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Review Paper
The elimination of open defecation and its adverse health
effects: a moral imperative for governments and
development professionals
Duncan Mara
ABSTRACT
In 2015 there were 965 million people in the world forced to practise open defecation (OD). The
adverse health effects of OD are many: acute effects include infectious intestinal diseases, including
diarrheal diseases which are exacerbated by poor water supplies, sanitation and hygiene; adverse
pregnancy outcomes; and life-threatening violence against women and girls. Chronic effects include
soil-transmitted helminthiases, increased anaemia, giardiasis, environmental enteropathy and small-
intestine bacterial overgrowth, and stunting and long-term impaired cognition. If OD elimination by
2030 is to be accelerated, then a clear understanding is needed of what prevents and what drives the
transition from OD to using a latrine. Sanitation marketing, behaviour change communication, and
‘enhanced’community-led total sanitation (‘CLTS þ’), supplemented by ‘nudging’, are the three most
likely joint strategies to enable communities, both rural and periurban, to become completely
OD-free and remain so. It will be a major Sanitation Challenge to achieve the elimination of OD by
2030, but helping the poorest currently plagued by OD and its serious adverse health effects should
be our principal task as we seek to achieve the sanitation target of the Sustainable Development
Goals –indeed it is a moral imperative for all governments and development professionals.
Duncan Mara
Emeritus Professor of Civil Engineering, Institute
for Public Health and Environmental
Engineering, School of Civil Engineering,
University of Leeds,
Leeds LS2 9JT,
UK
E-mail: d.d.mara@leeds.ac.uk
Key words |child health, diarrhea, environmental enteropathy, impaired cognition, open defecation,
stunting
INTRODUCTION
In 2015 965 million people had no sanitation facility and
were therefore forced to defecate in the open (WHO/
UNICEF )(Figure 1). The average proportion of ‘open
defecators’in developing countries is 16%, and in the
least-developed countries 20%. Table 1 lists those countries
with more than 15% open defecators and highlights those
with more than 50%. Most of these open defecators are
poor and live in rural areas –for example, in India, which
had a total of 564 million open defecators in 2015, 61% of
the rural population were open defecators vs only 10% of
the urban population (WHO/UNICEF ), and 95% of
the poorest quintile in rural areas were open defecators vs
only 2% of the richest quintile (Figure 2). However, in
low-income urban areas the number of open defecators
can also be very high: for example, in India Gupta et al.
()found that 35–47% of poor households in Delhi,
Indore, Meerut and Nagpur did not have any toilet facility.
Part of the sanitation target of the Sustainable Development
Goals is to eliminate open defecation (OD) by 2030 (United
Nations General Assembly ). If the same proportion of
‘open defecators’to the total without improved sanitation in
2015 (965 million to 2.4 billion, i.e. 42%) is assumed for 2030,
then 42% of the 2016–2030 population increase of 1.1 billion
(UNDESA ), plus the current number of open defecators,
1 Review Paper © IWA Publishing 2017 Journal of Water, Sanitation and Hygiene for Development |07.1 |2017
doi: 10.2166/washdev.2017.027
are required to move from OD to fixed-point defecation, prefer-
ably (in the new terminology of JMP b)to‘basic’sanitation
or ideally ‘safely-managed’sanitation, i.e. a total of nearly 1.4 bil-
lion people, or some 260,000 per day during 2016–2030.
In 1990, 31% of the then developing-country population of
4.1 billion were open defecators, and in 2015 16% of the then
developing-country population of 6 billion were open defeca-
tors, i.e. 1.29 billion and 965 million, respectively (WHO/
UNICEF ). Thus, during the whole of the 25-year period
1991–2015 there was a reduction in OD of 325 million
people, equivalent to only 36,000 per day; this was due in
part to the large population increase during this period.
In 2010, 19% of the then developing-country population
of 5.6 billion were open defecators (WHO/UNICEF ),
i.e. 1.069 billion people. Subtracting from this the 965
million open defecators in 2015 gives the number of
people removed from OD during the 5-year period 2011–
2015, i.e. 104 million, equivalent to 57,000 people per day.
This is better than that achieved during 1991–2015, but
it is still far short, by a factor of 4, of the requirement for
2030.
However, some countries have done very well in redu-
cing OD: for example, in rural Vietnam 43% of the
population practised OD in 1990, but by 2015 this had
been reduced to 1%; in Bangladesh the corresponding
figures were 40 and 2%; and in Mexico they were 51 and
4% (WHO/UNICEF ). Given that there are ‘no solutions
without political solutions’, the exceptionally good progress
in these and some other countries may have been due, at
least in part, to their politicians and senior civil servants
‘thinking clean’, i.e. deciding that OD was not ‘clean’and
that therefore something had to be done to reduce or elimin-
ate it, and then transposing this decision into action.
At the current rate of global progress, the target of no
OD by 2030 is unlikely to be realised. Thus to achieve the
SDG target of ‘No OD by 2030’requires a huge global
step-change in addressing and reducing to zero the preva-
lence of OD in developing countries. To do this, Ministry
of Health officials and development professionals need to
be fully aware of the major adverse health consequences
of OD, and how best to eliminate OD –in particular, what
mix of sanitation ‘hardware’, social-science ‘software’, and
financial support is appropriate.
Figure 1 |OD by a young boy in periurban India ( photograph courtesy of Professor
Barbara Evans, University of Leeds).
Table 1 |Countries with more than 15% and more than 50% of their populations practising OD in 2015 (WHO/UNICEF 2015)
Region Countries with >15% OD
a
and percentages of populations practising OD
b,c
Africa Angola (30%), Benin (53%), Burkina Faso (55%), Cabo Verde (24%), Central African Republic (22%),
Chad (64%), Côte d’Ivoire (26%), Djibouti (20%), Eritrea (77%), Ethiopia (29%), Ghana (15%), Guinea
(22%), Guinea-Bissau (17%), Lesotho (33%), Liberia (48%), Madagascar (40%), Mauritania (35%),
Mozambique (39%), Namibia (48%), Niger (73%), Nigeria (25%), São Tome e Principe (54%), Sierra Leone
(24%), South Sudan (74%), Togo (52%), Zimbabwe (28%)
Asia Pacific Cambodia (47%), India (44%), Indonesia (20%), Kiribati (36%), Laos (33%), Nepal (32%), Solomon Islands
(54%), Timor-Leste (26%)
Latin America &
Caribbean
Bolivia (17%), Haiti (19%)
a
The average 2015 OD rate for developing countries was 16%, and for the least developed countries 20%.
b
Some countries with high OD rates in 1990 reported in WHO/UNICEF (2015) have no reported OD rates for 2015 (and are thus excluded from this table).
c
Countries with >50% open defecators are shown in bold.
2D. Mara |The elimination of open defecation Journal of Water, Sanitation and Hygiene for Development |07.1 |2017
ADVERSE HEALTH EFFECTS OF OD
The adverse health effects of OD can be divided into acute
effects and chronic effects. Both cause a high burden of dis-
ease and a large number of premature deaths, especially in
children under five years of age. These adverse health effects
of OD occur because OD results in massive faecal contami-
nation of the local environment; consequently, open
defecators are repeatedly exposed to faecal bacteria and
faecal pathogens, and this is particularly serious for young
children whose immune systems and brains are not yet
fully developed.
Acute health effects of OD
The principal acute adverse health effect of OD is infectious
excreta-related intestinal disease, of which diarrheal dis-
eases (DD) are the most common. DD were the third
cause of death in children under five years of age (U5) in
2015 in low-income and lower-middle-income countries
(LICs and LMICs), resulting in 499,000 deaths (8.6% of all
U5-deaths), and a disability-adjusted life year (DALY) loss
of 45.1 million years (8.5% of total U5-DALY losses)
(IHME ). One of the commonly ascribed reasons for
high incidences of DD is a poor water supply, poor sani-
tation, and poor hygiene, especially poor hand-hygiene
(WHO ). The burden of U5-disease in LICs and
LMICs in 2015 due to no handwashing-with-soap was a
DALY loss of 26.4 million years (5.7% of total U5-DALY
losses); the corresponding figure for unsafe sanitation was
a DALY loss of 26.6 million years (5.7% of total U5-DALY
losses) (IHME ). The World is not good at handwashing:
Freeman et al. ()estimated that globally 81% of people
do not practise safe handwashing.
A further acute health effect of OD is adverse pregnancy
outcomes, such as increases in low birth weights, preterm
births, stillbirths, and spontaneous abortions (Padhi et al.
).
Finally, there is violence against women and girls, which
is often life-threatening. Violence against women and girls of
all ages in LICs and LMICs caused a DALY loss of 7.8
million years in 2015 (IHME ). Physical violence,
which may include murder, rape, stabbing and other
bodily harm, is a not uncommon experience for women
and girls as they journey to a place of OD, especially at
night (Gómez et al. ). Bhalla ()reported the occur-
rence of two ‘open-defecation murders’in rural India:
‘The two [girl] cousins, who were from a low-caste Dalit
community and aged 14 and 15, went missing from
their village home in Uttar Pradesh’s Budaun district
when they went out to go to the toilet [in a neighbouring
field]. The following morning, villagers found the bodies
of the two teenagers hanging from a mango tree in a
nearby orchard.’
It transpired that the two girls had been attacked and gang-
raped by five local men before they were hanged. Unfortu-
nately, such incidents are not at all uncommon: Gosling
et al. ()reported that many women in Bhopal and
Delhi, India, and Kampala, Uganda experienced violence
and harassment on a daily basis.
Such violence may often induce longer-term psychologi-
cal damage. To help counter such violence House et al.
()have prepared a practitioner’s toolkit on ‘Violence,
Gender and WASH’.
Chronic health effects of OD
There are five principal widespread chronic health effects
most probably due to OD: soil-transmitted helminthiases
(STHs), increased anaemia, giardiasis, environmental
enteropathy and small-intestine bacterial overgrowth
(SIBO), and stunting (low height-for-age) with accompany-
ing impaired cognition.
Figure 2 |Percentage of rural population in India practising OD, by wealth quintile (JMP
2015a).
3D. Mara |The elimination of open defecation Journal of Water, Sanitation and Hygiene for Development |07.1 |2017
Soil-transmitted helminthiases
The most common STHs are ascariasis (caused by the
human roundworm, Ascaris lumbricoides), trichuriasis
(caused by the human whipworm, Trichuris trichiura), and
human hookworm disease (caused by Ancylostoma duode-
nale and Necator americanus). Globally, an estimated 439
million people were infected with hookworm in 2010, 819
million with A. lumbricoides and 465 million with T. tri-
chiura (Pullan et al. ). The burdens of disease
associated with these STHs are high: in 2015 ascariasis in
LICs and LMICs caused an all-age both-sex DALY loss of
878,000 years, trichuriasis 340,000 years, and human hook-
worm disease 2.2 million years (IHME ).
Ascariasis, trichuriasis and hookworm disease cause
impaired cognition, notably in school-aged children
(Nokes et al. ;Partovi et al. ;Spears & Haddad
). The areas most affected are verbal fluency, short-
term memory, and speed of information processing, which
are precisely the areas most needed for people to be able
to contribute effectively to socio-economic development.
Infection with two or more of these helminths impairs cog-
nition to a greater extent than infection with only one
(Jardim-Botelho et al. ).
Trichuriasis is associated with ‘anaemia (see “Increased
anaemia”below), growth retardation (i.e. stunting –see
“Environmental enteropathy and SIBO”below) and intesti-
nal leakiness’(Cooper et al. ). In a study of 9,860
refugees in Texas, latent tuberculosis infection was found
to be positively associated in those refugees with hookworm
infection (Board & Suzuki ).
The World Health Organization has a global target to
eliminate morbidity due to STHs in preschool and school-
age children by 2020 (WHO ). This is to be achieved
by regularly treating (deworming at school) at least 75% of
the children in endemic areas –an estimated 873 million
children.
Increased anaemia
In adults, anaemia reduces productivity and is associated
with higher maternal mortality; in children, it impairs phys-
ical and cognitive development directly, and it also affects
human capital accumulation via impacts on behaviours
such as school attendance (Coffey & Geruso ). Iron-
deficiency anaemia caused an all-age both-sex DALY loss
in LICs and LMICs of 36.1 million years in 2015 (IHME
). In a study on anaemia in Nepal, Coffey & Geruso
()found that ‘poor local sanitation and, specifically,
OD cause lower hemoglobin and higher rates of anemia in
children’.
Giardiasis
The long-term post-infection consequences of giardiasis
include low height-for-age, low weight-for age, small mid-
upper-arm-circumference-for-age, low serum-levels of zinc
and iron, chronic and persistent diarrhea with consequent
malabsorption, irritable bowel syndrome deficiencies, and
impaired cognition (Halliez & Buret ).
Environmental enteropathy and SIBO
There has been considerable research on the association
between stunting (see ‘Stunting’below) and environmental
enteropathy (also called tropical enteropathy and environ-
mental enteric dysfunction). Environmental enteropathy is
a condition which results in the malabsorption of nutrients
in the small intestine and this leads to stunting; some or
many of the nutrients in a child’s foods are not absorbed
and so are unavailable for the child’s growth. The term
‘environmental enteropathy’was used by Fagundes-Neto
et al. ()to describe a common syndrome in which
there are non-specific histopathological and functional
changes of the small intestine in children of poor families
living in conditions lacking basic sanitary facilities and
chronically exposed to faecal contamination. They studied
112 children and found that carbohydrate load tests
revealed 49% lactose malabsorption, 30% sucrose malab-
sorption and 5% glucose malabsorption, and that small
bowel biopsy showed partial villous atrophy in 94% of the
samples studied.
More recent research has confirmed these findings.
Humphrey ()reported that a key cause of child under-
nutrition was environmental enteropathy, and that this
enteropathy is caused by faecal bacteria ingested in large
quantities by young children living in conditions of poor
sanitation and hygiene. She postulated that provision of
4D. Mara |The elimination of open defecation Journal of Water, Sanitation and Hygiene for Development |07.1 |2017
toilets and promotion of handwashing after faecal contact
could reduce or prevent environmental enteropathy and its
adverse effects on growth; and she noted that prevention
of this enteropathy, which afflicts almost all children in
the developing world, will be crucial to normalise child
growth, and that this will not be possible without the pro-
vision of toilets. Mbuya & Humphrey ()endorsed this
by stating that the unhygienic environments in which infants
and young children live and grow must contribute to, if not
be the overriding cause of, this environmental enteric dys-
function. They suggested that a household-level package of
‘baby-WASH’interventions (sanitation and water improve-
ment, handwashing with soap, ensuring a clean play and
infant-feeding environment, and food hygiene) that inter-
rupted specific pathways through which feco-oral
transmission occurs in the first two years of a child’s life
may be central to global stunting-reduction efforts.
Donowitz & Petri ()found that:
‘Small-intestine bacterial overgrowth (SIBO) occurs
when colonic quantities of commensal bacteria are pre-
sent in the small bowel. SIBO is associated with
conditions of disrupted gastrointestinal (GI) motility
leading to stasis of luminal contents. Recent data show
that SIBO is also found in children living in unsanitary
conditions who do not have access to clean water.
SIBO leads to impaired micronutrient absorption and
increased GI permeability, both of which may contribute
to growth stunting in children.’
Stunting
Target #2.2 of the Sustainable Development Goals includes
‘achieving, by 2025, the internationally agreed targets on
stunting and wasting in children under five years of age’
(United Nations General Assembly ). The ‘internation-
ally agreed target’for stunting is to reduce by 2025 the
number of stunted children under the age of 5 in 2010 by
40% (de Onis et al. ). Stunting is defined as a height
that is two or more standard deviations below the median
height for the child’s age and sex. (The World Health Organ-
ization publishes charts and tables for boys’and girls’
median heights-for-age and values of the appropriate stan-
dard deviations (WHO ). A ‘zscore’is used: for
example, a zscore of "2 means that a child’s height is two
standard deviations below the median height for that
child’s age and sex, and the child is therefore considered
stunted; for severe stunting the zscore is "3 or lower.) In
developing countries as a whole stunting is decreasing –
from 251 million children under five in 1990 to 156 million
children in 2014, except in Africa where it is increasing –
from 47 million children in 1990 to 58 million in 2014
(UNICEF ). Stunting affects poor children much more
than children from rich families: for example, in least devel-
oped countries, 49% of the poorest children are stunted vs
26% of the richest children; boys are more stunted than
girls (43 vs 38%), and children living in rural areas are
more stunted than those in urban areas (43 vs 32%)
(UNICEF ). In 2015 stunting caused a U5-DALY loss
in LICs and LMICs of 21.4 million years (IHME ).
Stunting is exacerbated by (a) the density of OD –the
number of people practising OD per km
2
(Spears ); (b)
environmental enteropathy and SIBO (see ‘Environmental
enteropathy and SIBO’above); and (c) DD and STHs (see
‘Soil-transmitted helminthiases’above) (Spears & Haddad
). In a 10-year study of 119 slum children in northeast
Brazil, Moore et al. ()found that children who had
had a high burden (∼9 episodes) of DD in their first two
years of life were on average 3.6 cm shorter at age seven
than other children, and those children who had also had
an early childhood helminthiasis were on average a further
4.6 cm shorter at the same age. In a study of children living
in a periurban shanty town in Lima, Peru, Berkman et al.
()found that:
‘During the first two years of life, 46 (32%) of 143 children
were stunted. Children with severe stunting in the second
year of life scored 10 points lower on the WISC-R [‘Wechs-
ler Intelligence Scales for Children –Revised’(Wechsler
)] test at age nine than children without severe stunting
[in their second year of life]. Children with more than one
episode of Giardia lamblia per year scored 4.1 points
lower than children with one episode or fewer per year.
Neither diarrhea prevalence nor Cryptosporidium
parvum infection was associated with WISC-R scores’.
Eppig et al. (), in their study on the prevalence of infec-
tious-disease agents and cognitive ability, postulated that the
5D. Mara |The elimination of open defecation Journal of Water, Sanitation and Hygiene for Development |07.1 |2017
bodies of young children face a competition for energy
(derived from their nutrient intake) between the develop-
ment and use of their brain and the development and use
of their immune system. Children repeatedly exposed to
infectious-disease agents are seriously disadvantaged:
‘[They] must activate [their] immune system to fight off
the infection, at energetic expense. Of these, diarrheal
diseases may impose the most serious cost on their
hosts’energy budget. First, diarrheal diseases are the
most common category of disease on every continent,
[…] Second, diarrhea can prevent the body from acces-
sing any nutrients at all. If exposed to diarrheal
diseases during their first five years, individuals may
experience lifelong detrimental effects to their brain
development, and thus intelligence’.
To this ‘brain’scenario can be added stunting: the more
nutrients children do not get through exposure to infec-
tious-disease agents or, in the reasoning of environmental
enteropathy given above, through continuous exposure to
faecal bacteria, the more they will be stunted.
The long-term consequences of childhood stunting include
adverse effects on cognitive development, school achievement,
economic productivity in adulthood, and maternal reproduc-
tive outcomes (Dewey & Begum ). Adverse ‘maternal
reproductive outcomes’include not only adverse neonatal
and infant outcomes, but also chronic diseases in adulthood
for the surviving children in their later life –for example,
increased cardiovascular disease, high blood pressure, respirat-
ory diseases, and Paget’s disease (Barker ).
Hoddinott et al. ()make the economic case for redu-
cing stunting. Using ‘credible estimates of benefit-cost ratios
(BCRs) for a plausible set of nutritional interventions to
reduce stunting’, they found that in 17 high-burden countries
these BCRs ranged from 3.6 (Democratic Republic of the
Congo) to 48 (Indonesia), with a median value of 18 (Bangla-
desh). Thus reducing stunting is a very good economic
proposition, and so investment in sanitation to reduce stunt-
ing is also a very good economic proposition (Augsburg
et al. ). The importance of this has been confirmed by
Danaei et al. (), who studied the risk factors for childhood
stunting at age two in 137 developing countries. They found
that 36% of two-year olds were stunted, and that unimproved
sanitation was the second highest risk factor for stunting, with
7.2 million attributable cases (out of a total of 44.1 million
cases –i.e. 16%); the highest risk factor was foetal growth
restriction (10.8 million attributable cases), and the third
highest was DD (5.8 million attributable cases).
In summary: (a) OD →violence against women and girls
as they walk to OD sites, including murder, rape, stabbing,
other serious bodily harm, and any resulting longer-term
psychological/psychosocial damage; and (b) high OD den-
sity →extreme faecal contamination of the local
environment →frequent ingestion of large numbers of faecal
bacteria and faecal pathogens, and frequent percutaneous
entry of hookworm larvae, by young children →high inci-
dence of infectious intestinal disease and helminthiases, and
mass development of SIBO and environmental enteropathy →
high levels of nutrient malabsorption and childhood stunting,
and all the cognitive and physical consequences thereof.
SOCIAL PREFERENCE FOR OD
Despite these associated adverse health outcomes, OD is
often a preferred practice, notably in rural India, where
61% of the population are open defecators (WHO/
UNICEF ), Coffey et al. ()found robust evidence
that supported a preference for OD, with many respondents
in their survey in rural India claiming that OD was more
pleasurable and desirable than latrine use. Devine & Kull-
mann ()found that in rural East Java, Indonesia, many
men considered OD ‘normal’, and that it had distinct
benefits such as social interaction and physical comfort
(especially in the case of defecation in a river). Tiwaril
()reported that in rural Uttar Pradesh, India, because
they were used to the ‘comfortable fields’, 90 families quietly
demolished the toilets inside their house that were built
under the Swachh Bharat Abhiyaan (see below), as they pre-
ferred to resume OD.
Figure 2 shows that even some of the two richest wealth
quintiles in India practise OD, presumably because they
prefer this to using a toilet (which they could easily afford).
Of course, in other countries where OD is common
(Table 1), a social preference for OD may not exist. People
in these countries may be practising OD because they
cannot afford a latrine (Augsburg et al. ), or because, if
6D. Mara |The elimination of open defecation Journal of Water, Sanitation and Hygiene for Development |07.1 |2017
they live in urban slums, there is no space available to con-
struct latrines.
SWACHH BHARAT ABHIYAAN –‘CLEAN INDIA
MISSION’
In his 2014 Independence Day speech, the Prime Minister of
India, Shri Narendra Modi, spoke about OD and the need
for toilets (Modi a):
‘Has it ever pained us that our mothers and sisters have
to defecate in open? Whether dignity of women is not
our collective responsibility? The poor womenfolk of
the village wait for the night; until darkness descends,
they can’t go out to defecate. What bodily torture they
must be feeling, how many diseases that act might engen-
der. Can’t we just make arrangements for toilets for the
dignity of our mothers and sisters?’
On 2 October 2014 Prime Minister Modi launched ‘Swachh
Bharat Abhiyaan’(SBA, ‘Clean India Mission’), one objective
of which is to end OD by 2 October 2019, the 150th anniver-
sary of Mahatma Gandhi’s birth (Modi b). This is clearly a
very ambitious five-year target, given that India has 565
million open defecators; this is the largest country-number
in the world (by over an order of magnitude) and represents
54% of all open defecators (WHO/UNICEF ).
SBA followed on from the Total Sanitation Campaign
(TSC) instituted in 1999. A review of TSC by WaterAid India
()found much variability in results from state to state,
especially in states where the approach was centralized,
rather than being decentralized to the community level.
Menon ()criticized SBA for this reason, stating that sub-
sidy-driven Swachh Bharat was a failed, old idea, and that a
community-driven approach was needed to stop OD. This is
in agreement with WaterAid India ’s()finding that commu-
nity-led total sanitation (CLTS) could be one ofthe approaches
explored for faster and more sustainable results on the ground.
THE CLTS APPROACH TO ENDING OD
IDS ()describes CLTS as:
‘An innovative methodology for mobilising communities
to completely eliminate open defecation (OD). Commu-
nities are facilitated to conduct their own appraisal and
analysis of open defecation and take their own action
to become open-defecation free (ODF).’
In Bangladesh, the success in reducing rural OD from 40% in
1990 to 2% in 2015 (WHO/UNICEF ), and to <1% in
2016 (Ministry of Local Government Rural Development
and Co-operatives ), has long been ascribed to properly-
designed and well-executed CLTS (Sanan & Moulik ).
Further information on CLTS and the elimination of OD
is given by Kar & Chambers ()and Bongartz et al.
(). Importantly, CLTS does not prescribe the adoption
of any one particular sanitation technology; thus all appro-
priate sanitation options should be considered with the
beneficiary communities, recognising that the available tech-
nical options are likely to be different in urban and rural
areas. WSP/MDWS ()details some of the best practices
in rural sanitation in India.
ACCELERATING THE ELIMINATION OF OD
If progress towards OD elimination is to be accelerated,
then a clear understanding of what prevents and what
drives the transition from OD to using a latrine is necessary.
Augsburg et al. ()found that cost was the principal con-
sideration that militated against latrine adoption in both
India and Nigeria; this indicates that subsidies and access
to credit (e.g. subsidized microfinance loans) are clearly
important (see, for example, Evans et al. ;Newman
et al. ).
Augsburg & Rodríguez-Lesmes (), working in low-
income urban areas and slums and rural areas in India,
found that there was a strong correlation of toilet ownership
with perceived health, with households that owned a toilet
believing themselves and their family to be healthier than
their peers who did not –thus suggesting that, contrary to
often held views, health considerations play at least some
role in the decision to acquire sanitation.
Village-wide and slum-wide elimination of OD depends
for its success on: (1) the selection and community-wide
installation, both with the participation of the beneficiary
7D. Mara |The elimination of open defecation Journal of Water, Sanitation and Hygiene for Development |07.1 |2017
community, of a locally-suitable sanitation technology,
which the local community understands and agrees to use
sustainably; and (2) the selection, installation (again with
community participation) and correct use of a locally appro-
priate handwashing-with-soap facility.
It is very important that the whole community becomes
‘open defecation free’(ODF). Andrés et al. (), in a study
involving 209,762 children under the age of four in rural
India, which investigated the potential benefits, in terms of
a reduction in diarrhea, to children living in households
with ‘improved’sanitation facilities, found that there was
no improvement at all until 30% coverage was achieved
(i.e. 30% of all households in the village community
having their own improved sanitation facility), and that
half of the potential benefits were only reached when cover-
age was approximately 75%. Vyas et al. ()found a
similar relationship between stunting and ODF status in
rural Cambodia: children living in completely ODF villages
had z-scores above "1.5 during the whole of their first five
years of life, whereas those living in villages where everyone
practised OD had z-scores below "2 from age 20 months
onwards; those children living in villages where some
people practised OD had z-scores close to "2 from age
two onwards. Such externalities (external, that is, to each
individual household) reflect the relative importance of
faeco-oral disease transmission in the ‘public’and ‘private’
domains, as discussed by Cairncross et al. (). In order
to interrupt transmission, interventions are needed in both
the private domain (individual household-level improved
sanitation) and in the public domain (all of one’s co-villagers
having their own improved sanitation facility). CLTS seeks
to establish a social norm for eliminating OD in the whole
community such that it, as a unit, realises all the disadvan-
tages of OD (especially those for women and girls), so that
every household in the community has and uses a safely-
managed latrine.
Sanitation marketing and behaviour change
communication
WSP ()defines sanitation marketing (SM) as:
‘An emerging field that applies social and commercial
marketing approaches to scale up the supply and
demand for improved sanitation facilities. While forma-
tive research is the foundation of any sanitation
marketing program, essential to understanding what pro-
ducts the target population desires and what price they’re
willing to pay for them, components such as the market-
ing mix, communications campaign, and implementation
are also critical to the design and implementation of
effective program.’
Devine & Kullmann ()recommend CLTS and behaviour
change communication (BCC) as useful adjuncts to SM
because, while CLTS focuses on changing community prac-
tices, BCC focuses on changing individual or household
behaviours. Thus BCC can be used to sustain and sup-
plement CLTS in motivating individuals to become open-
defecation-free and sustain this behaviour over time. Perez
()reported on research carried out in Bangladesh
which examined the long-term sustainability of sanitation
behaviours and facilities in areas that were declared ODF;
one of the main findings was that the BCC campaign
directed at households to stop practising OD was very perva-
sive: campaign messages were communicated through
various channels and settings, including messaging by mem-
bers and officers of the local Union Parishad (the smallest
rural administrative unit) at meetings, rallies, over loudspea-
ker announcements, and through household visits by Union
Parishad members or NGO workers.
ODFþand CLTS þ
There is currently a move, at least in thinking, from ODF to
‘ODF þ’–that is, to develop sound models to ensure that,
once ODF status has been achieved, it is sustained for all
time, and how CLTS might be modified (and perhaps
described as ‘CLTS þ’) to encourage this to happen, includ-
ing such topics as locally correct latrine selection, latrine
financing and possible subsidies, sufficient water supplies
for personal and domestic hygiene (handwashing with
soap, and cleansing used cooking and eating utensils), and
household- and community-level operation and mainten-
ance (Bongartz et al. ). ‘Nudging theory’has been
recommended as a means to change OD practice to
ODFþ(Neal et al. )–‘nudges’are small changes to
the mental environment that can channel decision-making
8D. Mara |The elimination of open defecation Journal of Water, Sanitation and Hygiene for Development |07.1 |2017
and behaviour in new ways. Nudging is based on scientific
findings from psychology, cognitive science and behavioural
economics, on which Neal et al. ()proposed a frame-
work of eight principles to support the initiation and
maintenance of OD behaviour change: (1) ensure critical
sanitation products and infrastructure are immediately and
consistently physically available for the users; (2) create or
capitalize on context change to drive new behaviour of
toilet use; (3) piggyback on other existing behaviours and
cues (e.g. washing clothes, water gathering); (4) strategically
increase friction for the undesired behaviour (OD) and
lessen it for the desired one (sustained toilet use); (5) support
context-stable repetition for latrine use; (6) embed ritualized
elements in the change process (e.g. integrate OD messaging
into already ritualized cultural practices); (7) leverage point-
of-action reminders and cues (e.g. use of coloured agents to
clean latrine slabs); and (8) highlight descriptive and loca-
lized norms that reduce cognitive demands (e.g. develop
systems to address the whole community or a women’s
group, rather than individual households).
CLTS þ, supplemented with ‘nudging’, would enable
rural households to move directly from OD to ‘safely-mana-
ged’on-site sanitation and hygiene –which is the SDG
target (JMP b). The technologies for safely-managed
on-site sanitation are well established –for example, arbor-
loos (which are especially suitable in low-density rural
areas; fruit or medicinal trees are planted in the shallow
pits when full to provide food and income) (Morgan ),
single-pit VIP latrines, urine-diverting eThekwini latrines
(which, because they are wholly above-ground, are suitable
in areas subject to flooding or with high groundwater
tables and where pit emptying is difficult or not well prac-
tised) (WIN-SA ), and single-pit or alternating twin-pit
pour-flush latrines.
In low-income urban areas it is more difficult to move to
safely-managed sanitation as faecal-sludge management is
more complex and more expensive than in rural areas. How-
ever, safely-managed sanitation can be readily achieved with
off-site systems such as condominial sewerage (Melo ,
); household financial costs for this sanitation system
are low –for example, in the state of Rio Grande do Norte
in Brazil (where the system was developed in the early
1980s) the monthly charge is only BRL 2.18 (GBP 0.50,
USD 0.63) per household per month (CAERN ). In
urban slums, which are home to some 881 million people
(30% of the urban population in developing countries, up
to 56% in Sub-Saharan Africa) (UN-Habitat ), house-
hold-level sanitation is infeasible due to space constraints.
Safely-managed shared sanitation is, however, a feasible
and tested sanitation option to replace OD in low-income
high-density urban areas (Burra et al. ;Mara ).
In addition, there is a need in CLTSþfor local
businesses and tradesmen to be trained in latrine selection,
construction, and financing, and also, where appropriate,
the provision of locally-produced and locally-suitable pour-
flush squat-pans or pedestal-seat units (Sy et al. ), hard-
ware for urine-diverting eThekwini latrines, pipework and
accessories for condominial sewerage, and also facilities
for handwashing with soap (Jenkins et al. ).
CONCLUDING REMARKS
1. This paper has sought to review and collate key evidence
on OD, especially the numbers of people practising OD,
the health effects of OD, and how best OD might be
eliminated.
2. The adverse health consequences of OD are so extreme
that, if ODFþstatus in not reached in rural villages, small
towns and low-income periurban areas, including slums,
there will be more ‘lost generations’of physically-impaired
and cognitively-challenged children and adults. All Minis-
try of Health officials and development professionals
need to be aware of the physical and mental outcomes of
OD in young children, some of which are irreversible.
3. The elimination of OD is primarily a complex sociocul-
tural and sociopolitical task. It is not a major technical
or financial challenge as CLTS, with its option to con-
sider all types of sanitation and handwashing facilities,
does not require the development of new technologies
specifically for OD elimination as several existing tech-
nologies are already fit-for-purpose; nor does it always
necessitate the provision of subsidies. The further devel-
opment and rigorous field-testing of ‘CLTS þ’is needed
to ensure that there is no reversion to OD in communities
which have become OD-free.
4. SM and BCC are very valuable techniques and should be
applied as the first steps in CLTS/CLTSþ–i.e. these
9D. Mara |The elimination of open defecation Journal of Water, Sanitation and Hygiene for Development |07.1 |2017
three techniques should be used in sequence for best
results.
5. It will be a major sanitation challenge to achieve the elim-
ination of OD by 2030, but it is a challenge that
governments and development professionals should
stand up to and embrace. Helping the poorest plagued
by OD should be our principal task as we all seek to
achieve the sanitation target of the Sustainable Develop-
ment Goals –indeed it is our moral imperative.
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