Open defecation despite latrine access is more common in households with government-constructed latrines

A government-constructed toilet
A government-constructed toilet

Excerpts from a recently-published research paper, “Revealed preference for open defecation: Evidence from a new survey in rural north India,” by Diane Coffey, Aashish Gupta, Payal Hathi, Nidhi Khurana, Dean Spears, Nikhil Srivastav, and Sangita Vyas

The SQUAT survey was a survey of Sanitation Quality, Use, Access and Trends in rural north India. From December 2013 to April 2014 we asked 3,235 rural households about their sanitation behaviour and beliefs, and collected data on the defecation practices of 22,787 people. We visited over 300 villages in 13 districts of Bihar, Haryana, Madhya Pradesh, Rajasthan, and Uttar Pradesh. What we found is surprising – and must be an important part of India’s plan to eliminate open defecation. Most people who live in India defecate in the open. Most people worldwide who defecate in the open live in India.

Open defecation has dire consequences: it kills babies, impedes the physical and cognitive development of surviving children, and reduces the human capital of India’s workforce. Open defecation is associated with significant negative externalities: it releases germs into the environment which harm the rich and poor alike— even those who use latrines. As the rest of the world steadily eliminates open defecation, this behaviour stubbornly persists in India. Indeed, with 67% of rural households and 13% of urban households defecating in the open according to the 2011 census, India now accounts for 60% of the world’s open defecation.

Our study focuses on sanitation in rural India for several reasons. First, open defecation is far more common in rural India than in urban India. Second, about 70% of the Indian population lives in rural areas. Indeed, 89% of households without a toilet in the 2011 census were in rural areas. Finally, improving rural sanitation poses particular challenges. India has seen decades of government spending on latrine construction and sustained economic growth, but rural open defecation has remained stubbornly high.

open defecation
Source: UNICEF-WHO Joint Monitoring Programme (JMP) in http://www.wssinfo.org/; GDP from World Bank

Why do people in rural India defecate in the open in such large numbers? Answering this question requires understanding the preferences of hundreds of millions of people. We are aware of no prior study that is similarly broadly representative of sanitation views and behaviours in India. We find that households believe that a latrine worth using is expensive. However, the great majority of households that do not own a latrine could afford to build one of the simple, inexpensive latrines that are ubiquitous in Bangladesh and other countries that are poorer than India. Additionally, many people who live in households that own working latrines nevertheless defecate in the open.

Open defecation despite latrine access is more common in households with government-constructed latrines than in households with privately constructed latrines. A simple model applied to our survey data predicts that if the government were to build a latrine for every household in Bihar, Madhya Pradesh, Rajasthan, and Uttar Pradesh without changing anybody’s preferences, most rural people that we talked to in these states would still defecate in the open. In short, we find that many people have a revealed preference for open defecation, such that merely providing latrine “access” without promoting latrine use is unlikely to importantly reduce open defecation.

The findings of our survey have clear implications for sanitation policy in India: programmes must concentrate on behaviour change and promoting latrine use, rather than building latrines. Although building latrines could be part of a successful policy package, little will be accomplished by planning to build latrines that will go unused. Latrine construction is not enough. Instead, if the Government is to achieve its goal of eliminating open defecation by 2019, it must concentrate on building demand in rural India for latrine use.

This paper is far from the first to emphasize the importance of latrine use, and to point beyond policies of latrine construction. Many of our conclusions will be familiar to sanitation professionals who have struggled for years to promote behaviour change in India and worldwide. Yet, the magnitude of resistance to latrine use in rural north India might surprise even experts: we find that even among the demographic sub-groups in our survey who are most likely to use a toilet, open defecation is still more common than among the populations of some of the poorest countries in the world. Open defecation is much more common in India than it is in many of the poorest countries of the world, such as the Democratic Republic of the Congo, Malawi, Burundi, and Rwanda – to say nothing of richer countries that are still much poorer than India, such as Afghanistan, Kenya, and Bangladesh.

open defecation1Many international sanitation professionals and experts describe a “sanitation ladder”: ranging from open defecation up to flush toilets with a piped sewer. Successive rungs on the ladder represent more hygienic and more expensive sanitation options. However, the sanitation ladder in India appears to be missing its middle rungs, with no intermediate steps on which households climb gradually up from open defecation. The data for India show a “missing middle:” no country listed has a smaller “middle” fraction of unimproved or shared sanitation. Many countries, in contrast, have both a lower fraction of the population defecating in the open and a lower fraction with improved sanitation.

In India, only 16% of the population is on a middle rung, compared with 40% in Bangladesh, and 45% in sub-Saharan Africa overall. Although the table only presents country-level statistics, in rural India the contrast is even starker: only 6% of rural Indians are in a middle category. In many countries, proceeding up the sanitation ladder was not only the path out of open defecation, but also an important step towards improved health and human capital. For India to follow this path, policymakers must learn how to convince rural Indians to use “middle” alternatives to open defecation.

In our survey, over 78% of respondents who do not have a latrine also cite the cost of a latrine as an important reason for why they defecate in the open. How can this perception be understood, in comparison with the international context? We find that respondents have a very expensive notion of what constitutes a latrine. We asked male respondents to enumerate for us what features an inexpensive, but usable latrine would have and how much each of the parts would cost. The latrines that they described cost more than Rs. 21,000, on average, and in many cases much more.

Given these large estimates, it is no surprise that people perceive cost as a barrier to building a latrine. What this suggests is not that these respondents could not afford to build latrines that safely contain faeces, but rather that there is a widely held belief that latrines are expensive assets, perhaps even luxuries. In fact, a usable latrine that safely contains faeces could be built much less expensively, and such a latrine could importantly improve health relative to open defecation. Indeed, the simple latrines that have been used to essentially eliminate open defecation in Bangladesh cost around Rs 3,000: much less than the Rs. 10,000 allocated for latrine construction by the Indian Government, and of course even less than the Rs. 21,000 which our respondents imagined.

Buying a toilet for each of the 123 million households that lacks one at our respondents’ estimated price of 21,000 rupees would cost Rs. 256,000 crore, or approximately one-sixth of the annual total expenditure of the Government of India in 2012-2013. This is therefore not a serious policy alternative to building demand for simple, “middle-rung” latrines.

open defecation3Measuring sanitation behaviour at the household level has created a blind spot for many studies in the literature: in rural north India, many households include some people who use a latrine and some people who defecate in the open. In our four focus states, 80% of all interviewed households had at least one member who defecates in the open. Strikingly, in these states, 45% of households with a latrine user also had at least one household member who defecates in the open. Person level statistics illustrate what is missed by household counts of latrine ownership. 57% of households in our sample do not own a latrine, but 64% of people defecate in the open. This gap is because many people in households with latrines do not use them.

Media coverage of sanitation in India often emphasizes the need for the government to provide “access” to sanitation. As we have seen, “access” is an importantly incomplete description of the sanitation challenge for rural India, where demand for latrine use is a key barrier. Here, we focus on a key question: Were the latrines that are being used provided by the government? Only a minority of all households in the survey – merely 9% – report having received either money or materials from the government for latrine construction; 32% of households in the survey own a toilet that was built without any government support, and the rest do not own a latrine.

People who live in households with a latrine that was built with government support are more than twice as likely to defecate in the open than are people who live in households with a latrine that was constructed by the household itself. Indeed, over 60% of households which received latrine materials from the government have at least one member who defecates in the open. This lower probability of using government latrines is seen for both men and women, at all ages. Fully government-constructed latrines are the least likely to be used. A majority of people who live in households with a fully government constructed latrine defecates in the open; and one-third of such latrines are not usually used by anyone at all. In households with a fully government-constructed latrine, even a majority of women in their 20s – a demographic group particularly likely to use latrines when one is available – defecate in the open.

These differences in use according to private or government construction reflect several possible mechanisms.

First is selection: households that build their own latrines are, on average, households that have more demand for latrines, possibly because of higher socioeconomic status, better education, or a greater awareness of the health benefits of latrine use. However, we find that wealth is not the whole story: among both rich and poor households, those who built their own latrine are more likely to be using it than those with a government latrine.

Second is quality: households that build their own latrines may choose to build a more expensive latrine, or one that more closely matches their own preferences. One important issue is latrine pit size. People are much more likely to use latrines with very large pits, and many households construct very large pits or septic tanks when they build their own latrines. The pits that the government builds are much smaller. In fact, the average pit that the government constructs for a latrine is less than one-fifth the size of the average pit that a household constructs for itself and uses. In qualitative interviews, people suggested that concerns about pit emptying importantly reduce use of latrines with smaller pits. Very large pits are perceived to last a family at least a generation.

Of course, this does not mean that the government should be constructing large and expensive pits – this would simply not be feasible on the scale required. Instead, policy-makers must explore ways to promote the use of simpler latrines – with smaller pits – of the type commonly used in other countries around the world.

Our respondents explain that there are many pleasant advantages of open defecation, and that using a latrine is probably no healthier for neighbouring children than going outside. We asked an open-ended question, so villagers could volunteer their explanations of what is good or bad about open defecation and latrine use. Of people who defecate in the open, 47% explain that they do so because it is pleasurable, comfortable, or convenient. Of individuals who defecate in the open despite having access to a latrine in their household, fully 74% cite these same reasons.

Open defecation is not generally considered unhealthy: among adults who defecate in the open, fully 51% report that widespread open defecation would be at least as good for child health as latrine use by everyone in the village. In a companion qualitative research project, many respondents explained that open defecation is part of a healthy, wholesome way of life.

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