The dust kicked up by brooms of the neo-sanitation evangelists have obscured more important issues. Hygiene is one. In its broadest sense this covers a broad spectrum of activities that ensure health. These cover washing hands with soap or ash after cleaning up after defecating and before eating or serving food; keeping drinking water covered and; cutting nails and hair to reduce the likelihood of gathering disease-causing germs.

Hygiene is different from cleanliness that has been interpreted to mean sanitizing the environment. It is a set of actions individuals take to reduce the chances of falling sick. Good hygiene can reduce sickness from eating or drinking contaminated foodor water by as much as 45 per cent. That is a lot of gain from the simple hygiene steps mentioned above. Washing hands with soap or ash after cleaning up after defecating is common sense but is not as popular as one may think. Studies show most Indians wash their hands with water but only a third use soap or ash.

Even though they are so obvious, hygiene practices need to be inculcated. Washing hands before eating is done in the breach more often than not; more people wash hands after eating than before. Cutting nails is another infrequent activity and dirty nails are a veritable sea of vicious bacteria gathered from all over, including faeces – yes, when one washes up after defecating some excreta finds its way under long uncut nails and thence into the food we eat.

Hygiene is the cement that binds water and sanitation into one whole and underpins good health. The purpose of improving sanitation and providing clean water is to improve health, education and other development indicators. But without hygiene to hold them together both sanitation and water supply become typical government engineering ‘feats of numbers’ where quantity trumps quality. In practice this translates into building toilets for the poor – very inferior in quality, poorly designed and situated – and sinking handpumps – a third or more fail within a few months.

Without hygiene, toilet use is abysmal. A series of studies since the late 1990s broadly say only about half of households in rural India with a toilet use it. According to the Census 2011 about 33 per cent have toilets. That means only 16.5 per cent actually use them. Reasons vary from poor and unfinished toilets to lack of understanding of hygiene. If an overarching reason be given, it is because people do not adequately appreciate how hygiene can improve health and where toilets fit in puzzle.

The other part of the picture is water. Hygienic handling of water is keeping drinking water in a covered pot and taking it out with a ladle or tap. This is also followed mostly in the breach with less than 30 per cent using covered vessels. To purify water half of the people use simple cloth filtration and a third boil water. Water that does not smell, have a bad taste or visible impurities is considered clean to drink. This is quite different from water that is actually safe to drink since bacteria and chemical impurities are not usually visible to the naked eye and seldom cause water to smell or taste bad.

Hygiene is critical because it teaches people how to cut disease vectors. Handwashing at critical times has the highest impact on incidence of disease. Some studies say this simple act can cut water borne diseases such as diarrhea by nearly half. Hands must be washed with at least ash if soap is not available after defecation, handling children’s stools and before eating or handling food. This aspect of hygiene can be extended to the need for separating and containing excreta, through toilets for example. By extension, the concept of sanitation can be brought in through the hygiene door by demonstrating how open defecation can increase the chances of falling ill. In fact, a recent study says that merely constructing toilets has little effect on the incidence of diarrhea. Even if as many 63 per cent households have toilets, their use hovers at 50 per cent, there is no noticeable drop in disease. Studies in other states indicate the use of toilets is 60 per cent.

The safe storage of water comes second and can reduce the incidence of diarrhea by about 28 per cent. If water is not contaminated at source, improper transport and storage inevitably results in contamination. Studies have put the rate of contamination as high at 76 per cent.

For the on-going Swacch Bharat Mission (SBM) hygiene becomes a central concern. Ensuring proper hygiene education during the sanitation project lifecycle is a non-negotiable. The most effective way is through personal contact between people trained in hygiene and the mass public. This is a slow and resource-intensive process. At the moment the government does have enough boots on the ground under the Mission to do so. It can use existing front-line workers such as auxiliary nurses-midwives, accredited social and health activists, village secretaries and water and sanitation committees. Non-government organizations have another large reservoir of human resources. Both resource pools need intensive training at the earliest to be repurposed and deployed. At the macro level, an intensive mass media campaign as is being done against smoking must be carried out to send out hygiene messages.

The government is clearly not serious about hygiene. It has cut the budget for hygiene promotion (under the guise of information education and communication) to just 8 per cent of the Mission’s funds down from 15 per cent earlier. Sure, government officials have been lousy at promoting hygiene as a study shows just 9 per cent of people constructed toilets after an official spoke to them. But cutting the budget is throwing the baby out with the bathwater.

This will undermine the utility of the Mission and the infrastructure it creates. Assuming we accept the role of the government is to provide subsidies for constructing toilets, this must be bolstered by an appropriately large fund for promoting hygiene. Hygiene will ensure people realize the importance of toilets in their health and use them once they have been built. The budget for promoting hygiene must be raised to at least 25 per cent of the total. Else SBM will be in danger of repeating mistakes of the past 28 years of sanitation programmes and build 110 million toilet nobody will want to use.

The author is Head of Policy, WaterAid India

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