People wear masks and use handwash to keep the virus away as a result of  fear of infection. One may also find this new behaviour as a formality among many persons and as a result of legalities.  And this is happening in a society which is least concerned about sanitary practices. In this new sanitary culture, the prominent internalised attitude could be about the other but about oneself.  This is compatible with the pre-existing health culture which makes people spit wherever possible and that also least concerned about the other. This is also happening in a culture in which open defecation and open urination are rampant. Plastics and other wastes are carelessly thrown into roadsides.  But these behavioural indiscretions occur largely as a result of lack of resources and unaffordability of sanitary facilities at home.

At the international level, in many low income and middle income countries, improved access to the safest drinking water or sanitation facilities since 2000 was observed between 2000 and 2017. However, many people  continued to not have access to such facilities especially in sub-Sharan African countries (Local Burden of Disease WaSH Collaborators, 2020). The last round of Demographic and Health Survey in India (National Family Health Survey, 2015-16), gives some indication as to which groups have at least the means to practice hand washing which is one of the most recognized, and irrefutable preventive measures to avoid the infection. NFHS data show that the upper castes have the luxury of soap and water in close to three-fourth of their households, while more than 60% of the scheduled tribes and half of the scheduled castes do not have soap and water facilities. Every one-in-five households of schedules tribes did not even have water, soap, or other cleansing agents. This is almost four times more than the proportion among higher castes. One in every five households in the lowest wealth quintile lacked water, soap, and other cleansing agents. The upper castes are predominantly rich (57% of the upper castes are in the richest two quintiles) while 70% scheduled tribes and 50% of scheduled castes belong to the lowest two quintiles. The socio-economic underpinnings of sanitary facilities is evident and it is therefore not always possible to highlight behavioural factors especially for sanitary practices as availability of facilities and their sustainability also determine such practices.

The recent initiatives at the national level in India known as clean India campaign or Swatch Bharat Mission (SBM) could have possibly made some changes. According to a recent study covering key stockholders in the mission, it is found that there are some changes in the administrative culture of slowness and creating bottlenecks which is characteristic of India’s bureaucracy (Curtis, 2019).  Open defecation is a serious problem in India and the focus of SBM is to eradicate this behaviour. The Swatch Bharat website shows that open defecation has been eradicated and household toilet coverage has increased from 38.7% in 2014 to about 100% in 2019. The success is attributed to use of modern technology, effective leadership and employee rewards.

The coverage of sanitary latrines has been made universal and all villages in India have been declared Open Defecation Free (ODF) on 2 October, 2019. However, this needs further empirical support as informal observations in many North Indian states present a contrary view. The perennial problems in many villages in India are non-availability of water and other ecological constraints which make the use of sanitary latrines an unpleasant experience. Evidently, infrastructural provision is not the only solution but sustainability is equally important.

One illustration of this experience despite the availability of water and personnel assistance is with respect to public toilets. For instance, Kerala which has better water availability, visiting a public toilet located in a number of public institutions such as Bus Stations, Railway Stations, Hotels and Offices apart from specific public comfort stations available in cities and towns is indeed an unpleasant experience.

Preliminary exploratory investigations as part of a research project show that the quality of such facilities is extremely poor and the maintenance is shoddy although some of these facilities are inaugurated with much fanfare. There may be number of factors responsible for the poor state of such facilities; some of them being the behavioural patterns of the people who use them and also lack of maintenance by the persons who manage such facilities.

The Sustainable Development Goals (SDGs) call for universal sanitation access and ending open defecation by 2030. Shared toilet models are not currently an acceptable form of safely managed sanitation and an alternative approach was tried in the country. However, given the complexity of sanitary behaviour of the population, it is extremely important to understand the multi-disciplinary dimensions of toilets as well as general sanitation in India. Constant monitoring and support to the population is essential than just provision to sustain the ‘claims of coverage’.

(K. Rajasekharan Nayar is affiliated to Global Institute of Public Health and Santhigiri Research Foundation, Thiruvananthapuram, Kerala)


Curtis V. Explaining the outcomes of the ‘Clean India’ campaign: institutional behaviour and sanitation transformation in India. BMJ Global Health. 2019;4:e001892. doi:10.1136/ bmjgh-2019-001892

International Institute for Population Sciences (IIPS) and ICF. 2017. National Family Health Survey (NFHS-4), 2015-16: India. Mumbai: IIPS.

Local Burden of Disease WaSH Collaborator (2020). Mapping geographical inequalities in access to drinking water and sanitation facilities in low-income and middle-income countries, 2000–17. The Lancet Global Health, Volume 8, Issue 9, September 2020, Pages e1101.




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