Feature Sanitation

More temples than toilets?

BMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f525 (Published 30 January 2013) Cite this as: BMJ 2013;346:f525
  1. Ankita Malik, freelance journalist, New Delhi
  1. mail.ankitamalik{at}gmail.com

India’s dearth of sanitary toilets means it tops the world leader board when it comes to open defecation, with huge implications for health, but times are changing, writes Ankita Malik

India has more temples than toilets, berated Jairam Ramesh, controversially making headlines last October. The union minister for rural development also urged women not to marry into families that do not have a toilet at home, and he also proposed a cut to defence budgets to fund toilets.

India is home to an estimated 626 million people who practise open defecation because of inadequate sanitation—nearly 60% of those who practise open defecation in the world, according to a report from Unicef, released recently.1

Open defecation leads to waterborne diseases and diarrhoea. Every year, about 2.2 million people die from diarrhoea; 90% of these deaths are of children, mostly in developing countries.2

Open defecation also contaminates groundwater and agricultural produce and promotes manual scavenging—that is, people clearing up untreated human excreta.

According to the Water and Sanitation Programme, a multidonor partnership administered by the World Bank, the economic impact of inadequate sanitation is about 2.4 trillion rupees (£0.028 trillion, €0.033 trillion, $0.044 trillion) or 6.4% of India’s gross domestic product.3 “Costs include health costs attributed to poor sanitation,” said Guy Hutton, author of the report, including “healthcare, lost productivity from sickness, and the value of lost lives from premature death.” He went on to explain that degradation of water quality and treatment also comes with a cost, as does “time spent accessing off-plot (out of house) sanitation facilities,” he said.

In 1993 the government introduced the Employment of Manual Scavengers and Construction of Dry Latrine (Prohibition) Act, which outlawed the construction or maintenance of dry latrines and the employment of manual scavengers.

Low cost sanitation

Since 1980 the government’s low cost sanitation scheme (ILCS) has been converting dry latrines into twin pit latrines with flush, which makes manual scavenging redundant. The scheme has also paid to install sanitary latrines for poorer (so called economically weaker section, EWS) households at a cost of 10 000 rupees to build each toilet with superstructure (12 500 rupees in northeastern states and hilly areas).

As part of the 11th five year plan the government converted 252 000 dry latrines and built 156 000 new toilets for EWS households under the scheme. But because huge sanitation problems persist in many areas, in November 2012 the union cabinet extended the scheme as part of the 12th five year plan.

A quarter of the scheme’s funds are reserved to build toilets for EWS households that lack latrines. Central government will pay 3.673bn rupees to state governments to run the scheme. The remainder of the estimated cost of running the programme, 4.81bn rupees over the five years, will come from state governments and beneficiaries of the latrines. The funding for each toilet has been raised to 15 000 rupees, with more money announced to fund environmentally friendly technologies, such as biodigesters.

“The link between health, sanitation and hygiene is well established. The burden of disease, especially gastrointestinal diseases, due to open defecation is very high. This results not only in high mortality but also morbidity,” said Subhadra Menon, director, Health Communication and adjunct additional professor, Public Health Foundation of India, a New Delhi based public-private initiative.

She added that the scheme had made progress in tackling open defecation but that the challenge is to overcome difficulties in implementation. She gave an example of a concrete toilet built in a village where there was no running water. This toilet was now being used as a store room.

Biodigester technology

“Zero waste biodigester technology breaks down human excreta into usable water and gas through anaerobic processes,” explained W Selvamurthy, chief controller of the research and development division at the central government agency the Defence Research and Development Organisation (DRDO). “It does not have any geographical or temperature limitations and also does away with the need to set up large sewerage networks.”

Ramesh announced in July 2012 that the organisation would implement 100 000 biodigester toilets in the next two years as part of central government’s flagship total sanitation mission. In the first phase of the initiative, toilets will be built in 300 gram panchayats, or village councils, which will cost 1.5bn rupees.

This decision was taken after the DRDO, along with the Federation of Indian Chambers of Commerce and Industry, successfully piloted six biodigester toilets at Dhamra district in Odisha in June, used by about 150 people each day.

All the states have reported that conversion of dry latrines is complete, and the ministry says that its programme has been a success, but open defecation is still occurring. “Only 25 000 villages have been declared as nirmal grams [villages where no open defecation occurs, and all houses, schools, and anganwadis—or courtyard shelters—have toilets] out of six lakh [600 000] villages in the country and [open defecation is] the root cause for spreading public health problems,” said Ramesh in October last year. He pointed out that in Rajasthan, for example, only 321 gram panchayats out of 9177 are now free from open defecation.4

“Manual scavenging is still prevalent in some states, but the municipalities and state government are shy to report it,” said a senior spokesperson at the ministry who did not wish to be named. “There are no official data on the number of manual scavengers in the country,” he added.

Emancipation of scavengers

Bindeshwar Pathak, founder of Sulabh International, a non-profit voluntary organisation dedicated to the Gandhian ideology of emancipation of scavengers, pointed out that the 2010-11 census recorded just 61 944 scavengers in the country. The Ministry of Social Justice and Empowerment has initiated a fresh survey through the state governments, he added. In 1992 the state governments carried out a survey and identified 770 000 scavengers for the Ministry of Welfare. Of these about 428 000 were manual scavengers, who, with their dependants, were rehabilitated in 1992-2005, and the number rehabilitated in 2007-10 was 78 941.5

Pathak said that in the India of the late 1960s he pioneered the concept of flush toilets, popularly known as “Sulabh Shauchalaya,” to replace dry latrines. According to the 2011-12 annual report of the Ministry of Housing and Poverty Alleviation the scheme has helped to construct or convert more than 280 000 latrines and liberate 60 952 scavengers. A total of 911 towns have been declared free of scavengers.6 Only the state of Sikkim has been declared free from open defecation. Himachal Pradesh is likely to too by March 2013 and Haryana by March 2014.

Cities are filthy

The 2010 Indian census found that urban areas still have some 208 000 latrines, where excrement has to be manually removed.7 Of these, more than half, 106 000, are in Uttar Pradesh.8 About 78% (4 819 740) of homes in the eastern state of Jharkhand9 and Odisha (7 531 789)10 have no toilet facilities, while the figure is 76.9% (14 573 393) for Bihar.11 In Jammu and Kashmir manual scavengers still empty the latrines of 8.9% [2 015 088] of households.12 Sanitation coverage in the country has increased to 46.9% , 30.7% in rural and 81.4% in urban areas according to the census. This has lessened the practice of open defecation from 73% in 1990 to around 50% in 2011.

A 2010 government survey rated cities’ hygiene based on the prevalence of open defecation and manual scavenging and the management of wastewater and solid waste.13 Of 423 cities surveyed not one achieved the “healthy and clean” category. Even Chandigarh, which got a top rating for cleanliness, was deemed “recovering but still diseased.”

Cities were rated red, black, blue, and green, with red cities at the bottom of the list. Almost 45% (189) of the 423 surveyed cities were judged red and in need of immediate remedial action. As many as 228 cities were rated black and need considerable improvement. Only two cities, including Chandigarh, were rated blue. More than 50 cities reported 90% or more safe collection of human excreta. But wastewater treatment levels are abysmal: 380 cities collect and treat less than 40% of the sewage they generate.

“What is needed is a political and social movement to cope with the problem, not just an administrative programme. The first and last man to spearhead the cause of hygiene and sanitation in the country was Mahatma Gandhi,” underlined Ramesh.


Cite this as: BMJ 2013;346:f525


  • Competing interests: I have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare.

  • Provenance and peer review: Commissioned; not externally peer reviewed.