Case3-June-2017
The Health Ministry’s draft National Health Policy reports states that “63 Million Indians are pushed into poverty by health expenses each year due to health care cost alone, because of lack of financial protection”1. “Inadequate Sanitation Costs India Rs.2.4 Trillion (US$53.8 Billion); which is 6.4 per cent of India’s GDP”2 reports Water and Sanitation Program.
As per the Census 2011 report, in Tamil Nadu, only 48 per cent of the households have access to toilet facilities and 5 per cent of households use the community toilets as against the all India average of 47 per cent and 3 per cent respectively. But in the state as high as 45.72 per cent households practice open defecation, against the all India average of 49.84 percent households. In rural areas of Tamil Nadu, this proportion is 73.27 per cent practice open defecation which is higher in rural India average of 67.33 per cent. In urban areas of Tamil Nadu, 16.21 per cent practice open defecation as against 12.63 per cent in India. Whereas the access to household amenities like vehicles, television and mobile phones are better in Tamil Nadu compared to other states in India.
Shanarpatty is one of the backward blocks in Dindigul district of Tamil Nadu. Shanarpatty has higher level of open defecation sites and is very backward on health parameters. The block has inter – district and intra – disparities in health parameters. The block constituted only of rural context with no town panchayats covering a total population of 123, 227. The SC/ST population covers 20.81%. The sex ratio is 992 / 998. Nearly one third of the total population (31%) is below poverty line. The block has 21 panchayats covering 217 villages with 25 revenue villages and 193 hamlets. The base line survey conducted in April 2016 reveals that out of 31,542 total households, only 5,138 (16.4%) households have toilets and nearly 26,367 (83.60%) households doesn’t have toilets.
The households without toilets defecate in the open areas such as approach road in the villages, banks of the stream, tank bunds, and uncultivable lands. Among which the adult males and boys prefer to go to the tank bunds and the adult females and girls prefer to defecate in the open uncultivable lands and the banks of the stream. The peculiar practice is to take the children under five years along with them and leave them on the road sides before they proceed to defecate into the fields in the hiding places. The old aged people defecate only in the road sides. There was practice of males who always prefer to defecate in the open areas because of the smoking habits which feels as a triggering factor for their natural calls. Even if they have toilets in their house, men wanted to go outside because of the comforts and the convenience in the open, a common reason being attributed by the men for practicing open defecation. Another aspect is the attitude of the men that the toilets are meant only for women, girls and children who needs more care safety and security. This attitude was also one of the reasons for wider practice of open defecation in the villages. Another reason is that in the early morning, the men do not want to wait for their turn to come to enter the toilet after three or four people.
The project “Elimination of Open Defecation to improve health, hygiene and sanitation by promotion of individual toilets and Behavioral Change Communication (BCC) strategy” aims to achieve Open Defecation Free status in the Shanarpatty block. This could be achieved by changing the behaviour and practice of the people through knowledge enrichment about the implications of open defecation. Constructing the toilets in the eligible or potential individual households and ensure the end usage of the toilet. Ensuring toilet usage by all the members of the households where the intensity of the issue of open defecation is at its higher rate is another core objective. The whole processes enable to bring the changes in knowledge, attitude, behaviour and practices among the potential and the non users who are keeping the toilets unused at their house. This can be achieved throughsensitizing the entire community through the Behavioural Communication Change (BCC) strategies to change the behaviour and practice aspects related to sanitation, which will strive towards achieving open defecation free status. The project also aims at developing and demonstrating cost effective models of toilets. This will trigger the interest of the community to construct toilet of their choice. The project is supported by State Planning Commission through the State Balance Growth Fund (SBGF) for a period of three years from April, 2015 to March, 2018 with a budget outlay of Rs. 76.49 lakhs.
The project is implemented by the District Rural Development Agency (DRDA), Dindigul through SUHAM (Sustainable Healthcare AdvanceMent) Trust of DHAN Foundation, Madurai. The SUHAM Trust is having three dimensions focusing on community health programme, curative care with primary and secondary care hospitals and the institute for paramedical sciences to cater the needs of the community with service providers. The WASH intervention is being implemented since 1995 as part of the health programme in terms of reducing morbidity and increasing the workman days of the community. It is being seen as part of Community Health and Nutrition Programme for women and children programme where safe water and sanitation plays major role in affecting the nutritional status of women and children specifically. In 2001, Bio-sand filter was taken as one of the mechanism to address the issue of safe water at highly affordable way. In 2005, sanitation accessibility was created through microfinance(MF) initiatives of DHAN. The product promotion was made for encouraging the SHG members to construct toilets.
The first step in the project was placement of ten health associates through interview and written test. Three days residential training programme was conducted in DHAN People Academy by out sourcing resource persons who are expertise in the field of sanitation. The module focused all about the organization, its focus, overview about the block where the project is going to be implemented, the project components, activities, implications of open defecation and importance of toilet construction in the households, strategies and proposed outcomes. The base line survey was done for the potential assessment of the eligible households in all the villages through door to door survey by the health associates. The process started with the formal introduction with the respective panchayat presidents briefing about the project focus in sanitation. The staffs were equipped with an increased knowledge level through an additional three days residential programme in Department of Rural Technology Center, Gandhigram Rural University. Subsequently the health associates were given Community Lead Total Sanitation (CLTS) training programme for three days in Dindigul as a residential programme. The training was given by State Planning Commission, DRDA along with SUHAM Trust. The main focus of the training was to improve health, hygiene and sanitation.
The baseline survey reveals that the total households 31,542 and there are 5,138 (16.40%) households alone have toilets, 26,367 (83.60%) households were without toilets. Then the process done was to get the data on the households having space to construct the toilets. Out of the households without toilets, only 14,568 households were having space for taking up the toilet product which accounts to be 55.25%. The need of the hour was to identify the members’ attitude and willingness to have the sanitation unit in their households which will benefit the health of their own family members. It was reported that out of the households having the space to construct toilets, only 13,938 (66.33%) households were willing to construct toilets in their houses.
After the potential assessment, Micro plan was prepared for all the panchayats doing the Participatory Rural Appraisal (PRA) exercise involving the local body leaders and the community as a whole through social mapping for the sanitation aspects. The list of the eligible households was matched and verified with the Master Sheet from the government list to ensure that the names enrolled are the authentic list. More than 25% of the households ID numbers were not found in the Master Sheet because of wide reasons. Most of the cases were covered under the Total Sanitation Project (TSP) of the previous phase, but the joint family has split as nuclear families after the son’s marriage were not found in the list.
There were lot of discrepancies in the data of the list of eligible members which was consolidated through door to door survey and the Master Sheet. Applications were generated with the ID numbers for the final eligible members and were submitted to the clerk of the respective panchayats. The panchayats verify the application for the authenticity and release the work orders with the signature of panchayat president and the same was submitted to the Block Development Office. The details of the application were computerized to check if there were any duplication.
The pedagogy of the training was class room session with lectures on the content, field level demonstration of how to give awareness education to the MGNREGA workers. The focus was on the implications of open defecation like contamination of feces in drinking water through a demonstrative mode. The process was making them to drink pure water in a glass first and took feces using a single hair and mixed it in the same water. When asked to drink the same water, the people refused to drink it since it has contaminated feces which they had observed with their naked eyes. This was followed with the awareness on how the limbs of houseflies carry the feces to our food stuffs. Feces when get contaminated results in dysentery, diarrhea and other health hazards. This process and demonstration helped the people to understand and think about the implications of open defecation.
During this process, ten volunteers were selected to work as the sanitation patrol in the early morning. The next process was the entire health team along with the selected volunteers in the respective villages was given a whistle and a bag full of mud in the early morning before 4.00 am. When the community people come out for the natural call, the team asked whether there is toilet in their houses, if they say yes, then the team asked them to go back to their homes. If they say no, then they were allowed to go out giving them the bag of mud and they were asked to dig a pit and defecate in order to avoid exposing the feces to the air which will pollute in all means.
The school children were focused through the school health education using the PRA technique and made them to plot the open defecation sites with yellow powder. When the children see their whole village in yellow powder in many places, they felt the situation very bad with the dirty expressions. Then the awareness education was given on the implications of open defecation and the need for the sanitation unit in their households. The CLTS was done in the schools as well as in all the villages of the block.
As an entry point programme before starting up the intervention, 48 cultural campaigns were conducted covering the 13 schools with 8,673 students and 35 villages to cover 4,566 through means of songs , street play and quiz. The awareness was given to the school students about the importance of toilets in the households. The effective use and maintenance of toilets along with the personal aspects like hand washing practices was emphasized. Even the anganwadi centers were also focused in order to inculcate the practices of using the toilets and also the hand washing practices. The children in the anganwadi were demonstrated how to use the toilets and were trained by the anganwadi worker.
In order to steer up the project propositions, 133 Village Health Monitoring Committees covering 756 members were promoted out of 217 villages leaving the hamlets with less than fifty households. The main purpose of promoting the committee is they are only responsible for the health agenda like, toilet construction, environmental sanitation, chlorination in water tanks and scheduling the cleaning of water tanks, maintaining the toilets in the schools and monitoring the collection of garbage from the households. The committee is constituted involving panchayat president, ward member, representatives from Village Poverty Reduction Committee (VPRC), Anganwadi worker, Kalanjiam secretary and volunteers from the village. The committee meeting gets conducted once in a month on a fixed date and time. The major points discussed during the meetings were on the total sanitation of the village. Construction of toilets in the left out households and ensuring the usage of the toilets by all the members of the family is also one of the main agenda.
Another way of approach was identifying Sanitation Ambassadors from the main villages who will take the health agenda at the village level. Nearly 132 ambassadors have been identified in the respective villages. The main responsibility is to document the different stage of construction of toilets and ensure the SBM incentive to the concerned beneficiary.
As a part of the awareness programme, Rallies were conducted in all the working panchayats to create a mass awareness among the community. Nearly six rallies covering 8,562 conducted in one year period involving the school children and the public. In addition to this, 224 street programmes were also conducted reaching out to 2,675 members who are interested in taking up the toilet construction in their households. The members enrolled under MGNREGS were oriented on sites where they are expected to work. Since the members working under MGNREAS are involved in the construction of toilets especially for the earth works and as construction assistants. 13 average man days got generated for the labours. Nearly 144 such meetings were conducted in the block covering 12,495 labourers.
The Kalanjiam Federations have the policy built within to have single loan for a member and it is strictly adhered by all the federations in Dindigul region. This is mandatorily followed in all the federations across the districts and states where the organization is working. But because of the vast awareness given on the implications of open defecation and the importance of toilets in the households through different strategies and the BCC practices, people came forward to have toilets in their houses. The members demand led to have a change in the lending policy at the federation and regional levels to have the second loan for the special products under sanitation and safe water. Because of the changes brought in the lending policy, nearly 585 loans have been given to the members for building toilets in the households to the tune of Rs. 8,205,900 during the project period. This helped the members to move ahead of the target in achieving the sanitation products.
Valuation certificate has been issued for 3153 Individual Household Latrine (IHHL) and 2714 NMR form under the scheme in SBM (Gramin) for each person who take up the construction of toilets in the households whose manpower is fully utilized for the earthworks and also the construction assistants. The annexure forms with the application to be submitted under SBM for availing the incentive for the toilet construction is application form, work order, certificate of authorization as a eligible beneficiary for toilet construction under the scheme. The members should submit the requisition letter from the beneficiary for the construction, Aadhar Card, bank pass book first page, MGNREGS individual job card with three stages of construction to the concerned block office. Once the construction is completed in full form, the structure should have the details of the SBM, panchayat name, and beneficiary name, constructed by and estimated amount. The information board will also have the detail about SUHAM Trust if additional loan amount has been given by the federations ranging from Rs. 7,000 or Rs. 8,000 in addition to Rs. 12,000 given under SBM for the members.
Nearly 3,966 applications generated at the start of the project, 2,062 work orders got released and construction works completed. The end usage of the toilets was ensured out of the total 1,402 (68.00%) constructed toilets. Balance of 452 households is under the process of construction and the pending toilet construction will get completed within two month period. The collaborative linkage was well established with the block and district levels during the project period. As a follow up of this, weekly review is regularly conducted for the health associates and the Engineers working for the project in the presence of BDO, DBDO, Overseer, Engineer and Personal from DRDA along with the Community People of Sanitation (CPS) and panchayat secretaries.
As an impact of the intervention, eight panchayats namely Veerachinnampatty, Emakkalapuram, Madoor, T. Panjampatty, Thavasi madai, Anjukulipatty, Raghalapuram and Aavilipatty were declared as the Open Defecation Free Panchayats by saturating the villages with the sanitation product. Awards were also given to Panchayat Presidents, Clerks and CPS of the ODF panchayats as a token of motivation for their efforts in creating Clean India.