References

1. Cover Letter to the MOH of the Country (10 lines)
To the Ministry of Health:
from India's practice of open defecation practice.defecation. The immense status of every citizenmillions of citizens and the to chronic illnesses,illnesses like diarrheadiarrhea, which is burden from the families and also the government. This will ensureTo achieve the development of multiple incentivesmost success in regards to accommodate to the population. We have discussed how most fundingsanitation and ending open defecation, our plan will occur to continue suppliesinvolve multiple stakeholders including health agencies, the community with their sanitation needs.government and the community. The end with the total change of plan is to implement to completely the way IndiansIndian citizens think about practice and to have them to their country's health.
Consultants' Report-2. Consultant’s Report (Add a Title for the Report)2. Consultant’s Report (Add a Title for the Report)
Recommendations for Improving Sanitation Related to Open Defecation in India
Isabelle E Michel
Consultants' Report-4. Problem Description (20 lines)4. Problem Description (20 lines)
India'sA larger portion of India's growing health issues are rooted in theircan be attributed to open defecation issues.defecation. Most of line has lowerbeen lowered tremendously from 21.9 percent (World Bank, 2011) because of Health Insurance Scheme.Scheme (World Bank, 2011). This scheme allows "aboutfor "around 75% of this scheme isto be provided by national government, with the remainder India's growing prosperity;prosperity, open defecation prevalent and a recurring problem rural communities. It is perplexing to think that even with the increasing health care access there are little to no increase in the population's general knowledge of personal hygiene. About half and thus continues the cycle.cycle is continued. This is Open defecation iscan also be viewed as open defecation. Leading illness cause by open defecation is chronic diarrhea diseases. Twenty-five percent practiced in both urban and rural areas.areas, yet rural areas have the highest rates. It iswas thought to believebe believed the occurrence of access ofto restrooms in with the implementingimplementation of more implementation of more toilets the reported the proportionsproportion of families proper restrooms have fellhas fallen from sixty-three (Nathoo, 2015). IndiaIn some cases, even when the government has spent about Rs 36,000 on public latrines (Nathoo, 2015) that most of the populationbuilt additional restrooms some citizens still refuse to use them because they much more convenient andconvenient, completely dismissing health issues.concerns. To truly to change. The main culprit of this issue is within themselves. The attitudes towards of open defecation need changeto change and not be taken as lightly as
Consultants' Report-5. Conclusion-Recommendations (25 lines)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 Indians 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 village and national levels.

Isabelle E Michel
Consultants' Report-4. Problem Description (20 lines)4. Problem Description (20 lines)
one. Individuals would usehave the option of using the facilities at workplace or schools.school grounds. When left taboo topic. Some Indians feel thisOpen defecation is the way of life or feel it is the government's responsibility to provide proper toilets (UNICEF, 2012).viewed as "wholesome, healthy and social" (Economist, 2014). This is
Open defecation is a cultural issue that is practiced in urban and rural areas. It is thought to believe the occurrence is higher in rural communities because of the lack of access of restrooms in their homes. However, even with the implementing of more toilets open defecation continues. With the implementation of toilets the census has reported the proportions of families living without proper restrooms have fell from sixty-three to fifty-three percent (Nathoo, 2015). India has spent about Rs 36,000 on public latrines (Nathoo, 2015) that most of the population refuse to use because they believe open defecation is much more convenient and completely dismissing health issues. To truly end this problem, there must be a movement within the Indian community to want to change. The main culprit of this issue is within themselves. The attitudes towards of open defecation need change change and not taken lightly as it has in the past.
Consultants' Report-5. Conclusion-Recommendations (25 lines)5. Conclusion-Recommendations (25 lines)

1. Cover Letter to the MOH of the Country (10 lines)
To the Ministry of Health:
elevate the costfinancial burden from the sanitation needs. OpenThe end of open defecation is a practice that will only havehappen with the
Consultants' Report-2. Consultant’s Report (Add a Title for the Report)2. Consultant’s Report (Add a Title for the Report)
Recommendations for Improving Sanitation Related to Open Defecation in India
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
Luthra, S. (2012). Healthcare in India: A call for innovative reform. The National Bureau of Asian Research. Retrieved on 10/10/2015 from http://www.nbr.org/research/activity.aspx?id=298
Retrieved from
http://www.independent.co.uk/news/world/asia/india-rejects-the-toilet-how-government-sanitation-drives-have-failed-to-sway-those-who-believe-10466041.html
PIB. (2012). India is the Second-Largest Mobile Phone user in World. Press Information Bureau- Government of India. Retrieved on 10/15/2015 from http://pib.nic.in/newsite/erelease.aspx?relid=85669
Spears, D., So, J. (2013). Ending open defecation, not by evidence alone. The World Bank. Retrieved on 10/20/2015 from http://blogs.worldbank.org/water/ending-open-defecation-not-by-evidence-alone
The World Bank. (2014). Mortality Rate, Infant (per 1,000 live births). Retrieved on 10/29/2015 from http://data.worldbank.org/indicator/SP.DYN.IMRT.IN
11/01/2015 from
http://data.worldbank.org/country/india#cp_fin
10/29/2015 from
http://unicef.in/Whatwedo/11/Eliminate-Open-Defecation
World Health Organization. (2015). Water Sanitation Facts. World Health Organization. Retrieved on 9/20/2015 from
http://www.who.int/water_sanitation_health/monitoring/jmp2012/fast_facts/en/
11/01/2015 from
http://www.who.int/bulletin/volumes/88/7/10-020710/en/

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
Luthra, S. (2012). Healthcare in India: A call for innovative reform. The National Bureau of Asian Research. Retrieved on 10/10/2015 from http://www.nbr.org/research/activity.aspx?id=298
Nathoo, L. (2015). India's trouble with toilets: Government sanitation drives fail to sway those who believe going outdoors is more wholesome. The Independent. Retrieved from
http://www.independent.co.uk/news/world/asia/india-rejects-the-toilet-how-government-sanitation-drives-have-failed-to-sway-those-who-believe-10466041.html
PIB. (2012). India is the Second-Largest Mobile Phone user in World. Press Information Bureau- Government of India. Retrieved on 10/15/2015 from http://pib.nic.in/newsite/erelease.aspx?relid=85669
Roy, N. New Study on Indian Government Health Insurance Scheme Shows Significant Reduction in Mortality among the poor/ World Bank. Retrieved from http://www.worldbank.org/en/news/press-release/2014/10/08/new-study-indian-government-health-insurance-reduction-mortality-among-poor
Spears, D., So, J. (2013). Ending open defecation, not by evidence alone. The World Bank. Retrieved on 10/20/2015 from http://blogs.worldbank.org/water/ending-open-defecation-not-by-evidence-alone
The World Bank. (2014). Mortality Rate, Infant (per 1,000 live births). Retrieved on 10/29/2015 from http://data.worldbank.org/indicator/SP.DYN.IMRT.IN
WHO.The World Bank. (2011). India Data: World Dvelopment Indicators. Retrieved on 11/01/2015 from
http://data.worldbank.org/country/india#cp_fin
UNICEF. (2012). Eliminate Open Defecation. Retrieved on 10/29/2015 from
http://unicef.in/Whatwedo/11/Eliminate-Open-Defecation
World Health Organization. (2015). Water
http://www.who.int/water_sanitation_health/monitoring/jmp2012/fast_facts/en/
World Health Organization. (2010). India tries to break cycle of health-care debt. Retrieved on 11/01/2015 from
http://www.who.int/bulletin/volumes/88/7/10-020710/en/

1. Cover Letter to the MOH of the Country (10 lines)
(This should be a brief but “official” letter that has the report as an Attachment.)
To the Ministry of Health:
plan is to implement to completely
Consultants' Report-2. Consultant’s Report (Add a Title for the Report)2. Consultant’s Report (Add a Title for the Report)
Recommendations for Improving Sanitation Related to Open Defecation in India
Isabelle E Michel
Consultants' Report-4. Problem Description (20 lines)4. Problem Description (20 lines)
(Taken from Scope of Work of TOR but you should refine it.)
India'sIndia's growing health defecation issues. In the past, mostMost of the poverty line diddo not have restrooms because of their homes wereare not equipped to healthcare costs.costs and allows them to have to chance to save the little income they do earn. However, even place and India isIndia's growing in prosperity; open to think about whenthat even with the increasing health care access should alsothere are little to no increase yourin the population's general knowledge of by children from what they see and thus defecation continues. With the implementation of toilets the census has reported the proportions of families living without proper restrooms have fell from sixty-three to fifty-three percent (Nathoo, 2015). India has spent about Rs 36,000 on public latrines (Nathoo, 2015) that most of the population refuse to use because they believe open defecation is much more convenient and completely dismissing health issues. To truly the past.
http://data.worldbank.org/country/india#cp_fin
http://unicef.in/Whatwedo/11/Eliminate-Open-Defecation
http://www.who.int/bulletin/volumes/88/7/10-020710/en/
*could maybe talk about financial implications, or go into more depth about the cultural reasons
Consultants' Report-5. Conclusion-Recommendations (25 lines)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 Indians 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 village and national levels.

(This should be a brief but “official” letter that has the report as an Attachment.)
To the Ministry of Health:
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 the population. We have discussed how most funding will occur to continue supplies the community with their sanitation needs. Open defecation are linked. Our plan is to completely change the way Indians think about this cultural practice and to have them begin to truly see how their actions are detrimental to their country's health.
Consultants' Report-2. Consultant’s Report (Add a Title for the Report)2. Consultant’s Report (Add a Title for the Report)
Recommendations for Improving Sanitation Related to Open Defecation in India

1. Cover Letter to the MOH of the Country (10 lines)
(This should be a brief but “official” letter that has the report as an Attachment.)
of Health: You have laid out
We, the true problem we face in India is the desperate need to implement programs to control their poor sanitation and limited healthcare access. Weconsultant team, have developed programs that are cost-effective and that are inprepared a report to combat the best interest ofhealth issues stemming from India's impoverished communities and suitable to India's growing population. In your report, you stated India's populationopen defecation practice. The immense pressure of this cultural tradition is taking toll on theirthe health care system. We agree that India's overpopulationstatus of every citizen and the ever-growing population is an important factoradded incentive to take into consideration when implementing new health care incentives.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. In our planreport, we wanthave developed cost-effective incentives to elevate the cost from the families and the government. This will ensure the development of multiple incentives to accommodate to the rural areas include access for the country's' population. To combat the sanitation issue, which is rooted in India's openOpen defecation problem, startsis a practice that will only have with the change of behavior and attitude of the Indian community. In our report, we discuss our support of organizations who are educating the
Consultants' Report-2. Consultant’s Report (Add a Title for the Report)2. Consultant’s Report (Add a Title for the Report)
Recommendations for Improving Sanitation Related to Open Defecation in India
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 Indians 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 village 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 should be distributed by state governments to help fund these committees.
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 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.
Consultants' Report-6. Background Information (20 lines)6. Background Information (20 lines)

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 should 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.
encouraging safe hygienehygiene.
Consultants' Report-6. Background Information (20 lines)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).