Toilet trouble

How Sikkim built toilets for all – and why the rest of India is struggling to catch up

A cultural aversion to toilets is among the biggest hurdles to 100% sanitation.

Earlier this month, the ministry of drinking water and sanitation reaffirmed that Sikkim was the only state in the country to have achieved 100% sanitation.

It's an admirable achievement for the tiny mountain state, considering that India has the world’s largest population of people who defecate in the open. According to the 2011 census, 53% of Indian households do not have toilets. In villages, the figure is even higher: 59.4% of rural India practices open defecation, according to December 2013 data from the National Sample Survey Office.

But India wants every village in the country to be free of open defecation in eight years, with a toilet in every rural household.

The country has been on a toilet-construction mission 1986, when began to offer subsidies for building latrines under a programme that is now known as the Nirmal Bharat Abhiyan. Since 2001, the central government has spent Rs 15,000 crore to build 93.5 million toilets across the country. The latest report from the ministry of drinking water and sanitation has ranked Sikkim first in implementing this programme, the state government announced earlier this month.

Sikkim actually achieved the goal in December 2008, when it was declared a ‘Nirmal Rajya’, a state completely free from open defecation. That year, the centre gave the state’s 163 gram panchayats the Nirmal Gram Puraskar, a monetary incentive ranging from Rs 1 lakh to Rs 30 lakh, to ensure that every household has a toilet. "Sikkim has also set new benchmark for utilisation of funds under the scheme," the state government said. "The utilization percentage was 99.2 percent till February 2014."

But what made Sikkim a success story? Was it only because it is the second-smallest state in India, with a population of just over 600,000 people?

“Open defecation has not really been a part of Sikkimese culture all these years,” said Bijoy Gurung, associate editor of Sikkim Express in Gangtok. “People are conscious not so much about hygiene but privacy, so even before the government started its programme, villagers used locally-made bamboo structures as toilets.”

In addition, says Gurung, all the pure water streams running across the state are treated as incarnations of the divine. “The streams are our lifeline and people did not want to pollute them,” he said.

These factors made the government’s job much easier when it began constructing toilets in homes, schools and anganwadis. Since 1999, the state’s government built 98,043 household toilets, most of them for families below the poverty line. The programme included door-to-door campaigning and working with school children to convince families about the health benefits of using toilets. “The government got local panchayats involved to sensitise people, particularly about hygiene and the fact that Sikkim has to maintain a good image as a tourism state,” said Gurung.

But other states are lagging. Despite concerted efforts by the government and non-profit organisations, most states have failed to achieve even 50% of their targets. Jharkhand, where 90% of the rural population lives without access to toilets, is the worst performer. The 2022 deadline is sure to be missed, and the reason, say experts, is almost entirely socio-cultural.

In societies that have a long tradition of just heading to the fields to do one’s business, toilets are perceived as restricted, dirty spaces that should not be near one’s house, says Chandra Ganapathy, programme support manager at Water Aid, an international NGO that works on water sanitation and hygiene. In one of its programmes, Water Aid is working with governments in ten different states to help implement the toilet initiative.

Casteist attitudes are also a major hurdle in rural India. “Across the country, people still believe that sanitation is the duty of the untouchables” who carry away excrement from homes, said Bezwada Wilson, founder of the Safai Karmachari Andolan.

Though many villages in India have been declared open-defecation free and awarded the Nirmal Gram Puraskar, experts say the awards have not been a success. “In many cases, there are slippages – villages are open-defecation-free for a few months and then they slip back,” said Ganapathy.

Wilson is even more sceptical. “Barring the north-eastern states and perhaps Haryana and Punjab, there is not a single district in India that is open defecation free even today,” he said. “The government claims it gives people subsidies, but how much of that goes into building toilets? Not much.”

To help over come the cultural aversion to toilets, several non-profit organisations, such as Arghyam (in Karnataka), Water Aid and Sulabh International, are working to educate communities about the necessity of sanitation.

“Most people don’t associate open defecation with diseases like diarrhoea, which alone kills nearly 200,000 children under the age of five in India every year,” said Ganapathy. So an effective way to create the need for toilets is convincing people that they will keep the whole neighbourhood safe from such diseases. “It’s easier to convince younger people that the cost of building a toilet is eventually cheaper than the cost of not having one,” she said. Women are also easily convinced about toilets because they guarantee them safety and privacy.

The goal of being open-defecation free is, however, linked inextricably with water supply, particularly in rural areas and pockets of urban poverty, where there is no direct water connection. “Sanitation has not been a top priority for rural populations because water supply is a major concern for them,” said Sudhakar Kini, chief architect of toilet innovators Sulabh International.

In 1968, Sulabh began to promote its twin-pit latrine design, which requires just 1.5 to two litres of water to flush, compared to the 12 to 15 litres that modern toilets use up per flush. “But water supply and toilets also have to be clubbed together with solid waste management (which deals with other kinds of waste) in order to achieve total sanitation,” said Kini.

 
We welcome your comments at letters@scroll.in.
Sponsored Content BY 

What hospitals can do to drive entrepreneurship and enhance patient experience

Hospitals can perform better by partnering with entrepreneurs and encouraging a culture of intrapreneurship focused on customer centricity.

At the Emory University Hospital in Atlanta, visitors don’t have to worry about navigating their way across the complex hospital premises. All they need to do is download wayfinding tools from the installed digital signage onto their smartphone and get step by step directions. Other hospitals have digital signage in surgical waiting rooms that share surgery updates with the anxious families waiting outside, or offer general information to visitors in waiting rooms. Many others use digital registration tools to reduce check-in time or have Smart TVs in patient rooms that serve educational and anxiety alleviating content.

Most of these tech enabled solutions have emerged as hospitals look for better ways to enhance patient experience – one of the top criteria in evaluating hospital performance. Patient experience accounts for 25% of a hospital’s Value-Based Purchasing (VBP) score as per the US government’s Centres for Medicare and Mediaid Services (CMS) programme. As a Mckinsey report says, hospitals need to break down a patient’s journey into various aspects, clinical and non-clinical, and seek ways of improving every touch point in the journey. As hospitals also need to focus on delivering quality healthcare, they are increasingly collaborating with entrepreneurs who offer such patient centric solutions or encouraging innovative intrapreneurship within the organization.

At the Hospital Leadership Summit hosted by Abbott, some of the speakers from diverse industry backgrounds brought up the role of entrepreneurship in order to deliver on patient experience.

Getting the best from collaborations

Speakers such as Dr Naresh Trehan, Chairman and Managing Director - Medanta Hospitals, and Meena Ganesh, CEO and MD - Portea Medical, who spoke at the panel discussion on “Are we fit for the world of new consumers?”, highlighted the importance of collaborating with entrepreneurs to fill the gaps in the patient experience eco system. As Dr Trehan says, “As healthcare service providers we are too steeped in our own work. So even though we may realize there are gaps in customer experience delivery, we don’t want to get distracted from our core job, which is healthcare delivery. We would rather leave the job of filling those gaps to an outsider who can do it well.”

Meena Ganesh shares a similar view when she says that entrepreneurs offer an outsider’s fresh perspective on the existing gaps in healthcare. They are therefore better equipped to offer disruptive technology solutions that put the customer right at the center. Her own venture, Portea Medical, was born out of a need in the hitherto unaddressed area of patient experience – quality home care.

There are enough examples of hospitals that have gained significantly by partnering with or investing in such ventures. For example, the Children’s Medical Centre in Dallas actively invests in tech startups to offer better care to its patients. One such startup produces sensors smaller than a grain of sand, that can be embedded in pills to alert caregivers if a medication has been taken or not. Another app delivers care givers at customers’ door step for check-ups. Providence St Joseph’s Health, that has medical centres across the U.S., has invested in a range of startups that address different patient needs – from patient feedback and wearable monitoring devices to remote video interpretation and surgical blood loss monitoring. UNC Hospital in North Carolina uses a change management platform developed by a startup in order to improve patient experience at its Emergency and Dermatology departments. The platform essentially comes with a friendly and non-intrusive way to gather patient feedback.

When intrapreneurship can lead to patient centric innovation

Hospitals can also encourage a culture of intrapreneurship within the organization. According to Meena Ganesh, this would mean building a ‘listening organization’ because as she says, listening and being open to new ideas leads to innovation. Santosh Desai, MD& CEO - Future Brands Ltd, who was also part of the panel discussion, feels that most innovations are a result of looking at “large cultural shifts, outside the frame of narrow business”. So hospitals will need to encourage enterprising professionals in the organization to observe behavior trends as part of the ideation process. Also, as Dr Ram Narain, Executive Director, Kokilaben Dhirubhai Ambani Hospital, points out, they will need to tell the employees who have the potential to drive innovative initiatives, “Do not fail, but if you fail, we still back you.” Innovative companies such as Google actively follow this practice, allowing employees to pick projects they are passionate about and work on them to deliver fresh solutions.

Realizing the need to encourage new ideas among employees to enhance patient experience, many healthcare enterprises are instituting innovative strategies. Henry Ford System, for example, began a system of rewarding great employee ideas. One internal contest was around clinical applications for wearable technology. The incentive was particularly attractive – a cash prize of $ 10,000 to the winners. Not surprisingly, the employees came up with some very innovative ideas that included: a system to record mobility of acute care patients through wearable trackers, health reminder system for elderly patients and mobile game interface with activity trackers to encourage children towards exercising. The employees admitted later that the exercise was so interesting that they would have participated in it even without a cash prize incentive.

Another example is Penn Medicine in Philadelphia which launched an ‘innovation tournament’ across the organization as part of its efforts to improve patient care. Participants worked with professors from Wharton Business School to prepare for the ideas challenge. More than 1,750 ideas were submitted by 1,400 participants, out of which 10 were selected. The focus was on getting ideas around the front end and some of the submitted ideas included:

  • Check-out management: Exclusive waiting rooms with TV, Internet and other facilities for patients waiting to be discharged so as to reduce space congestion and make their waiting time more comfortable.
  • Space for emotional privacy: An exclusive and friendly space for individuals and families to mourn the loss of dear ones in private.
  • Online patient organizer: A web based app that helps first time patients prepare better for their appointment by providing check lists for documents, medicines, etc to be carried and giving information regarding the hospital navigation, the consulting doctor etc.
  • Help for non-English speakers: Iconography cards to help non-English speaking patients express themselves and seek help in case of emergencies or other situations.

As Arlen Meyers, MD, President and CEO of the Society of Physician Entrepreneurs, says in a report, although many good ideas come from the front line, physicians must also be encouraged to think innovatively about patient experience. An academic study also builds a strong case to encourage intrapreneurship among nurses. Given they comprise a large part of the front-line staff for healthcare delivery, nurses should also be given the freedom to create and design innovative systems for improving patient experience.

According to a Harvard Business Review article quoted in a university study, employees who have the potential to be intrapreneurs, show some marked characteristics. These include a sense of ownership, perseverance, emotional intelligence and the ability to look at the big picture along with the desire, and ideas, to improve it. But trust and support of the management is essential to bringing out and taking the ideas forward.

Creating an environment conducive to innovation is the first step to bringing about innovation-driven outcomes. These were just some of the insights on healthcare management gleaned from the Hospital Leadership Summit hosted by Abbott. In over 150 countries, Abbott, which is among the top 100 global innovator companies, is working with hospitals and healthcare professionals to improve the quality of health services.

To read more content on best practices for hospital leaders, visit Abbott’s Bringing Health to Life portal here.

This article was produced on behalf of Abbott by the Scroll.in marketing team and not by the Scroll.in editorial staff.