India’s National Sanitation Policies: Evolution,Impact and Recommendations

Abstract

India has launched five national sanitation policies since independence, and among these, the Swachh Bharath Mission-Grameen is the world’s largest sanitation campaign. Despite this achievement, the literature on understanding the evolution and impact of these policies is scarce. We are one of the earliest studies to address this literature gap. We find that as the campaign progressed, the programmes gained rigour in constructing toilets and in terms of behavioural change to induce people to use these toilets. However, despite the government’s claim of India being declared an open defecation–free (ODF) nation at the end of SBM, other government of India data sources claim otherwise. Hence, tracing the evolution and impact of national sanitation policies gives us valuable lessons to make India ODF in the future: (a) efforts to implement context-specific behaviour change campaigns can bring a sustained change in the social attitudes of people regarding sanitation, (b) optimising toilet infrastructure and aligning its pace of construction, (c) allocating budget for upkeep of already-built toilets under government programmes will reduce and even eliminate reversion to open defecation and (d) moving the sanitation outcomes from access to adoption will present an actual state of the sanitation environment in India. This article is one of the earliest in exploring rural sanitation in India from a policy history perspective, considering how sanitation practices and trends changed every time there was a change in the rural sanitation policy.

Keywords

Sanitation policies evolution India Swachh Bharath Mission Total Sanitation Campaign Central Rural Sanitation Programme Nirmal Bharat Abhiyan

Introduction

Eliminating open defecation (OD) is a public sector priority in India. To achieve this goal, India launched its first national sanitation policy [Central Rural Sanitation Programme (CRSP)] in 1986, with Swachh Bharath Mission-Grameen (SBM-G) being inaugurated in 2014. SBM-G is considered to be the world’s largest toilet construction and behaviour change mission. Despite the scale of the policies launched, the literature on the comprehensive assessment of the development and impact of these policies remains scarce. In this context, this article studies the evolution of India’s sanitation policies and their effectiveness in terms of sanitation outcomes such as access to and adoption of toilets. The lessons learned from this analysis are critical to providing recommendations that can be useful in designing future sanitation policies.

Sanitation has been a priority in India since ancient times (Dutta, 2017). This was substantiated by the discovery of remnants of toilets found in the sites of the Indus Valley. However, sanitation ceased being a priority during colonial times due to a general disinterest in managing rural water and sanitation issues (Dutta, 2017; Jangra et al., 2016). In 1947, the Indian population of 300 million people had less than 1 per cent sanitation coverage. These statistics remained stagnant for a considerable time, as the 1981 census reported that rural sanitation coverage in India was only 1 per cent, while urban sanitation coverage was 27 per cent (Government of India, 2014). Sanitation coverage is defined as the proportion of households owning a toilet in the community.

To combat this challenge, the Government of India (GOI) launched the first sanitation programme, the CRSP, in 1986 to improve the quality of life in rural areas and provide dignity and privacy to women. Financial subsidies were provided to the below poverty line (BPL) households to construct individual household latrines (IHHL). Research informs us that CRSP, although a significant step for India’s sanitation landscape, was marred due to the slow construction of toilets and the exclusion of any component that was focused on transforming the sanitation behaviour of people (Alexander et al., 2016). Hence, it was decided that to provide sanitation for all, inculcation of some form of behaviour change communication (BCC)—which will change people’s attitude towards OD—should become a part of the following sanitation policy.

In 1999, CRSP was restructured as a demand-driven, community-led and people-centric programme called the Total Sanitation Campaign (TSC). Besides continuing financial subsidies to BPL households, TSC emphasised information, education and communication (IEC) activities. Nirmal Gram Puraskar (NGP) (translated as clean village prize) was also introduced to recognise the achievements of the Gram Panchayats (GPs) (translated as village council) in attaining universal sanitation coverage and complete elimination of OD. Despite the restructuring, TSC was also found to be ‘infrastructure-led’ and lacking a thorough implementation of IEC activities (Hueso & Bell, 2013).

The TSC was succeeded by Nirmal Bharat Abhiyan (NBA) in 2012 and shared the common objectives of the previous two programmes. Within 18 months, the prime minister of India launched the SBM-G on October 2, 2014, to accelerate the efforts to achieve universal sanitation coverage by 2 October 2019. The programme has achieved the construction of 10 crore or 100 million toilets, higher than in any previous sanitation programme. Still, the independent, nationally representative first phase of the National Family Health Survey (NFHS-5) 2019–2020 data found that only 77 per cent of households were using an improved source of sanitation. SBM-G has also been criticised for not emphasising BCC and using coercive tactics to construct the toilet (Gupta et al., 2019).

To our knowledge, ours is one of the earliest articles to detail the evolution of the sanitation policy in India and discuss the evidence regarding its effectiveness on sanitation coverage and adoption. A nuanced understanding of the lessons learned from the research on each of these policies will be helpful for future policymakers and programme implementers of sanitation campaigns in India. The conclusion from every round of policy has taught us that OD is enduringly prevalent in India. Why is that so? Empirical research has shown that there is a revealed preference for OD in rural India; that is, people will prefer OD even in the presence of toilets (Coffey et al., 2014). This can be attributed to multiple factors: low awareness of the health benefits (adverse impact) of using toilets (practicing OD), a misplaced conception that toilets will impose a huge cost and are unaffordable and a similar erroneous notion that emptying the pits of toilets will be expensive (Coffey et al., 2014). Using a toilet also requires at least 10 litres of water for flushing, and since the rural households in India use pit (not pour-flush) latrines, it imposes an additional burden on the members to fill and carry water.¹ As opposed to this, OD only requires a mug of water for anal cleansing, and hence, it is perceived to be a healthier, more sustainable alternative to toilets (Routray, 2017).

We now ask an important question: What policy lessons can be learned from research on the previous sanitation programmes? Our analysis suggests that future undertakings of SBM-G should refrain from deploying coercive tactics to build toilets and instead emphasise the dissemination of BCC messages that inform people not only about the ills of OD but also about the multitudes of benefits of sustainable use of toilets (Gupta et al., 2019). Future sanitation policies, unlike SBM-G, should not just provide subsidies for twin-pit toilets but also understand the regional heterogeneity. For instance, the latest sanitation technologies that utilise less water, like EcoSan toilets, should be harnessed for water-scarce regions (Exum et al., 2020; Moudgil, 2019).² International experience from Bangladesh, India’s neighbouring country, which has successfully eliminated OD, teaches us that women can be the drivers of sanitation change. Their participation and leadership during community-led BCC will accelerate the pace of using toilets (Ahmad, 2019; Montu, 2016).

The following section details the evolution of India’s sanitation policies and discusses their impact on sanitation outcomes. It also outlines the lessons learned from each policy and how the following policy improved upon those shortcomings. The third section enlists the policy recommendation from the analysis and discusses the limitations of the article. Finally, the fourth section concludes the article.

Evolution and Effectiveness of Sanitation Policies in India

India has had five national sanitation policies since 1986 (see Figure 1). We explore the details and discuss the research that has studied the impact on outcomes such as sanitation coverage and adoption. We also elucidate the lessons learned from each of these policies.

Figure 1.

Timeline of the National Sanitation Policies in India.

Central Rural Sanitation Programme (1986–1999)

The GOI launched the first national sanitation campaign, the CRSP, in 1986. The objective of the programme was to ‘improve the quality of life of the rural people and also to provide privacy and dignity to women’ (Government of India, 2007). Further, the programme was projected to increase rural sanitation by 25 per cent (Mohapatra, 2019). The programme was also the first to provide financial assistance to BPL households to promote the construction of toilets. Table 1 depicts the guidelines launched by the GOI to divide the cost of construction of toilets under CRSP (Government of India, 2007).

Table 1.

Cost for Construction of Toilets.

Basic Low-cost Unit Cost	Contribution Percentage
	GOI		State		Household
	BPL	APL	BPL	APL	BPL	APL
Model 1: Up to ₹1,500 (including superstructure)	60	Nil	20	Nil	20	100
Model 2: Between ₹1,500 and ₹2,000	30	Nil	30	Nil	40	100
Above ₹2,000	Nil	Nil	Nil	Nil	100	100

Besides the construction of IHHLs, the programme allocated ₹2 lakhs, or ₹0.2 million, for the construction of community sanitary complexes. The construction of these complexes will subsume adequate toilet seats for the community members, cubicles for bathing, washbasins, etc. and will be located in an area that is convenient and acceptable to the village members. Further, the programme acknowledged the role of children in bringing about sustained change as they are more willing to learn and pass on the education to their families. The programme aimed to build gender-segregated toilets in all types of government schools.

The Planning Commission estimates that between 1986 and 1997, CRSP led to the construction of more than 4 million toilets (Datta, 2017). This translated to an increase in IHHL in rural areas from around 3 per cent in 1986 to 17 per cent in 1999, or around a 1 per cent increase annually (Government of India, 2008) (see Figure 2). This was 8 percentage points lower than the targeted 25 per cent increase in rural sanitation. Hence, the programme was criticised for its sluggish construction. Not only was the construction slow and below the target, but the rate of adoption was also abysmally low. The limited success of CRSP has been attributed to the lack of community participation, the complete absence of a behavioural approach to enhancing the adoption of toilets and poor construction standards (Mauro, 2015; Routray, 2017; The World Bank, 2010).

Figure 2.

Sources: Ministry of Drinking Water and Sanitation (MoDWS) and Census of India (The World Bank, 2010).

The programme was instrumental in providing key lessons for the future development of sanitation policies. It was learned that the construction of toilets did not lead to a concomitant increase in their adoption. Elimination of OD necessitated an emphasis on behaviour change communication (BCC), as OD was deeply ingrained in rural India. Considering all the lessons, the government replaced CRSP with TSC in 1999.

Total Sanitation Campaign (1999–2011)

The main objective of the TSC was to improve the general quality of life and provide universal sanitation coverage in rural areas by 2012 (Government of India, 2010a). This programme was renewed to make sanitation interventions community-led, people-centred, incentive-based and demand-driven (Hueso & Bell, 2013). A major part of the programme was a clearly defined focus on IEC activities. The role of the IEC was to generate demand for sanitation through a one-time community-led BCC session with all the members of the community. To ensure adequate implementation of the IEC activities, 15 per cent of the programme’s total budget was reserved for this purpose (Government of India, 2010a).

Similar to CRSP, BPL households were given subsidies for the construction of IHHLs. A model of cost-sharing for a toilet costing ₹2,500 was mentioned in the guidelines. If the beneficiary contributed ₹300, ₹1,500 and ₹700 were given from the central and state budgets, respectively. It is important to note that while IEC was to be disseminated among all the members of the community, the subsidies were offered to only the BPL households. Above poverty line (APL) households were expected to be sufficiently motivated after the IEC session to undertake the construction themselves. From CRSP, TSC also retained the construction of community sanitary complexes.

To celebrate the achievements gained through TSC, the GOI launched the NGP in 2003 (Government of India, 2010b). NGP was a monetary award to be given to the ODF village committees or GPs. The award was designed to bring sanitation issues in rural areas to the forefront of discussion and to recognise the efforts of regions that have achieved freedom from OD. These communities were envisioned to be highlighted and to serve as role models for other communities.

GOI’s Ministry of Drinking Water and Sanitation (MoDWS), led by TSC, touted it as a successful sanitation strategy. Their official statistics reported that rural sanitation increased from 22 per cent in 2001 to 65 per cent in 2010 (The World Bank, 2010) (see Figure 2). However, the GOI’s census data indicated that there was a modest rise in rural sanitation coverage from 22 per cent in 2001 to 31 per cent in 2011 (Government of India, 2011). The inconsistency between the two GOI data sources can be explained as MoDWS overestimated the toilets built under TSC. It is important to note that the 2011 census data indicates that progress under TSC was less than 1 per cent per annum, even lower than the 1 per cent increase per annum in rural sanitation coverage under CRSP. The rise in toilet usage was found to be even lower (Barnard et al., 2013; Coffey et al., 2014).

After the implementation of TSC, several independent studies have evaluated its impact on toilet coverage and use. In Table 2, we summarise the five studies that have used rigorous research designs and econometric methods [e.g., randomised control trials (RCT)] to assess the impact of TSC. Table 3 presents the results from four qualitative studies that have investigated the effects of TSC. Both quantitative and qualitative studies on TSC jointly conclude that (a) the increase in coverage under TSC was less than universal, (b) the toilets constructed were found to be lacking important structural components that inhibited their adoption, (c) personnel in charge of IEC activities also lacked the training to conduct the behavioral change activities and hence failed to motivate people and (d) the decline in OD was lower than the increase in toilets, as both technological and behavioural barriers impeded commensurate adoption.

Table 2.

Summary of Quantitative Studies Assessing the Impact of Total Sanitation Campaign (TSC).

Study Reference	State and District	Intervention	Study Design	Follow-up Period	Sanitation Coverage		Net Change in Coverage	Sanitation Use		Net Change in Usage
Study Reference	State and District	Intervention	Study Design	Follow-up Period	Treatment (T, %)	Control (C, %)	T − C (%)	Treatment (T)	Control (C)	T − C (%)
Pattanayak et al. (2009)	Bhadrak district, Orissa	TSC+ intensified IEC	CRCT	1 year	32	13	29	nr	nr	nr
Clasen et al. (2014)	Puri district, Orissa	TSC	CRCT	3 years	63	12	51	36	9	27
Patil et al. (2014)	Ten districts in Madhya Pradesh	TSC	CRCT	21 months	41	22	19	27	16	9
Hammer and Spears (2016)	Ahmednagar district in Maharashtra	TSC	CRCT	18 months	nr	nr	8	nr	nr	nr
Arnold et al. (2010)	Near the city of Tiruchirappalli, Tamil Nadu	TSC-like	Before-and-after	5 years	48	15	33	23	12	11

nr: not reported

Table 3.

Summary of Qualitative Studies Assessing the Impact of the Total Sanitation Campaign (TSC).

Study Reference	Context	Findings
Barnard et al. (2013)	20 villages in the Puri district of Orissa	The programme managed a substantial gain in coverage (about 72% in treatment villages), yet about 40% were not used by any household member. Over one-third of the household members who owned toilets reported never using them for defecation, and only slightly less than half of the households reported using them at all times for defecation. Upon further investigation of the reasons for the toilets’ abandonment, the authors found a preference for OD and poor-quality toilets. About 47% of the constructed toilets met the bare minimum criteria of functionality, i.e., the presence of a door, four walls and a roof to ensure privacy. The remaining toilets were either broken or missing certain parts, making them unfit.
Hueso and Bell (2013)	Villages in Haryana, Himachal Pradesh, Madhya Pradesh and Uttar Pradesh	Implementation of the TSC in the field was government-led, subsidy-based, infrastructure-centred and supply-led, as opposed to the established objective of the TSC being a community-led, incentive-based, people-centred and demand-driven programme. The officials managing the project were often overworked and lacked motivation for achieving universal sanitation. It was also found that the staff lacked proper training to conduct IEC with the communities. This impeded demand generation for sanitation. Despite the clarity in the TSC guidelines that funds should be disbursed to the households only after construction and adoption, it was found that payment was made upfront to the households.
Coffey et al. (2014)	13 districts of five northern states of India (Bihar, Haryana, Madhya Pradesh, Rajasthan and Uttar Pradesh)	More than 60% of the households that received toilet construction materials from the government had at least one member practicing OD between 2012 and 2013. Household members who built toilets entirely with government subsidies were twice as likely to practice OD as households that built self-financed toilets. Finally, 47% of the people surveyed reported a preference for OD even in the presence of toilets, leading the authors to conclude that including BCC activities in any sanitation intervention is crucial to changing people’s preferences and leading to sustained adoption of toilets. The authors explained how the programme implementation and construction of toilets happened without taking into account people’s preferences (such as ignoring preference for OD and desire for a large pit size). If it were to continue doing so, then the toilets would continue to remain unused.
Routray et al. (2015)	Ten villages in Puri district of Odisha between July 2011 and September 2012	TSC had been implemented in these villages 3–5 years before the commencement of this study. The authors found that most government-constructed toilets were unfinished, as they lacked an essential structure (door, roof and walls) to maintain privacy and a nearby water source. Respondents complained that the pit size of the government toilets was too small. Further, self-financed toilets were found to have complete structures and higher adoption rates compared to government-subsidised toilets. However, the poor quality of toilets built under TSC was not the sole reason for continued OD. People also stated their preference for OD, suggesting the need to develop programmes that overcome behavioural constraints to adoption.

Nirmal Bharat Abhiyan (2012–2014)

TSC was renamed Nirmal Bharat Abhiyan (NBA) in 2012 to increase sanitation coverage in rural areas (Government of India, 2012). Similar to TSC, the programme was structured as community-led and people-centred. Demand generation for toilets through rigorous implementation of the IEC activities was retained as the cornerstone of the programme. This sanitation programme was the first to extend financial support for the construction of IHHLs to APL households, a drastic shift from the previous policies that included only BPL households. However, the subsidies provided to the APL households were restricted to only ‘SCs/STs, small and marginal farmers, landless laborers with homestead, physically handicapped and women-headed households’ (Government of India, 2012). NBA increased the cost of the model toilet from ₹2,500 (in TSC) to ₹5,500. Central and state governments would contribute ₹3,200 and ₹1,400, respectively. The household would contribute the remaining in cash or labour.

Table 4 lists findings from the study that measured the impact of NBA in 10 villages in Odisha. The study found that, much like TSC, there was an inconsistent implementation of IEC activities. The study also went beyond the behavioural and technological barriers and brought forth another dimension, that is, complex caste politics, that further inhibited the adoption of toilets. Like its predecessors, the NBA’s success was limited to the construction of toilets. 18 months after the launch of this programme, NBA was restructured and launched as SBM-G.

Table 4.

Summary of a Qualitative Study Assessing the Impact of Nirmal Bharath Abhiyan (NBA).

Study Reference	Context	Findings
Routray (2017)	Ten randomly selected villages (of the 50 project villages) in one district of Odisha	NBA was implemented one year before the study, and the results revealed an inconsistent implementation of the programme, a lack of adequate training of the IEC facilitation team and a lack of clarity on the role of government and NGOs in the entire process. The caste and social divide dictated the campaign’s effectiveness, as male upper-class members often dominated the sanitation meetings, excluding lower-caste members and women from the process. The implementers estimated an increase in sanitation coverage from 7 percentage points in the baseline to 19 percentage points across the 50 villages one year after the NBA.

Swachh Bharat Mission Grameen (2014–2019)

SBM-G (translated as Clean Indian Mission (Rural)) was launched on 2 October 2014, to improve the general quality of rural life by eliminating OD in India by 2 October 2019 (Government of India, 2014). In line with the TSC and NBA, SBM-G also focuses heavily on community-led BCC to generate awareness about the adverse impact of OD and bring about demand for toilets.

Financial incentives for the construction of toilets were provided to BPL and certain APL households (as mentioned under NBA). It was expected that the APL households not covered under the scheme would be sufficiently motivated to build one using their finances once IEC activities were conducted in their communities. The incentive or grant-in-aid for IHHLs was earmarked at ₹12,000, where the contribution of the central and state governments would be 3:1, respectively. The households were not expected to contribute any portion of the cost.

The SBM-G statistics suggest that while the sanitation coverage was achieved slowly during CRSP and TSC, it eventually gained momentum during SBM-G as India was declared an ODF nation based on these statistics. SBM-G statistics inform us that sanitation coverage increased from 39 per cent in October 2014 to 100 per cent in 2019 (see Figure 3). Over 10 crore or 100 million crore toilets were built during SBM-G, and all villages across the districts of India were declared ODF. However, the recently released first phase of another GOI dataset, NFHS-5, questions the validity of these statistics (see Figure 4). Besides Kerala and Lakshadweep, no state is close to achieving the ODF status.

Figure 3.

Source: https://swachhbharatmission.gov.in/SBM-Gcms/index.htm.

Figure 4.

Difference in the Percentage of Households Using Improved Sanitation as Reported Under NFHS-5 and the ODF Status.

Independent studies have also raised similar doubts about the SBM-G data. We report the results from these studies in Table 5, which jointly conclude that the increase in toilet coverage is far from universal, and adoption is even lower than the toilets built. While this finding aligns with the previous sanitation programmes, SBM-G was noted for using coercive tactics on the ground to speed up the construction process. These included discontinuing government benefits (such as access to subsidised food rations, etc.), with a disproportionate burden falling on marginalised communities (Gupta et al., 2019). So, while the previous policies have taught us key lessons on the importance of using rigorous BCC and the construction of quality sanitation facilities, SBM-G takes us a step further and introduces us to refraining from using such tactics (Cullet, 2018; Gupta et al., 2019). These results also highlight the need for more independent studies to evaluate the effectiveness of SBM-G, as the official statistics appear to be incongruent with the work of independent researchers.

Table 5.

Summary of Studies Assessing the Impact of the Swachh Bharath Mission (SBM-G).

Study Reference	Context	Findings
Gupta et al. (2019)	13 districts of five northern states of India (Bihar, Haryana, Madhya Pradesh, Rajasthan and Uttar Pradesh)	In a follow-up study to Coffey et al. (2014), Gupta et al. (2019) re-surveyed the same households in 13 districts in five northern states in India. The authors report that between 2014 and 2018, i.e., the duration of the SBM-G, the percentage of people who owned a toilet and still practiced OD remained unchanged, at 23%. Additionally, the households that received the money to build their toilet were 10% less likely to practice OD than those that owned a GOI-constructed toilet. Finally, over 50% of the households complained of coercive tactics being employed to achieve construction and adoption. The authors insist on ending the intimidation tactics to achieve sustained adoption. They conclude that SBM-G could not address social attitudes towards OD and suggest a rigorous focus on BCC activities for future sanitation campaigns.
Andres et al. (2020)	200 Gram Panchayats (GPs) in rural PunjabThe study was conducted from 2015 to 2021	Multi-arm RCT: The first experimental arm had the regular implementation of SBM-G in GPs, the second arm included SBM-G in schools and regular SBM-G in GPs, and the third arm included an intense follow-up campaign besides regular SBM-G. The authors report an increase of 6.8–10.4 percentage points in toilet coverage across different arms relative to the control group (households that did not receive any intervention). The decline in OD was noted at 7.3–7.8 percentage points. There was a limited impact on the use of soap for handwashing and other hygiene practices.
Exum et al. (2020)	Around 20,000 households in Rajasthan	Another study attempted to investigate the claim of the open defecation–free (ODF) status of Rajasthan by the GOI by assessing the OD trends from 2016 to 2018. The study used four rounds of repeated cross-section data on household water and sanitation. OD declined from 63% to 46% in rural households and from 13% to 9% in urban households. Hence, Rajasthan is far from achieving ODF status. The study’s insights suggest that water-stressed households practiced more OD than those with lower water stress. The unavailability of water was the key reason for the persistence of OD in the region. It is important to note that Rajasthan is a water-scare state, and the twin-pit model suggested for construction under SBM-G ignores the water required for its functioning and maintenance.
Dandabathula et al. (2019)	Acute diarrheal disease (ADD) outbreaks for 9 years (2010–2018) retrieved from the Integrated Disease Surveillance Programme (IDSP), the Government of India’s weekly outbreaks database	This study investigates the trend of ADD outbreaks occurring over 9 years and correlates with SBM’s objective. 2017 and 2018 recorded the lowest number of total ADD outbreaks. In 2018, certain environmental corrections seemed to have happened, as these four months of monsoon- May, June, July, and August recorded a lesser number of outbreaks in comparison to previous years. The authors attribute this to toilet construction under SBM-G and the mass-level behaviour change movement.
Singh et al. (2021)	Three publicly available population-level survey datasets in India: 1. District Level Household and Facilities Survey (DLHS), Round 4 (2013); 2. Annual Health Survey (AHS, 2013–2014); and 3. National Family Health Survey (NFHS), Round 4 (2015–2016). These surveys are representative at the district and state levels.	The study examines whether SBM-G is associated with reducing stunting (low height-for-age) among children under 5 years old in India. Stunting declined by 0.06% with every percentage increase in households with toilets post-SBM-G. Rural regions and districts with higher pre-SBM-G toilet availability show a greater decline in stunting post-SBM-G.

However, it is equally important to be aware of the many benefits that the programme did have. The mission has brought about positive health impacts by promoting better hygiene practices. Increased access to toilets has decreased waterborne diseases and improved child height-for-age (stunting), contributing to overall improvements in community health (Dandabathula et al., 2019; Singh et al., 2021). SBM emphasised BCC to shift cultural norms and attitudes towards open defecation. This awareness campaign was crucial in encouraging communities to adopt healthier sanitation practices and abandon open defecation (Sumedh, 2023). Improved sanitation has broader economic and social benefits. It enhances the dignity and well-being of individuals, particularly women, by providing them with safe and private sanitation facilities. This, in turn, contributes to gender equality and empowerment (UNICEF, 2020). In general, SBM-G reflects a firm commitment from the government towards achieving sanitation goals. The mission’s sustained efforts and continued support indicate a dedication to maintaining a positive momentum in the sanitation sector.

Rural Sanitation Strategy (2019–2029)

In 2019, the Government of India launched the 10-Year Rural Sanitation Strategy (2019–2029), which focuses on sustaining the sanitation behaviour change achieved under the SBM-G and increasing access to solid and liquid waste management (Government of India, 2019). The 10-year strategy also calls for targeted intervention in capacity building, IEC, biological waste management, water management and plastic waste management.

The elements of the strategy to achieve the ODF Plus status for villages are stated as follows:

Sustained usage of IHHLs

Ensuring no one is left behind and providing sanitation access to new households

Sanitation coverage of public spaces (through public and community toilets)

Implementation of Solid and Liquid Waste Management (SLWM) in rural areas

Visible cleanliness and solid and liquid waste management

We now assimilate the lessons learned from India’s policy evolution and present policy recommendations.

Discussion and Policy Implications

The evolution of Indian sanitation policies and their impact are summarised in Table 6.

Table 6.

Summary of National Sanitation Policies and Their Impact in India (as per Government Sources).

Years	Sanitation Policy	Policy Brief	Policy Impact
1986–1999	Central Rural Sanitation Programme	Improve the quality of life of rural people and also provide privacy and dignity to women. Increase rural sanitation coverage by 25%. For a ₹1,500 toilet model, the BPL households would receive 60:20 of the cost from the central and state governments; remaining to be covered by the households.	IHHL went from around 3% in 1986 to 17% in 1999 in rural areas.
1999–2011	Total Sanitation Campaign	Improving the general quality of life and providing universal sanitation coverage in rural areas by 2012. Apart from toilet construction, emphasis on information, education and communication activities (IEC). For a ₹2,500 model toilet, BPL households will get ₹1,500 and ₹700 from the central and state budgets, respectively; remaining to be covered by the households.	IHHL increased from 22% in 2001 to 31% in 2011.
2012–2014	Nirmal Bharat Abhiyan	Increase sanitation coverage in rural areas. IEC activities are retained as the cornerstone of the programme. First to include certain above-poverty line (APL) households. For a ₹5,500 model toilet, the eligible households will get ₹3,200 and ₹1,400 from the central and state budgets, respectively; remaining to be covered by the households.	Due to the short duration of the programme, there are no government statistics on the impact.
2014–2019	Swachh Bharat Mission-Grameen	Improve the general quality of rural life by eliminating open defecation in India by 2 October 2019. More flexibility is provided to the states. Inclusion of urban areas for the first time Continued inclusion of BPL and certain APL households Retained emphasis on IEC activities. For a ₹12,000 model toilet, the eligible households will get ₹9,000 and ₹3,000 from the central and state budgets, respectively.	Government statistics claim 100% coverage across rural and urban areas in India.
2019–2029	Rural Sanitation Strategy	Sustaining the gains of the SBM-G and ensuring sustained access to safely managed sanitation for all rural Indians; achieve a clean-living environment through solid and liquid waste management.	Yet to be determined

We now ask a pertinent question: what lessons do India’s past sanitation policies teach us that can make India ODF?

Understanding the Context of BCC Implementation

The IEC strategies employed during the period from the 1980s to the 2000s primarily focused on health benefits, emphasising how the use of toilets could reduce the disease burden. While health-focused campaigns provided a rationale for toilet adoption, the slow pace of adoption suggests limitations in solely relying on positive reinforcement.

Post-2012, the government adopted a mixed approach to SBM, tailoring strategies to be context-specific. Some areas focused on promoting ‘dignity’, while others employed ‘shaming’. Framing sanitation as a matter of dignity aimed to empower individuals, especially women, is a good strategy for promoting pride and ownership in using toilets. On the other hand, shaming or coercive tactics aimed at creating social pressure to conform to using the toilet can lead to backlash and resistance, potentially undermining the sustainability of behavioural change. Coercive tactics raise ethical concerns and might not be well received in certain cultural contexts. For instance, in a paper titled ‘Shame or Subsidy Revisited: Social Mobilization for Sanitation in Orissa, India’, the authors found that subsidies can overcome severe budget constraints but are not necessary to spur action (Pattanayak et al., 2009). Hence, shaming can be very effective by harnessing the power of social pressure and peer monitoring in rural Odisha.

Besides choosing the right message, the implementers should also focus on selecting the right target group to whom the message would be communicated. Experience from Bangladesh, India’s neighbouring country, which has successfully eliminated OD, has taught us that sanitation progress is accelerated if the demand for toilets comes from women, as they suffer disproportionately in its absence. Women also have the most influence on the hygiene practices of their children in households (Jha, 2003). Therefore, banking on the experience from other countries, any sanitation intervention should first incorporate a door-to-door initiation of contact with the women of the communities, separate focused group discussions with them to educate them about the benefits of toilets for them and their families, mandate their presence in the community-level sanitation meetings and ask for their decision regarding the location and type of toilet to be built.

India’s diverse cultural landscape demands tailored approaches for different regions. Future sanitation policies might be more effective at promoting ‘dignity’ (i.e., fostering a sense of pride and self-respect associated with toilet use) in places (say, urban residences or residences where women are more likely to be dissatisfied with the current practice of OD) where communities are willing to embrace toilets as a symbol of improved living standards. However, in certain contexts, like rural areas, ‘shaming’ (i.e., creating social pressure and stigma around open defecation) may trigger behavioural change by leveraging social norms and community perceptions, although its sustainability and ethical implications require careful consideration.

Optimising Toilet Infrastructure and Aligning Its Pace of Construction

SBM-G recommends the construction of twin-pit toilets because the structure, if used properly, allows safe and inexpensive faecal sludge management. Since only one of the two pits is used at any given time, the first pit, after a couple of years of use, can be closed to let the faeces decompose. This converts the faeces into an organic compound that can be collected safely and used as a fertiliser for agriculture. Even though the intent behind SBM-G propagating the construction of twin-pit toilets was right, policymakers must realise that this design is not suited to all regions. For instance, twin-pit toilets should not be built in flood-prone areas as they contain a higher risk of leaching and contamination of drinking sources (Bharat et al., 2020). Similarly, banking on cost-effective waterless sanitation technologies like EcoSan toilets for water-scarce regions will be the right call. Accounting for the regional heterogeneity during construction is important to ensure safe sanitation for all.

Another crucial policy consideration centres around the interplay between the ‘desired pace’ of constructing and adopting toilets and the ‘feasible pace’ of such construction and adoption. When there is a misalignment between the desired and feasible paces, it raises pertinent questions about the effectiveness of the sanitation initiatives. In the context of the SBM, which set targets to achieve open-defecation-free status within 60 months (from 2014 to 2019), the article emphasises the need to assess the feasibility of reaching these targets within the same timeframe. This entails exploring the preparedness required to align the pace of implementation with the desired objectives. These considerations introduce interesting dimensions that sanitation professionals actively seek answers to, as they are pivotal in shaping effective policies and programmes.

Despite recognising the importance of financial resources, this article underscores the equally critical role of time as a resource often overlooked or taken for granted by the government. The analysis emphasises that while funds are undeniably crucial, the temporal dimension must not be neglected. This brings to light the vital issue of managing time and factoring it into the planning and administration of India’s sanitation policies and programmes.

Upkeep of Already-built Toilets

Even after the successful implementation of BCC and people initiating the use of toilets, research has shown that people revert to OD (Evans et al., 2009). Reversion to OD occurs when the toilets are not structurally sound, are missing important components like doors or walls, become too claustrophobic or the owner cannot manage the waste collected over time (Bharat et al., 2020). A study of 116 African villages recommends sustainable toilet use only when adequate technical support is provided to communities after BCC, especially when the toilets begin to deteriorate (Tyndale-Biscoe et al., 2013). Just as toilet construction cannot be considered a stand-alone sanitation strategy for India, similarly, focusing on complementing BCC with good-quality toilets ensures that reversion to OD does not happen. Hence, we recommend that future sanitation policies allocate a budget for the maintenance of the already-built government toilets.

Moving the Sanitation Outcomes from Access to Adoption

It is important to note that India was declared an ODF nation based solely on the number of toilets. ODF means freedom from open defecation, which comes from using toilets on a sustainable basis. Hence, even if SBM-G data (which records only access) informs us about universal coverage, the first phase of NFHS-5 data reports that only 77 per cent of households use improved sanitation sources. Adoption lags behind access, which can be attributed to behavioural and technological barriers (Coffey et al., 2014). Since NFHS-5 is a more apt representation of the sanitation environment in India, sanitation outcomes must shift from access to adoption to measure India’s ODF status in the future.

India’s resolution to eliminate OD gives it a rich history of national sanitation policies, with SBM-G classified as the world’s largest sanitation campaign. Yet, the literature on the comprehensive understanding of their evolution and effectiveness remains scarce. In this context, we summarise these policies, evaluate their development and study the impact on access to and adoption of toilets. While our study has recommended essential lessons for future sanitation strategies in India, it focuses on rural sanitation issues. The discussion of urban sanitation challenges differs from what the study has explored and can be taken up by researchers for future studies.

Conclusion

This study provides a comprehensive examination of the evolution and impact of India’s sanitation policies, focusing on access to and adoption of toilets. From the inception of the CRSP in 1986 to the Rural Sanitation Strategy in 2019, we analyse the strengths and shortcomings of each policy, emphasising the need for a nuanced approach to addressing the persistent challenge of OD in the country.

Our findings underscore the importance of context-specific BCC implementation in sanitation policies, suggesting a shift from coercive tactics to empowering messages that highlight the health and societal benefits of using toilets. Additionally, the pivotal role of women as agents of change is emphasised, drawing insights from successful sanitation interventions in neighbouring countries, like Bangladesh. The significance of context-specific infrastructure construction, considering regional heterogeneity and leveraging waterless technologies like EcoSan toilets in water-scarce regions, emerges as a key recommendation. The analysis also highlights the critical interplay between the desired and feasible paces of implementation, urging policymakers to align objectives with realistic timelines. Moreover, we stress the need for ongoing support and maintenance of existing toilets to prevent reversion to open defecation, addressing structural issues and ensuring sustainable usage. Finally, we advocate for a paradigm shift in measuring sanitation outcomes from mere access to the widespread adoption of toilets, as reflected in the NFHS-5 data.

The evolution of India’s sanitation policies offers valuable insights for shaping effective strategies, ultimately contributing to the nation’s journey towards becoming ODF on a sustainable basis. Our hope is that policymakers, researchers and implementers can use these lessons to design more effective and inclusive sanitation initiatives for the diverse landscapes of India.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The authors received no financial support for the research, authorship and/or publication of this article.

Notes

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