That high toilet coverage without concomitant utilisation of the facilities at a very high level and washing hands with soap will not bring about a reduction in diarrhoeal episodes and worm infestation, or any improvement in nutrition and growth, has been clearly brought out in a study undertaken in rural Odisha. The study involved about 4,600 households from 50 villages grouped in an intervention arm and about 4,900 households from 50 villages in a control group; there were nearly 25,000 individuals in each group. The coverage of toilets shot up from 9 per cent to 63 per cent among those in the intervention arm within 18 months, compared with an increase from 8 to 12 per cent in the control villages. Eleven of the 50 villages in the intervention arm had toilet coverage of 50 per cent and above; only two villages in the control group had coverage that was this high. Despite usage at the household level in the intervention arm being 84 per cent for women and 79 for men and children, it translated to only about 50 per cent at the community level. As a result, in both the arms the number of children below five years who were affected by diarrhoea was nearly the same. There was no difference in worm infestation rates or any improvement in nutrition or growth rates, either. There was no decrease in faecal contamination of water or any significant drop in contamination of the hands of individuals.
The results of the trial should serve as a painful reminder that emphasis on high toilet coverage without ensuring very high usage will not lead to improvement in health indicators. After all, the only way to reduce the overwhelming load of diarrhoeal and other pathogenic bacteria in the environment and improve health indicators is to refrain from shedding such bacteria in the environment. The timing of the results is perfect. The government recently rolled out its ambitious Swachh Bharat Mission with the aim of ensuring a toilet in every Indian household by the end of 2019; an earlier programme primarily targeted families that were below the poverty line. Building toilets is the necessary but easier part; bringing about behavioural change is the more daunting challenge. This is amply reflected in the study, done in accordance with the government’s earlier programme. The Mission should not remain a mere infrastructure-centred programme but should give equal priority to creating awareness of the benefits of toilet usage through a massive campaign. On paper, the “top priority” of the Mission is to improve toilet usage by bringing about behavioural change. There is also a provision to “monitor usage”. It is important that such ideals get translated into discernible actions and results on the ground.