India's Total Sanitation Campaign
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The Total Sanitation Campaign (TSC) in India was introduced by the GoI in 1999 as a restructure of the CSRP. It was implemented by the Ministry of Rural Development and the central government to "improve the general quality of life in rural areas [and] accelerate sanitation coverage in rural areas through access to toilets to all by 2012".
The TSC programme emphasised Information, Education and Communication (IEC) as a means of promoting sanitation facilities, and providing a stronger support system, including trained workers, building materials and production centres. It also emphasised the importance of school sanitation and hygiene education (SSHE) as an entry point for encouraging a wider acceptance of these practices.
The programme also recognised the importance of local leadership, and integrated rewards to encourage participation. “Recognising the role of elected local representatives (Gram Panchayats [GPs]) to promote sanitation through collective community action, the GoI instituted an award, called Nirmal Gram Puraskar (NGP) in October 2003. The NGP awards are given to districts, blocks, and GPs that have achieved 100 percent sanitation coverage of individual households, 100 percent school sanitation coverage, are free from OD, and conduct clean environment maintenance.”
TSC projects were scaled significantly in the first decade, and by 2012 the programme was operational in 572 rural districts, with additional districts planned to be added in subsequent years.
Rural sanitation was addressed by the Government of India (GoI) in the 1980s through the Central Rural Sanitation Programme (CRSP). The CRSP "was started in 1986 to provide sanitation facilities in rural areas. It was a supply driven, highly subsidy and infrastructure oriented programme".
The sanitation problem in the country had a strong cultural component. A study published in 2013 estimated “that 72.63% in rural India in the sample states practise Open Defecation (OD) irrespective of having or not having toilet facilities. The predominant reasons for the OD are lack of awareness, established age-old practice, nonexistence of community latrines and insufficient number of latrines.”
The conditions also varied substantially across the country. An all-India survey on conditions of drinking water, sanitation and hygiene during the period January to June, 1998 was carried out by the National Sample Survey Organisation, and results showed significant disparities across rural and urban populations:
- The proportion of households reporting that they had no bathroom was much higher in rural areas (81 percent) than in urban areas (35 percent).
- As many as 83 percent of households in rural areas reported using no latrines as against only 26 percent in urban areas.
- Only about 8 percent and 1 percent of rural households reported using a septic tank and sewerage system, compared to 35 percent and 22 percent of urban households.
Similarly, the Central Bureau of Health Intelligence in the Ministry of Health and Family Welfare reported in 1998-99 that:
- On an average, 30 million persons in rural areas suffer from sanitation-related disease
- Five of the ten most dangerous fatal diseases of children aged from one to four in rural areas are related to water and sanitation.
The public impact
The TSC achieved some advances in the construction of sanitation infrastructure and in increasing awareness, but there was also widespread evidence that funds destined for the TSC were not allocated effectively.
On the positive side, of the 138.2 million rural households in India (a 2001 figure), nearly 3.5 million had constructed household toilets with support from the TSC by 2007. “Over 1,700 women's complexes and41,000 school toilets have been built, apart from other support facilities such as rural sanitary marts, at a total cost of just over INR2.92 billion (approximately USD62 million).”
On the other hand, a Comptroller and Auditor General of India (CAG) audit covering the TSC from 2009 to 2014, identified a weak performance against its targets, and limited use of resources towards the stated objectives. “Our audit has brought out planning level weaknesses which were critical for the success of programme. Nearly INR10, 000 crore was spent on the rural sanitation programme by the central government in the five years covered by audit and large-scale diversions, wastages and irregularities were noted. More than 30 percent of individual household latrines were non-functional for reasons like poor quality of construction, incomplete structure, non-maintenance etc.”
Similarly, there were claims that available funds remained unused in some states. "Pointing to a case in the management of funds, the CAG report said the Ministry [for water resources, and drinking water and sanitation] released only 48 percent of the funds demanded by the states and 16 states did not release their share of funds during 2009-14. Despite availability of funds of INR13, 494.63 crore, only INR10, 157.93 crore was spent on scheme implementation during the period 2009-10 to 2013-14. The unspent amount on annual basis varied between 40 percent and 56 percent.”
There was not enough emphasis placed on the social aspects of the initiative, which was one of its major components. With regard to IEC and convergence, the report stated: “We found that due importance was not given to IEC and 25 percent of the total IEC expenditure during the years 2009-10 to 2011-12 was incurred on activities unrelated to IEC”.
Overall, the progress of the initiative was found to be limited, and efforts were not sufficient to achieve significant progress. "TSC implemented with support from the WSP only slightly increased the availability of individual household latrines and only slightly decreased the practice of OD. Importantly, these findings showed that these modest improvements in sanitation and in defecation behaviours were insufficient to improve health outcomes among children."
The main stakeholders were the GoI and its Ministry of Rural Development along with the governments of the 29 states and 7 union territories (UTs) in India. They were supported by external stakeholders such as NGOs and schoolteachers.
The National Scheme Sanctioning Committee (NSSC) was created to approve project proposals for districts which were received from the state governments. The NSSC was made up of representatives from the Ministry of Rural Development and sanitation experts:
- “Secretary, Department of Drinking Water And Sanitation, Ministry of Rural Development - Chairperson
- “Additional Secretary & Financial Advisor, Ministry of Rural Development - Member
- “Four non‐official experts in the field of rural sanitation - Members
- “Secretary in charge of rural sanitation of the State whose proposal is to be considered - Member
- “Joint Secretary, Department of Drinking Water And Sanitation, Ministry of Rural Development - Member Secretary.”
There was also a Plan Approval Committee for the release of funds to state level. It was "headed by Joint Secretary (Sanitation) with representative of IFD, secretary of the state concerned, nominated experts on sanitation if any and representatives of
Ministries of Health and Family Welfare, Women and Child Development, School Education and Literacy and of Panchayati Raj."
Similarly, the initiative had as a priority the inclusion of stakeholders who had been ignored by the CRSP, and whose omission was considered to be instrumental in its failure. Therefore, the TSC made an effort to incorporate a range of state- and district-level actors. “TSC implementation has given emphasis on capacity of different stakeholders like... NGOs, schoolteachers, Anganwadi workers, masons, health workers, engineers, district and block level programme managers.” (Anganwadis are basic healthcare centres in India.)
The initiative has been largely funded by state and local governments, who have also launched several initiatives to both improve the sanitation infrastructure and provide social support for sanitation improvement across the country.
The TSC has been financed by resources from central and state governments as well as contributions from beneficiaries to promote access to sanitation facilities. The total commitment by 2010 had been approximately INR17,866 crore (USD3,888 million), of which low-income households committed INR2,016 crore (USD438 million or 11.4 percent). “The allocation and expenditure is divided between the national government, state government and beneficiaries.”
The government allocated an annual stock of resources and coordinated a state-level multimedia campaign aimed at influencing the rural public regarding sanitation practices and generating demand for individual household toilets. To encourage the population to participate, it also launched an award scheme in 2003 called "Nirmal Gram Puraskar" (Clean Village).
The GoI's commitment to the TSC has continued over the years, with President Pratibha Patil declaring in December 2008 that “a TSC would go a long way in reducing economic losses and make people conscious about the benefits of cleanliness. The president urged the people to show commitment in keeping villages clean by adhering to the slogan Once Nirmal, always Nirmal."
The programme has been relaunched several times under different names, but its central objectives continue to be pursued by the government. The TSC was renamed Nirmal Bharat Abhiyan in 2012, and relaunched as Swachh Bharat Abhiyan in 2014.
There is evidence that cultural resistance to the changes introduced by the TSC was one of the main challenges to its implementation, and this was a major reason why the it had education as one of its main focuses. In addition, there were reports from several villages that people were dissatisfied with the amount of funding made available as well as the lack of existing infrastructure to support the TSC's goals.
A report on the TSC published in 2005 found that district officials were largely critical of the amount of funding, although with a few exceptions. “Almost all the district implementing agencies (DIAs) pleaded that the present amount of subsidy is inadequate for a complete and satisfactory execution of the scheme... However, in Medinipur (West), Sehore, 24 Parganas (North) and South Tripura, the DIAs supported the ongoing subsidy structure”.
A mason who was interviewed for the 2005 report identified two reasons for public resistance to the TSC. “The main constraint regarding the TSC, in his opinion, is that it is difficult to convince people about the need for household latrines as they are in the habit of using open space for the same. He also feels that the unit cost is insufficient to build toilets of good standard.”
Clarity of objectives
The TSC's goals were overall too broad to be measurable and there were significant strategic changes to the approach of the TSC over time.
The TSC's guidelines were modified five years into the initiative. “In 2004, the revision in TSC guidelines followed a mid-term review of the programme. The revision led to a focus on sanitary arrangements, not merely on the construction of household toilets. The SSHE component was strengthened; and the provision of toilets was extended to Anganwadi Centres, [and] all levels of schools (primary, middle, secondary, etc.)... The GoI sought to reorient the focus of the sanitation programme to achieving the outcome of an OD-free environment. Thus, not only individual households but also communities, villages, and Panchayat governments started to be targeted."
There was a further modification three years later. “In 2007, the TSC guidelines were modified again to include an emphasis on developing community managed and ecologically safe environmental sanitation systems focusing on [Solid and Liquid Waste Management (SLWM)]. Up to 10 percent of the project costs could now be used for meeting upfront capital costs incurred under the SLWM component.”
The main objectives of the TSC as of 2012 were:
- “Bring about an improvement in the general quality of life in the rural areas
- “Accelerate sanitation coverage
- “Generate demand for sanitation facilities through awareness creation and health education
- “Cover all schools and Anganwadis in rural areas with sanitation facilities and promote hygiene behaviour among students and teachers
- “Encourage cost-effective and appropriate technologies development and application in sanitation
- “Endeavour to reduce water- and sanitation-related diseases.”
Strength of evidence
In order to obtain insights into community practices and attitudes to sanitation, a baseline survey had been launched in 1996-97. "A comprehensive Baseline Survey on Knowledge, Attitudes and Practices in rural water supply and sanitation was conducted during 1996‐97 under the aegis of the Indian Institute of Mass Communication, which showed that 55 percent of those with private latrines were self‐motivated. Only 2 percent of the respondents claimed the existence of subsidy as the major motivating factor, while 54 percent claimed to have gone in for sanitary latrines due to convenience and privacy. The study also showed that 51 percent of the respondents were willing to spend up to INR1,000 crore to acquire sanitary toilets.”
A 1998-99 report from the Central Bureau of Health Intelligence (see The Challenge above) showed that, on average, 30 million people in rural areas suffered from sanitation-related disease. This pointed to the failure of the CRSP in improving sanitary conditions in rural India.
One of the main causes for this failure was found to be the “total lack of community participation in this traditional supply-driven, subsidy-oriented government programme. There was poor utilisation of whatever toilets were constructed under the programme, which was due to many reasons, e.g. lack of awareness, poor construction standards, emphasis on high-cost designs, absence of participation of beneficiaries, etc. Most of the states could not provide adequate priority to the sanitation programme. The CRSP had also neglected school sanitation, which is considered as one of the vital components of sanitation. CRSP also failed to have linkages with various local institutions.”
Based on this evidence, the TSC was created, characterised by its "demand-driven" approach.
Most of the financial resources were made available at the state level, with capped expenditure which the funding beneficiaries considered to be inadequate. "Funding for School Sanitation in a TSC Project is provided by the central and state government in the ratio of 70:30. Accordingly the central assistance per unit will be restricted to 70 percent for a unit cost of INR35,000 crore."
Surveys implemented two years after the TSC was put in place revealed that, in many instances, the funds made available were insufficient to cover the objectives of the campaign. "The state government thereafter evaluated the programme in 2003-04 and realised that the financial subsidy did not help in increasing effective coverage and it was also not possible to provide for the large number of families to be covered (as per Census 2001 only 21 percent to 22 percent used sanitary toilets). Therefore, the rural sanitation programme was relaunched in all 25 Districts of the State as per the fresh national guidelines.”
Similarly, there were failures in the planning process. "The country's sanitation programmes have failed to achieve the desired targets largely due to planning level weaknesses even as large-scale diversions, wastages and irregularities were detected.”
There was no evaluation of the resources that would be needed to achieve the intended objectives. “The targets for construction of toilets were fixed by the state governments without taking into account the fund availability and their capacity to execute the approved plans. This resulted in substantial amounts remaining unspent at the end of each year ranging from 40 percent to 56 percent of the available funds.”
There was also a shortage of qualified people to work on the programme. “In nearly half of the studied districts, it was reported that adequate staff and capacity was not available at the block and sub-block level to implement the programme effectively. In some cases, this could be because of the remote location of these areas which makes these less attractive postings within the government system and also for professionals recruited from the open market."
The TSC was led by local governments and implemented by district councils or "Zilla Panchayats". “The TSC is being implemented in districts of the states/UTs with support from the GOI and the respective state/UT governments… In case a Zilla Panchayat is not functional, the District Water and Sanitation Mission (DWSM) can implement the TSC. Similarly, at the block and the Panchayat levels, Panchayat Samitis and respective GPs are involved in implementation of the TSC.”
However, the progress of the implementation was no more than gradual. Given that it was a local initiative, state governments needed to allocate a higher priority to the TSC than they did. “Though most states have included the TSC in their programmes, financial allocations for sanitation often are not adequate due to [the] lack of priority attached to the programme. which often takes a back seat to water, which is a more politically important area.”
There was a good measurement mechanism in place to track the progress of the TSC. However, the collection of data and varied across the country, and there is evidence that the funds allocated for monitoring purposes were not fully utilised.
Monitoring systems were put in place throughout India to monitor progress of the TSC. “In a majority of the sample districts, a monitoring system to track progress on sanitation exists at the village level... Monitoring is done on indicators prescribed by the GoI, such as construction of toilets by different categories of households, construction of school and Anganwadi toilets, etc.” The data was collected at the village level and compiled by districts in a monthly progress report.
The indicators used to track progress under the TSC included:
- The number of households and institutions without access to sanitation
- The amount TSC financial allocation and expenditure that reached the poorest members of the population.
However, the tracking of these metrics was very inconsistent across the various states. The monitoring system for TSC reported toilet coverage accurately in only half of the sample districts, according to a 2010 report published in 2010. “Tracking usage of toilets constructed emerges as one of the weakest links of the TSC monitoring system in the sample districts studied. Toilet usage is monitored by only one-third of the sample districts, of which around half reported undertaking this activity on an ad hoc basis.”
A performance audit of the TSC published in 2015 also indicated that most of the resources intended for monitoring purposes were diverted to other activities, indicating that the proper resources were not properly used. "The Ministry failed to utilise funds approved under ‘Monitoring and Evaluation (M & E) - Other Charges' and INR0.032 million only (out of INR2.240 million booked under the head) was utilised on the activities covered under M & E during the period 2009-10 to 2013-14, diverting the remaining amount of INR 2.208 million to other activities.”
The dispersed structure of the TSC made communication and alignment difficult. The TSC represented a big change from conventional rural sanitation programmes by seeking to be community-led and demand-driven rather than target-led and supply-driven, and there was a general awareness across government of this fact. “In 89 percent of the sample districts, senior district-level officials share this understanding of the TSC framework and principles.”
In line with this, a priority was given to capacity-building: “all the states have been asked to identify state-level resource centres for taking up capacity-building activities". Relevant institutions were identified as "Key Resource Centres" and received funding accordingly from the GoI.
However, studies showed that in over half of the sample districts, there was significant room to improve the interdepartmental coordination with the DWSM. “At the district level, the DWSM is the coordinating body for sanitation. Therefore, although the structures are largely in place, the use of this arrangement for coordinating implementation remains a challenge. This could be because the frequency of meetings varies across the sample districts, and even if meetings are held regularly, sanitation in some cases is the last agenda point as the DWSM is mainly focused on water supply.”
Similarly, it was a challenge to coordinate the work at sub-district level. "In 43 percent of the study districts, although the core team understands the TSC principles and programme framework, this vision is not uniformly shared at sub-district implementation levels. This factor may be responsible for the ‘patchwork' results visible in some districts in which certain blocks or GPs are able to achieve excellent results but the district is unable to scale up these pockets of excellence.”
The Effect of India's Total Sanitation Campaign on Defecation Behaviors and Child Health in Rural Madhya Pradesh: A Cluster Randomized Controlled Trial, Sumeet R. Patil, Benjamin F. Arnold, Alicia L. Salvatore, Bertha Briceno, Sandipan Ganguly, John M. Colford Jr and Paul J. Gertler, 26 August 2014, PLOS Medicine