Earlier efforts of rural sanitation programmes in India could still be sighted as tiny graveyards of sanitation built without any public participation and mostly by toilet contractors. I could recollect the similar sights of children blowing balloons and quite clearly efforts of family planning in India, which was dumping millions of condoms to health sub centres. It did not take much of googling efforts to get the representative pictures of both toilet graveyards and blowing balloons, which is pasted there.
Though googling also thrown quite a beautiful toilets recently being built and also beautiful models/celebrities and others blowing condoms as part of HIV/AIDS campaign and some condom Adv. Surprisingly google scholar also produced academic references of Nirodh- brand name of condoms supplied by the government been blown by children. "Nirodh is used for balloon and children buy them for play" write B B Mandal in his book "Child and Action Plan for Development" in 1990.
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| Children playing with Condom Ballooon |
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| Random picture of toilet |
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| Children blowing balloons in Chitrakoot |
History of family planning and sanitation in India have very interesting trajectory. Both are mostly incentivised, political class have always been talking about it in different decades with some or the other names. The orientation of the programme and programme implementation changed over decades with increased focus on inter personal communication and use of IEC. I had fortune of being association with both programmes across few laggard state in India particularly Bihar and Uttar Pradesh. I shall be trying to talk about similarity and what sanitation programme in India could learn from family planning.
Issue at hand: Choice of use of family planning methods and toilet at home are inherently person choice which people make. But this personal choice have many dimensions constantly operating or rather mediating it. These are larger ecosystem such as family, caste, religious belief, broader economic and social standing, which often determine the probability of making one particular choice over others.
India has been pioneer and lauded for its efforts of being the first county in the world to have started family planning under the government immediately after independence. Similarly, persistence of successive Indian governments in making rural India open defecation free is noteworthy. Though rural sanitation was almost 3 decade behind in terms of initiation.
Family planning space has witnessed various phases of programme implementation. Being merely outreach programme to phase of intense coercion in 70s and 80s and then having taken development orientation. The language have also changed from family planning to family welfare and so on.
Rural Sanitation have also witnessed its own growth and changing optics from being support programme to total sanitation, nirmal bharat and now swachh bharat. Perhaps in some sense what rural sanitation is witnessing today is repeat of 70s and 80s of what family planning programme in India had witnessed. Therefore, programme wise it is good to look at achievements of family planning in India and implementation of sanitation programme to draw lessons for better programme outcomes.
Comparing the coverage: Current coverage of family planning at India level and in Bihar & UP looks strikingly similar to that of Sanitation. The following data is picked from NFHS 4 and today's MIS for family planning and sanitation. Higher coverage on sanitation could be attributed in data term to its coverage indicators and not use as the case for contraceptives. Adjusting with the usages, my crude case is it would either go to contraceptive way or even lower.
Modern Contraceptive
Use
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Sanitation Coverage
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Bihar
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24
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39
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UP
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46
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57
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India
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54
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77
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Unmet Needs: Both family planning and sanitation have clearly recognised unmet needs. Current data of NFHS-4 estimates unmet needs for family planning at 13%. We don't have credible or such elaborate survey instrument to gauge the unmet needs for sanitation. However, the proximate indicators which I could possibly recall is one of the formative research in Bihar done by the Water and Sanitation Programme women and men put sanitation at their priority number 4th and 5th respectively. Therefore, it does indicate that there is latent unmet need for sanitation though slightly lower in the priority.
Temporary/spacing Vs permanent/ limiting instruments: Family planning claims to provide age appropriate methods depending on the need of the couple to either space or limit their family. Various methods from tradition ones- withdrawal, rhythm to condom, pills, injectables, IUD to terminals methods of tubectomy to vasectomy.
In the similar way, classically sanitation talks about whole sanitation ladder from unimproved dug pit to improved one of leach pit/septic tank/with toilet attached to sewerage line.
However, India landscape for both family planning and toilet technology use is very different. Field observations in both cases clearly favours use of terminal methods specially tubectomy as most preferred methods of family planning. Quite strikingly, among all toilet technology people have preference for septic tank toilet over the predominantly promoted or rather built two leach pit technology.
Septic tank is treated as permanent method or terminal solution to the toilet needs, if two leach pit is built under the government promotion at best it is treated as temporary method. Again, the data looks very interesting. I have taken all India figure for contraceptive technology and one survey from one of the districts in Bihar. This is for data point comparisons only. One can argue it as case of comparing apple and oranges but it has great programmatic significance. Please mark the numbers for Female Sterilisation and Septic tank toilets.
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| Preference for contraceptive & toilet technology |
Discontinuation of Modern Spacing Method and leach pit toilet: The following graph gives interesting comparison about discontinuation of temporary contraceptive methods and leach pit toilet. The first graph is from NFHS-4, which puts discontinuation rate for all temporary methods at 44% where as in the second graph which is taken from the Nirmal Gram Sustainability study done by the Ministry of Drinking Water and Sanitation. This is to highlight under almost all toilets constructed under NBA/TSC were leach pit and study clearly found discontinuation of toilet use by all members in the family were more than 30%.
What government programme has been doing: Both these programmes provides useful insights into how government had been doing business. Both talks about providing the client with basket of choice specially in terms of technology. However, they end of promoting terminal methods. This is to highlight here that tubectomy is incentivised.
Guidelines of various rural sanitation programme in the similar fashion talks about giving household rights to build their toilets thereby choosing technology of their choice. However, leach pit is the technology which is promoted almost universally and incentivised.
Disclaimer: Views expressed in blogs are personal and no way represents views of the organizations that I work with or worked with in the past.
References:
1. A photograph of children in Chitrakoot playing with all the free condoms. Credit: Khabar
2. https://books.google.co.in/books?id=qktDh5ytSUYC&pg=PA85&lpg=PA85&dq=nirodh+balloon&source=bl&ots=pFhc42ioLg&sig=6cY4RHxyOH8O9w0YJVemeLGar14&hl=en&sa=X&ved=0ahUKEwiojqXfxYLZAhUK448KHSXvA8wQ6AEIKzAA#v=onepage&q=nirodh%20balloon&f=false
