Original research BMJ Glob Health: first published as 10.1136/bmjgh-2019-002277 on 25 March 2020. Downloaded from Evaluating the declarations of open defecation free status under the Swachh Bharat (‘Clean India’) Mission: repeated cross- sectional surveys in Rajasthan, India 1 2 3 4 Natalie G Exum , Emma M Gorin, Goutam Sadhu, Anoop Khanna, Kellogg J Schwab1 To cite: Exum NG, Gorin EM, ABSTRACT Key questions Sadhu G, et al. Evaluating Background The most ambitious sanitation campaign the declarations of open to end open defecation (OD) in India came to a close What is already known? defecation free status under on 2 October 2019 and there are limited independent, the Swachh Bharat (‘Clean Since the 2014 initiation of the Swachh Bharat robust data to measure its success. We aimed to evaluate ► India’) Mission: repeated cross- Mission (SBM) in India there has been limited inde- Rajasthan’s claim of open defecation free status in March sectional surveys in Rajasthan, pendent monitoring of toilet construction to measure 2018 under the Swachh Bharat Mission (SBM) or ‘Clean India. BMJ Global Health success of the campaign at scale. 2020;5:e002277. doi:10.1136/ India Mission’ by measuring OD trends from 2016 to 2018. ► Rajasthan state, within the rural areas, was declared bmjgh-2019-002277 Methods We used publicly available data from open defecation free (ODF) in March 2018. Performance Monitoring and Accountability 2020, Handling editor Seye Abimbola a representative survey with two- stage stratified What are the new findings? cluster sampling. Enumeration areas were the primary ► Evidence to assess SBM from a large, randomly sam- Received 27 December 2019 sampling units selected by the probability proportional pled statewide household survey in Rajasthan found Revised 14 February 2020 to size method. The repeated cross- sectional surveys open defecation practices decreased from 63.3% in Accepted 28 February 2020 independently collected household water and sanitation October 2016 to 45.8% in July 2018 among rural data in Rajasthan (n=20 485). Among households reporting Rajasthan households. toilet access, the data were pooled across the four rounds ► In July 2018 an additional 21.7% of rural households http://gh.bmj.com/ for an observational analysis using logistic regression. with a toilet facility reported that at least one mem- The primary outcome measure was regular OD among ber continues to openly defecate. households with access to toilet facilities. © Author(s) (or their Findings Between October 2016 and July 2018 main OD What do the new findings imply? employer(s)) 2020. Re- use ► There is a need for credible, independent monitoring permitted under CC BY- NC. No practices in rural Rajasthan households decreased from commercial re- use. See rights 63.3% (95% CI 57.0% to 69.6%) to 45.8% (95% CI 38.4% to that can offer robust, statewide representative esti- and permissions. Published by 53.2%) and in urban households from 12.6% (95% CI 6.0% mates to measure outcomes towards an ODF India. on September 25, 2021 by guest. Protected copyright. BMJ. to 19.1%) to 9.4% (95% CI 4.0% to 14.7%). Households ► Continued investments are needed to ensure that 1Environmental Health and with regular OD occurring despite access to a toilet made up toilet construction will be affordable and continue Engineering, Bloomberg School 21.7% (95% CI 16.9% to 26.6%) of rural and 12.1% (95% into the post- SBM future. of Public Health, Johns Hopkins CI 3.6% to 20.7%) of urban Rajasthan as of July 2018. The University, Baltimore, Maryland, multivariate logistic regression revealed that factors related USA to water stress and sanitation sharing were associated with 1 2 diarrhoeal disease accounting for an esti- International Health, Bloomberg household members regularly practising OD. 2 School of Public Health, Johns mated 13% of the deaths in India, creates Conclusions These data highlight the importance of a Hopkins University, Baltimore, undignified and unsafe conditions for women continued focus on constructing toilets that are affordable Maryland, USA and girls,3–7 transmits community- acquired 3 with low water requirements during the next phase of SBM. School of Development multidrug resistant infections across borders,8 Studies, Indian Institute of An independent survey that can provide robust estimates of 9 Health Management Research OD is needed to monitor progress of toilet construction and and contaminates the environment. The University, Jaipur, India use. majority of the world’s OD takes place in 4Indian Institute of Health India. As of December 2015, almost two- Management Research, Jaipur, thirds of the 892 million people worldwide India still practising OD were estimated to be in 10 Correspondence to INTRODUCTION India. The Government of India was moti- Dr Natalie G Exum; Open defecation (OD) is a widespread and vated to end OD entirely and in 2014 initiated nexum1@ jhu. edu persistent practice in India that spreads the Swachh Bharat Mission (SBM) or ‘Clean Exum NG, et al. BMJ Global Health 2020;5:e002277. doi:10.1136/bmjgh-2019-002277 1 BMJ Global Health BMJ Glob Health: first published as 10.1136/bmjgh-2019-002277 on 25 March 2020. Downloaded from India Mission’. The goal of SBM was to accelerate sanita- limited surface water sources. The per capita water availa- tion coverage so all households have access to a toilet and bility is less than half (807 m3) of India’s national average eliminate OD by October 2019, designed to coincide with (2000 m3) and is expected to decline to 457 m3 by 2045 Mahatma Gandhi’s 150th birthday. moving Rajasthan into absolute water scarcity.17 Toilet construction is a critical element of SBM. Under the programme over 100 million toilets have been built PMA2020 data and household survey as of the close of the first phase of SBM on 2 October The data for this evaluation came from the PMA2020 2019 and almost all states in India have been declared survey initiated in Rajasthan in 2016. The goal was to open defecation free (ODF) as documented by the real- collect family planning and WASH data in semiannual time, publicly available data on the SBM dashboard.11 surveys representative of the state’s entire population. Rajasthan state, where nearly eight million toilets were PMA2020 uses a cross-sectional design with two-stage, constructed in rural households, was declared ODF in cluster random sampling implemented by IIHMR in March 2018. The progress made to construct toilets and Jaipur, a public health research organisation with a focus reduce OD in India over the past 5 years has been remark- on management research, education and training in the able, however the claim that OD has ended is in question. health and related sectors. The survey had endorsement Estimates as of late 2018, found that 53% of individuals and technical support provided by the International in rural areas still openly defecated, indicating that Institute for Population Sciences (IIPS) and the Ministry Rajasthan had not yet achieved ODF status.12 Ongoing of Health and Family Welfare. Interviews for the surveys monitoring of toilet coverage and use is key to ensuring are conducted by female enumerators that hold at least a long- term sustainability of ODF in Rajasthan. Since secondary education and are trained in the interviewing 2016, Performance Monitoring and Accountability 2020 methods necessary to administer household question- (PMA2020), in collaboration with the Indian Institute of naires on WASH infrastructure and practices. Enumer- Health Management Research University (IIHMR), has ators were also trained on the use of mobile phones and collected state- wide data on the practice of OD in Rajas- Open Data Kit (ODK) software to ensure proficiency in than on an independent basis. PMA2020 was created to the technology that enables rapid data collection. All provide rapid and frequent estimates of family planning PMA2020 questionnaires were administered using ODK outcomes and provided an ideal opportunity to also software and Android smartphones. The questionnaires monitor SBM.13 In Rajasthan the PMA2020 survey was were in English and could be switched into Hindi on the designed to be representative of the state and collected phone. household water, sanitation and hygiene (WASH) data PMA2020 uses standardised household questionnaires on a semiannual basis. that allow for comparability across programme countries The objective of this study was to investigate the OD and are consistent with existing national surveys. Prior to trends in Rajasthan during SBM from 2016 to 2018 and launching the survey in Rajasthan, local experts reviewed analyse the main household characteristics associated and modified these questionnaires to ensure all ques- http://gh.bmj.com/ with OD practices in households with access to toilet tions were appropriate for the Rajasthan setting. The facilities. This was achieved using a pooled cross- sectional household questionnaires were based on model surveys analysis from four survey rounds that collected house- designed by PMA2020 staff at the Bill & Melinda Gates hold data on the WASH characteristics and the OD prac- Institute for Population and Reproductive Health at the tices of individuals in the household. Johns Hopkins Bloomberg School of Public Health in Baltimore, Maryland, USA, IIHMR University in Jaipur, on September 25, 2021 by guest. Protected copyright. and fieldwork materials of the India National Family METHODS Health Survey. Setting Rajasthan is the seventh most populous state in India Sampling strategy and is categorised as one of the seven low income states The PMA2020 data collection in Rajasthan, India (LIS) with 69 million people of whom 10 million are cate- (PMA2016/Rajasthan) used two-stage cluster sampling gorised as poor.14 The urban versus rural breakdown of from urban/rural strata with a sample of 147 enumera- the population as of 2011 is 25% urban versus 75% rural tion areas (EAs).