Sanitation
is a fundamental public health intervention. Sanitation reduces the risk of
water-borne diseases such as diarrhea, cholera, typhoid, hepatitis, worm infestations,
malabsorption, and as also, malnutrition. A World
Health Organization (WHO) study in 2012 estimated that
for every US$ invested in sanitation, there was a return of US$ 5.5 in
lower health costs, more productivity and fewer premature deaths.
Sanitation in
India has a deep-rooted history, tracing back to the Indus valley civilization where
scientific methods for toilet construction and waste management were practiced.
Our scriptures say,
Despite this rich
legacy, India’s journey towards comprehensive sanitation coverage has been
fraught with challenges. By the time of the 1981 census, a mere 1% of rural
households had access to toilets. This paved the way for the launch of sanitation
programmes by government of India - the Central Rural Sanitation Programme, the
Total Sanitation Campaign, and the Nirmal Bharat Abhiyan. These initiatives
pushed the rural sanitation coverage to 39%.
India accounted
for almost 60% of the world’s open defecation load with over 50 crore people practicing
open defecation. Our women were caught between attending to basic needs in
darkness, and maintaining their dignity and safety.
It was in this
backdrop that the Prime Minister Shri Narendra Modi launched the Swachh Bharat
Mission (SBM) in 2014 with the goal to make rural India Open Defecation Free
(ODF) in five years. Bharat achieved this milestone on 2nd October
2019, the 150th birth anniversary of Mahatma Gandhi. In five
momentous years, the rural
sanitation coverage rose to 100%.
Under the
mission, more than 11.7 crore toilets have been constructed since 2014 with a
public investment of over 1.4 lakh crore. This was not merely an asset creation
exercise; it was a nationwide movement that galvanized over a billion people,
blending infrastructure development with robust behavioral change revolution.
The hall mark was people’s movement (‘jan
andolan’) and perhaps the world’s biggest behavior change exercise.
Children, women, men, community leaders, civil society and government machinery
worked in unison. Messages on sanitation reached people through every channel.
Celebrities joined the chorus. Village-level volunteers (‘swachhagrahis’) became the champions of change on the ground.
Prime Minister led and inspired the nation through his speeches, meetings,
Mann-ki-Baat conversations and role model acts of cleaning places and premises.
Following the
success of the SBM Phase I, Phase II was launched. This phase aims to sustain
the ODF achievements while addressing the broader aspects of solid and liquid
waste management, visual cleanliness, and overall rural sanitation. By 2024-25,
the goal is to transform all villages into ODF Plus Model, characterized by
sustainable practices and enhanced cleanliness. The mission's next goal is
Sampoorna Swachhata—complete cleanliness—that will require continued dedication
from every citizen, community, and institution in India.
A recent study
published in the top international journal ‘Nature’ underscores the profound
impact of SBM on public health, particularly in reducing infant mortality
rates. The study, titled, ‘Toilet construction under Swachh Bharat Mission and
infant mortality’, analyzed data from 35 Indian states and 640 districts over a
10 year time frame (2011-20) on trends in infant mortality rate (IMR) and
under-5 mortality rates (U5MR). The authors document a strong association
between increasing toilet access and declining child mortality. Results from the
study imply that for every 10 percentage point increase in district level
access to toilets following SBM corresponded to a reduction in district level
IMR by 0.9 points and U5MR by 1.1 points on the average. There is further
evidence of a threshold effect wherein the district level toilet coverage of
30% (and above) corresponded to a reduction of 5.3 points in the IMR and 6.8 points
in the U5MR per thousand live births. The authors estimate that toilet
access at-scale due to SBM contributed toward averting 60,000 – 70,000 infant deaths
annually.
However, it must
be pointed out that this is not the only impact study which sheds light on the
transformative role played by SBM. According to WHO (2018), SBM averted over 300,000
diarrheal deaths between 2014 and 2019. The Bill & Melinda Gates Foundation
(2017) reported that there were 37% lower cases of wasting among children in
ODF areas compared to non-ODF villages, validating how sanitation positively
impacts childhood nutrition. The incidence of diarrhea in children was lower by
almost one third in the ODF villages. In a study in 2017, UNICEF estimated that
93% of women felt safer after having a toilet at home, reflecting the role of
SBM in enhancing the safety and dignity of women. Additionally, economic analyses
in the study showed that each household in ODF villages saved approximately INR
50,000 annually on reduced healthcare costs plus economic value of saved lives
and time savings.
Given the link
between sanitation and health, public health gains from SBM are inevitable.
What we have from the recent study is a robust quantification of child survival
improvements attributable to toilet access. Sanitation transformation on a
national scale will surely have impact in reducing water-borne infections among
adults as well, as also possibly on reducing the burden of antimicrobial
resistance. Sustained effects on childhood stunting and development are also assumed.
ICMR and academia should undertake objective studies on these dimensions of
SBM.
The Swachh Bharat
Mission is an exemplar of what can be achieved through dedication,
collaboration, planning, brilliant execution, and relentless jan andolan. The 4P mantra of
SBM—political will, public finance, partnerships, and public
participation—along with persuasion, has been instrumental in the program's
success and outreach. This ‘strategy package’ is a template for other social
transformation missions in the country and beyond.
As we strive
toward a Viksit Bharat @ 2047, we need to emerge as global leaders in
sanitation and cleanliness. the commitment to sustaining behavioral change,
ensuring continued use of the constructed toilets and integrating advanced
waste management solutions should remain unwavering. Cleanliness must become a
shared value, one that is owned and practiced by us all.
The mission
celebrates its 10th anniversary next month on the Gandhi
Jayanti. A decade of SBM has yielded
unprecedented gains – clean environment, women’s dignity and safety, ease of
living, household savings and a culture of hygiene aligned with our tradition. Now
we also see a robust evidence of SBM on improving public health and in saving
lives.
Success of this noble mission is indeed a matter of pride for every Indian.
(Dr Vinod Paul is a Member of NITI Aayog. Views are personal. A PIB feature)