On rural sanitary latrines

Health is wealth - so goes the adage. But wealth is health, in the context of Bangladesh. Only those with money can afford to get good treatment either at home or abroad; those without it are destined to die. Fortunately, the poor people in the rural areas are afflicted with diseases that can be cured with behavioural changes, only with a little cost. Most of the diseases stem from water and sanitation practices for which availability of pure drinking water and sanitary latrines at household levels are considered as important determinants of health status of the rural people. It is thus no surprise that one of the important planks of MDGs (Millennium Development Goals) pertains to water and sanitation. The government of Bangladesh and the NGOs (non-governmental organisations) have been serious about supplying inputs of these to households.
Empirical evidences, however, show that the proportion of the households accessing safe drinking water is higher than those with access to sanitary latrines. In developing countries, only 53 per cent population has access to sanitary latrines with a wide difference ranging between urban (71 per cent) and rural (39 per cent) areas. Currently, the majority of the people lacking sanitation live in rural areas and globally eight out of ten are users of unhygienic facilities and six out of seven people who defecate in the open live in rural areas.
In Bangladesh, the use of sanitary latrines has been on the rise to keep rural people on a good health status. Besides efforts at government level, a large number of NGOs are also working on sanitation. We can recollect that Bangladesh NGO Foundation (BNF) has been providing grants to local NGOs to provide sanitary latrines to extreme poor households. It was assumed at all levels of the input suppliers that supply would eventually create its own demand, and it needs to be known whether that has actually happened.  However, research on impact assessment or evaluation of the use of sanitary latrines has been rare, if not non-existent.
To break the ice perhaps, a group of young researchers (Tahera Akhter, Abu RMM Ali and Nepal C. Dey) of the Research and Evaluation Division (RED) of the BRAC, conducted a research on transition overtime in household latrine use in rural Bangladesh. It is based on a longitudinal cohort study. Among the poorest in rural Bangladesh, "almost one in three people defecates in the open, making the environment unsafe, threatening public health, spreading diarrhea, typhoid and other diseases through pathogens in feces, the leading cause of death among children below the age of five (including 20 per cent of all infant deaths) due to diarrheal
diseases".
The government has set a national target of 100 per cent sanitation coverage by 2013, a step towards attaining MDGs. The government, NGOs and private sector have been putting their best to achieve this goal. Notably among these, the BRAC has introduced a comprehensive Water, Sanitary and Health (WASH) intervention programme in 2006 in 150 upazilas.
Quite obviously the researchers attempted to evaluate the performance of the WASH over time covering 30,000 households determined by using a multi-stage random sampling technique. The study shows that 57 per cent of sample households were using sanitary latrines in 2011 and suggests an increasing trend in the use of sanitary latrines. This is borne out by the information that the proportion of people defecating in the open has significantly been reduced from baseline of about 24 per cent to about 14 per cent recently. Again the proportion of households owning such latrines increased from about 73 per cent to 81 per cent during the comparable periods while share of shard latrines decreased from 27 per cent to about 19 per cent. Over time, the quality of latrines used (cleanliness) also depicted an upward trend. But all sanitary latrines were not being used hygienically excepting a majority from WASH of the BRAC that emphasised motivation by training and door-to-door visits by village WASH committee. "Increasing the number of latrines alone cannot lead to improved public health if those latrines are not maintained and used hygienically".
The crux of the problem is whether the same set of households is performing in the positive direction. The transition matrix made by the researchers tends to answer that question. It shows that three-fourths of the original users continued with the practice while one-fourths switched to other unsanitary practices such as ring-slab without water seals, pit latrines and open defection. Among those  found using  ring-slabs latrines without water seals at the baseline survey, more than half of them shifted to sanitary practices while the rest recourse to original method. Similarly, among open defectors, almost half of them graduated to improved condition while the rest to unsanitary practices.
There are a number of factors that determine the use of sanitary latrines and the researchers have allowed us to read them. Those who had exposure to education were roughly one and a half times more likely to use sanitary latrines than those without schooling; those who had access to radio/TV at home were almost the same compared to those without such access. The ultra poor were the least users of sanitary latrines. Another good news is that the proportion of households switching to sanitary practices was higher than that of those switching to unsanitary practices. This implies that people are growingly adopting scientific practices.
However, the concern of the research paper centres around the incidence of some households shifting from sanitary to unsanitary practices thus putting a question mark to the sustainability of the programme. This happens mostly with ultra poor who cannot afford to maintain the latrines or in areas where there is acute water scarcity. "Several factors such as poverty, lack of awareness, and water shortage induce households to adopt unsanitary practices". Despite the odds, the condition of sanitation is improving over time but to increase awareness, periodic home visits to monitor usage and maintenance of latrines are necessary.
The writer is a Professor of Economics at Jahangirnagar University.
 [email protected]