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India’s Water and Sanitation 3.0: A Blueprint for Sustainable Development

Photo: Amarjeet Kumar Singh/Anadolu/Getty Images

Commentary by Bhawna Prakash

Published April 25, 2024

This summer, 969 million Indians will vote for their national government. From increasing access to potable water to widescale implementation of hygiene promotion programs, Prime Minister Modi’s government has made commendable efforts since 2014. However, the new government will face the challenge of establishing robust water and sanitation delivery mechanisms amid escalating climate crises and water shortages . These systems must ensure universal, equitable, affordable, sustainable, and safely managed services, as envisioned under the United Nations’ Sustainable Development Goal 6 . To address this challenge, the government should implement a revamped water, sanitation, and hygiene (WASH) program focusing on three strategic priorities: performance enhancement and system reforms, a thriving WASH market for the private sector, and integrated planning and management.

The Journey So Far

In the last decade, India made strategic WASH investments through national missions. The first iteration, “WASH 1.0” (2014–19), prioritized basic sanitation to address the dignity of millions and launched the Swachh Bharat Mission (SBM) across urban and rural areas. Notably, SBM Rural built over 100 million household toilets and 230,000 community and public toilets between 2014 and 2019.

“WASH 2.0” (2019–24) introduced water as a strategic focus. The budget for SBM Urban increased from $7.6 billion for 2014–19 to $17.3 billion for 2021–26. The Jal Jeevan Mission achieved significant progress in portable water access. Additionally, the Atal Mission for Rejuvenation and Urban Transformation (AMRUT) focused on basic urban infrastructure, including WASH for cities with populations exceeding 100,000.

India requires further enhancements in solid waste processing. Embracing circularity across value chains and wastewater treatment are necessary. Additionally, as India elects the new government, the focus must be on WASH systems and markets.

The Road Ahead: WASH 3.0

The incoming government should double down on its efforts, broaden their scope, and execute three strategic imperatives as part of a “WASH 3.0” program:

Prioritize performance enhancement and system reforms . Most water, wastewater, and waste services are provided by government bodies. Inadequate data and reporting limits their assessment. These agencies should be required to regularly publish detailed operational, financial, and management data. The sustainability of these services hinges on their ability to recover costs, whether partially or in full, and to demonstrate operational excellence. Accountability for financial performance is crucial.

The government must prioritize service charge recovery to prevent waste of valuable resources. Pricing decisions tend to be influenced by political economy. While ensuring equitable WASH for all, the government can selectively implement recovery mechanisms in progressive cities, balancing value recognition with public goods. Addressing the issue of “non-revenue water”—water that remains unbilled—would significantly enhance the sector’s financial health.

Responsible governance, accountability, and transparency are vital in the sector, further necessitating an evaluation of an economic regulator for WASH.

Create a thriving WASH market for the private sector . Water and sanitation are not only public responsibilities but also economic opportunities. By fostering a vibrant WASH market, India can unlock innovation, efficiency, and accountability. While public funds have driven water and sanitation initiatives, limited private sector involvement exists through corporate social responsibility and some public-private partnerships. The government should strengthen private sector participation by leveraging the recent surge of start-ups in the sector and companies committed to environmental, social, and governance (ESG) investments. Energy, transport, consumer goods, cement, construction, infrastructure, and technology companies can play a critical role by emphasizing resource efficiency, developing a circular economy, and optimizing supply chains.

WASH 3.0 should adopt a market-based approach, incentivizing micro, small, and medium enterprises (MSMEs) and community-based initiatives. Forming innovative financing partnerships with development financial institutions (DFIs) and philanthropic organizations, in addition to leveraging civic and IT innovations, will be crucial. The government should primarily play an enabling role, setting policy and enforcing it.

The future of the sector hangs in the balance. Is India ready for privatization of WASH utilities and services? As the government evaluates this question, it must confront the challenges of delayed payments, regulatory approvals, contractual risks, working capital gaps, inadequacy of trained resources, and safety concerns.

Integrate planning and management . A unified approach is needed to break silos to forge a resilient and interconnected system of water, sanitation, wastewater, and waste. The water shortages in Bangalore and Chennai are glaring examples of WASH emergencies exacerbated by climate change and the inefficacy of erstwhile water management approaches.

Integrated water planning often gets lost amid the complexity of multiple government schemes, departments, and silos. To address this, the government should envision an integrated water-security management platform for cities and states to bridge gaps between agencies, fostering collaboration and improving planning. Through this new platform, states should prioritize water security, ensuring safe water and sanitation services across regions while breaking down operational barriers.

A digitized view encompassing water sources, deployment, usage, infrastructure, costs, and charges is urgently needed. For instance, in water-scarce Rajasthan, responsibilities are divided: the Public Health and Engineering Department handles infrastructure, the Water Resource Department oversees canals and dams, and the Panchayati Raj Department manages rural sanitation and wastewater. An integrated approach to optimize planning and ensure safe water supply for newly constructed taps is essential.

For WASH 3.0, the challenges lie in effective resource management. While water remains a public good that is critical for India’s growth, performance enhancement and private sector participation can alleviate sectoral pressures. To achieve India’s $5 trillion economy vision, valuing water—both fresh and wastewater—is paramount. Initiating progressive discussions on planning, resourcing, and management is imperative for a sustainable future.

Bhawna Prakash is a non-resident fellow with the Chair in U.S.-India Policy Studies at the Center for Strategic and International Studies in Washington, DC.

Commentary is produced by the Center for Strategic and International Studies (CSIS), a private, tax-exempt institution focusing on international public policy issues. Its research is nonpartisan and nonproprietary. CSIS does not take specific policy positions. Accordingly, all views, positions, and conclusions expressed in this publication should be understood to be solely those of the author(s).

© 2024 by the Center for Strategic and International Studies. All rights reserved.

Bhawna Prakash

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Achievements and challenges of India's sanitation campaign under clean India mission: A commentary

Manas ranjan behera.

School of Public Health, KIIT Deemed to be University, Odisha, Bhubaneswar, India

Himanshu Sekhar Pradhan

Deepanjali behera.

1 National Health Mission, Department of Health and Family Welfare, Government of Odisha, Odisha, Bhubaneswar, India

Damodar Jena

2 School of Rural Management, KIIT Deemed to be University, Bhubaneswar, Odisha, India

Sudhir Kumar Satpathy

Universal access to safe sanitation is yet to be accomplished in India. Although Clean India Mission (named as “Swachh Bharat Mission (Gramin)” for rural India) claims that the sanitation coverage in rural India has increased from 39% to 100% of households from 2014 and 2019, yet open defaecation continues in India in large numbers. This article discusses the achievements on Swachh Bharat Mission (Gramin) and identifies the existing challenges that need to be acted on to achieve the success of India's Swachh Bharat Mission. We searched international database mainly Google scholar, Pubmed, Medline, Scopus, and Science direct using “Clean India,” “Swachh Bharat,” “Sanitation,” “Open defecation,” “Environmental heath,” and “India” as search keywords in different combinations. In addition, websites of relevant United Nations (UN) agencies, Government of India and leading newspaper and national agencies were also searched manually for related publications and reports. In the last 5 years (2014-2019), significant efforts have been made for the Swachh Bharat Mission by creating various social movements and awareness program to improve toilet coverage throughout India. Over 100 million, latrines have been built as of the end of the first phase of Swachh Bharat Mission (Gramin) as on October 2, 2019 and all villages across the districts of India have been declared Open Defaecation Free. Still, nearly half of the rural population (52.1%) defecate in the open. Lack of piped water supply, poor construction of toilet substructures and misconception among people about toilet use remain as key challenges in the achievement of India's sanitation mission. Sanitation-related behavioral change and improvement in toilet facilities must be prioritized to ensure usage of built toilets and eventually can accelerate the universal access to sanitation and meet Sustainable Development Goals.

Introduction

The Global Nutrition Report 2018 states, the prevalence of stunting among children under 5 years of age in India is 37.9%,[ 1 ] which is highest in the world.[ 1 ] Also as per the latest National Family Health Survey IV (2015-2016), 38.4% of children below 5 years suffer from stunting.[ 2 ] In addition, diarrhea is the third most common cause of death among children below 5 years in India and is responsible for 13% of deaths in this age group.[ 3 , 4 ] Thus, in India, death due to diarrhea alone constitutes an estimated of 300,000 children per year.[ 3 , 4 ] Both these conditions are strongly associated with the unsafe water, poor sanitation, and hygiene practices. Evidences suggest, three main pathways between poor sanitation and stunting, for example, environmental enteric dysfunction (EED),[ 5 ] diarrheal diseases,[ 6 ] and nematode infections.[ 7 ] First, a study in Gambian children illustrates that growth retardation had an association with persistent abnormalities to the intestinal mucosa, leading to EED.[ 8 , 9 ] This is proposed to be primary causal pathway between poor sanitation and stunting.[ 5 ] The second casual pathway where households are not practicing safe disposal of stool can result in the spread of fecal contamination to the environment. If left untreated, human feces containing pathogens enter the fecal-oral route of transmission,[ 10 ] causing diarrhea.[ 6 , 11 ] The repeated episode of diarrhea results in stunting or chronic malnutrition. The third casual pathway suggests, poor sanitation had an association with stunting is through soil-transmitted infections (helminths), such as Trichuris Trichiura, Hookworm, and Ascaris Lumbricoides. These infections create mal-absorption of nutrients resulting growth failure among children.[ 12 ] Evidence highlights the use of toilet facilities reduces the soil-transmitted infections (helminths), confirming the third casual pathway.[ 13 , 14 ] Hence, safe sanitation is essential for growth of the child, for reduction of the infectious diseases, for human dignity, health, and wellbeing and for gender equity,[ 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 ] has yet to reach 25% of the global population.[ 24 ]

Open defecation and poor sanitation facilities hinder any country's public health development and directly associated with child's growth resulting premature mortality.[ 25 ] Literatures suggest that open defecation plays a crucial role in determining childhood malnutrition in India.[ 26 , 27 ] However, few studies have also pointed out that genetics might have the reasons for the stunted growth of Indian Children,[ 28 ] but most studies contradicting this point claim that stunted growth among children is strongly correlated with unsafe environmental condition and open defecation. In addition, lack of sanitation leads to psychosocial stress among girls and women because of the environmental obstacles, such as unsafe toilets and physical distance, fears of sexual violence, and social factors.[ 21 ] UNICEF also estimates that inadequate sanitation costs about $189 billion (i.e., 7.9% of GDP) to India due to productivity lost, losses in tourism, and medical costs.[ 29 ]

Although open defecation in rural India has declined significantly and improvements in toilet coverage has been made under Swachh Bharat Mission (Gramin), still interstate variations across regions in coverage and toilet uptake has been found. Many researchers have also expressed uncertainty about how open defecation-free (ODF) status is verified and about the statistics that government publishes publicly.[ 30 , 31 ] For example, one study reported that out of eight villages that had actually universal sanitation coverage in 2018, only one declare to be ODF.[ 32 ] Therefore, in this paper, we examine the achievements on Swachh Bharat Mission (Gramin) and identify the existing gaps and challenges that need to be acted upon to achieve the success of India's Swachh Bharat Mission.

About India's Swachh Bharat Mission

Many countries especially, South East Asia and sub-Saharan Africa, have engaged in putting efforts to improve their latrine ownership rate. India – a part of global south, in the past 5 years have been transformed through centrally led government program named the Clean India Mission (Swachh Bharat Mission) (Gramin) or SBM (G). The SBM is the world's largest sanitation program, launched in the year of 2014 by the current Indian Prime Minister Mr. Narendra Modi. It aims to achieve universal access to sanitation for all and to make villages clean, sanitized, and ODF.[ 33 ] Since its inception, official figures suggested nearly 100 million toilets have been built, by providing monetary incentives to the eligible households, engaging local governments (also known as Panchyat Raj Institutions) and communities in toilet construction, by conducting mass awareness campaigns for behavioral change and in monitoring the progress to achieve the targets.[ 34 ] In 2015, India puts national sanitation coverage at 39%[ 35 ] and rural India, was accountable for 60% ODF.[ 36 ] Today, India has reached at milestone, where the latest SBM data show almost 100% sanitation coverage in total population[ 33 ] and other sample studies reveals, in rural India, there is good progress insanitation coverage (93.3%),[ 37 ] but latrine ownership rate is found to be lower (71.3%).[ 38 ]

The basic of sanitation in public health is to prevent the harmful pathogens entering into human bodies and to stop fecal-oral transmissions. SBM, therefore, constituted an instrumental barrier in terminating this though construction of latrine and the promotion of the latrine usage. Studies across the globe demonstrates, widespread sanitation practice have a significant association with the improvement of health and nutritional status among children; thereby reducing catastrophic household health-care expenditure.[ 29 , 39 , 40 ] Now, India needs to accelerate this nationwide sanitation drive by strengthening the links between health and sanitation to optimize potential gains attributed by SBM.

Sanitation Technology under Swachh Bharat Mission

The safely managed sanitation in households is mainly dependent on the adaption of toilet technology, and the availability of space for on-site containment system. There are various safe sanitation technologies available such twin leach pit, eco scan, bio-toilets, and septic tank with soak pit. However, SBM encouraged in building twin-leach pit latrines. These latrines are made up with low-cost sanitation technology, easy to build and have simpler on-site treatment process, which can effectively deal with excreta, if constructed correctly. However, misconception about, this technology has limited acceptance due to poor construction of toilet substructures and incorrect architecture modification, that reduces toilet efficacy.[ 41 ] Many rural households have built structure for excreta containment that fails to treat human waste from toilets, rather it just holds the excreta. This is because, people belief that these latrines (twin-leach pit) are meant for poor households and fears that the pits will fill-up in a rapid way. Family occasionally construct wider or deeper pits that have flout design principle, without referring the suggestive distance recommended by government from the water sources.[ 41 , 42 ] Across country, water table variation and terrain difference (hilly, rocky, coastal, and dessert) exit, that calls for adapting different technologies for toilet construction; failure to which can lead environmental contamination.[ 41 ] There is need for site-specific solutions to ensure safe sanitation for all. In addition, single leach pit latrines, septic tanks and containment structures, once filled, require skilled services for emptying and transportation of the fecal sludge to the treatment facilities for its subsequent disposal or reuse.[ 43 ] The absence of such facilities mainly in rural areas can lead to in-human practice of manual scavenging resulting caste-based stigma and oppression among marginalized sections of society.[ 44 ]

Some Challenges and Focus on Behavior Change

Infrastructures for toilet are important, but cannot alone stand as pre-requisite to interrupt fecal-oral transmission of pathogens. In rural areas, lack of water supply is a key issue,[ 30 ] only 42.5% of households had access to water for use in toilets,[ 45 ] which increase toilet nonusage rates. Other challenges such as improper fecal sludge management, inappropriate toilet technologies, and inadequate human resources persist that endanger in achieving sanitation coverage in rural areas. Important considerations such as appropriate and sustainable technologies, full involvement in sanitation program, social norms and individual attitude toward latrine use, sanitation-related behaviors, awareness creation, and various social movements are needed which not only increase toilet use, but also, helps in sustaining ODF status that ultimately, reap benefits to population health.

Sanitation-related behaviors require top priority in this context. Recent national surveys indicate that 95.7% of females and 94.7% of males used toilet regularly in rural areas among those households had access to toilet.[ 46 ] Another study conducted in four north Indian states suggest that toilet usage in rural households are increasing to an extent of 56%.[ 38 ] In addition, research in rural India and field experience suggest that people are slowly developing the habit of using toilet. Data suggest that open defecation has decreased by 12% from 2015 to 2019, which means that nearly half of the rural population still defecates in the open.[ 24 ] Open defection is traditional behavior in rural India and people perceive it to be healthier, cleaner, and sometimes “religiously acceptable.”[ 34 ] This issue of open defecation is of greater concern and worrisome because government studies indicate, the proportion of children below 15 years of old is practicing open defecation more frequently than other age groups.[ 45 ] Nearly, 57% of children younger than 10 years in cities and 15 years in rural areas are defecating in the open. This puts the child health at risk, leading to various diseases that are linked to unsafe sanitary practices. The recent study suggests that unsafe stool disposal is one of the major causative factors accountable for stunting and under-five mortality in India.[ 47 ] The prevalence of diarrhea and stunting is clearly found to be higher in those households, where unsafe stool disposal and open defecation was practiced.[ 47 , 48 ] Therefore, investment alone cannot be held responsible to bring improvement of the sanitation program in India. O'Reilly and Louiss in their study in rural villages of Himachal Pradesh and West Bengal suggested three factors (i.e., Toilet Tripod) (1) favorable political environment, (2) strong political will, and (3) person to person contact (proximate) social pressure can be considered as successful adaption of the sanitation program in India.[ 49 ] Another important cost-effective public health intervention is hand hygiene,[ 50 ] which are as important as toilet use. Even though, an individual use toilet but if he/she cannot wash hands post-defecation or after handling child excreta, then they still remain at a risk of transmitting pathogens to the children during feeding the child, cooking, and eating. Hand washing facilities such as water, soap, and hand washing space are not always available; thus practice of hand washing with soap and water becomes inconsistent in many areas of rural India.[ 51 ] To bring out favorable health outcomes, well-designed strategies addressing sanitation and hygiene behaviors are fundamental to ensure availability of water and soap while using toilet.[ 52 ]

Discussion and Way Forward

While, India has made substantial progress in sanitation coverage, some individuals, households, and community belonging to disadvantage sections of the society such as female-headed household, landless people, migrant laborers, and disable people-still do not have toilets in their home or find the existing toilets not accessible. It is crucial to support these un-served populations both from human rights and public health perspectives because these marginalized sections are already without access to basic services and experience various health issues. Educational institutions, child-care centers, hospitals, and other government facilities need further development in sanitation practices. Sanitation coverage disaggregated data in public facilities and among the disadvantaged sections of society requires innovation to cover missed population will be vital in this context.

For India to realize in achieving sustainable development goal 6 (SDG), i.e., “ensure access to water and sanitation for all” by 2030, a number of factors needs to be considered. Country like India, which is vast in her diversity, culture, and population, where 60% of total population resides in rural areas,[ 53 ] only access to toilet does not ensure hygienic and safe sanitation practices. For instance, lesson from the India's first sanitation program “Central Rural Sanitation Programme” launched in 1986, stated that only toilet construction did not translate to usage of toilets. This program focused on the household toilets construction and promotion of the pour-flush toilets. However, this program lacks the focus on behavior change toward toilet use that led failure of the program.[ 34 , 46 ] Further, the succeeding Total Sanitation Campaign (TSC) which launched in 1999, aimed at making India ODF by 2017. Unfortunately, this campaign blamed with poor results mainly due to inadequacy in political leadership, the misuse of subsidies, lack of confidence to measure success, poor monitoring mechanisms, and supply-led top-down approach.[ 54 ] Under TSC, nearly 34.8 million toilets in below poverty line households and 64.3 million individual household toilets were constructed. Despite, such efforts and investments, a review of TSC mentioned, nearly 72.63% of household in rural areas still defecates openly even though they have access to toilets.[ 55 ] Considering this fact, the SBM (G) has learnt how to resolve, some of these issues, by capitalizing political support, to pay subsidies directly to households through e-banking, strengthening monitoring system through technological platform and broadcasting the success of the program. Moreover, one of the main aims of the SBM (G) is to change behavior of the people through information, education, and communication campaign and to provide individual toilet facilities in all households to achieve the goal of ODF by October 2, 2019 – to honor the 150 th birthday of Mahatma Gandhi. The central government is also focusing how to change the mindset of the people to adopt improved sanitation and to stop open defecation. It also emphasizes on the adverse heath outcome that comes as a result of unsafe sanitary practices. The Swachha Status Report of GoI states, in rural areas, only 45.3% households reported access to sanitary toilets that ensures hygienic practices of sanitation and safe stool disposal. Empirical evidence also highlights the benefits of having improved sanitation facilities and safe disposal of stool that significantly reduce the under-5 mortality rate and childhood stunting.[ 47 ] The rural population must be made aware about the adverse health conditions due to unsafe sanitary practices. Movies like “ Toilet: Ek Prem Katha ” (”Toilet: a love story”) role played by popular country actor must be screened and promoted in rural India. This can make general public be aware of about the necessity of toilet use and the adoption of hygienic and safe household sanitation practices. Some studies highlighted that school teachers and local leaders from the community act as catalyst in spreading awareness and encouraging behavioral changes.[ 56 ] Education should be made to village leaders and key informants to spread awareness on healthy sanitation.

This paper is relevant in highlighting the sanitation coverage and ODF status in the last 5 years from 2014 to 2019 under first phase of SBM (G). Most studies have looked at the sanitation programming, such as community participation,[ 57 , 58 ] construction of toilets,[ 59 , 60 ] technology options,[ 61 ] environmental factors,[ 49 ] provision of subsidy,[ 62 , 63 ] and impacts of sanitation program,[ 64 , 65 , 66 ] but in this paper, we try to find out the challenges and success of centrally led government sanitation programs. The noble aspects of this study were to focus on the behavioral change among people to improve the overall cleanliness in villages and neighborhood, so that children can spend the childhood free from stunting and malnourishment. This is not an impossible task for India as Mawlynnong village of the Meghalaya state in India has declared as the cleanest village in Asia.[ 47 ]

The first phase of SBM (G) has got over (2014-2019) and the government report suggest that all villages and districts across the country had declared themselves ODF.[ 67 ] Currently, SBM (G) phase II (2020-2025) has been implemented by the Government of India with a total estimated cost of Rs. 1,40,881 crores[ 67 ] with main aim to transform all villages from ODF to ODF plus. The key objective of SBM (G) phase II is to sustain the investment made in SBM (G) phase I on ODF status of villages and to improve the cleanliness level in rural areas through effective management of liquid and solid waste, making villages ODF plus.[ 67 ] The ODF plus village is defined as a village that must sustains the ODF status, ensure solid, and liquid waste management and visually clean.[ 67 ] We have to watch and see how SBM (G) phase II will be impacting millions of people in rural villages by maintaining ODF status and ensure proper solid and liquid waste management activities by 2025. In addition, the reasons for non-usage of toilet must be addressed, so that health and well-being of people in India can continue to be improved. Further, an independent credible robust monitoring tool must be put in place to accurately measure the sanitation progress of the country under phase II SBM (G).

No doubt, India has made rapid progress to achieve the SDG 6 by increasing nationwide toilet access under SBM (G). At the same time, India must scrutinize its success within the framework of environment safety and fecal-oral transmission of disease that help, especially to children to spend their childhood free from malnourishment or premature death. By doing so, and by responding to the complexities of SBM identified in this study, will show India and other countries, the pathways of full-filling the sanitation agendas, by achieving universal sanitation for all and to meet the SDGs.

Financial support and sponsorship

Research grant has been provided by the Indian Council of Social Research (ICSSR), Ministry of Human Resource Development, Government of India for this ongoing project.

Conflicts of interest

There are no conflicts of interest.

Acknowledgment

We are thankful to the Indian Council of Social Science Research (ICSSR), Ministry of Human Resource Development, Government of India, for providing financial support for this on-going research project (No. IMPRESS/P101/414/2018-19/ICSSR).

• Open access
• Published: 21 November 2022

India's achievement towards sustainable Development Goal 6 (Ensure availability and sustainable management of water and sanitation for all) in the 2030 Agenda

• Sourav Biswas   ORCID: orcid.org/0000-0002-2715-2704 1 ,
• Biswajit Dandapat 2 ,
• Asraful Alam 3 &
• Lakshminarayan Satpati 4  

BMC Public Health volume  22 , Article number:  2142 ( 2022 ) Cite this article

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Clean water and sanitation are global public health issues. Safe drinking water and sanitation are essential, especially for children, to prevent acute and chronic illness death and sustain a healthy life. The UN General Assembly announced the 17 Sustainable Development Goals (SDGs) and 169 targets for the 2030 Agenda on 25 September 2015. SDG 6 is very important because it affects other SDG (1, 2,3,5,11,14 and 15). The present study deals with the national and state-wise analysis of the current status and to access deficiency of India's achievement towards SDG 6 (clean water and sanitation for all) for the 2030 agenda based on targets 6.1, 6.2,6.4,6.6 from 2012 to 2020.

Materials and methods

Data of different indicators of SDG 6 are collected from different secondary sources—NSS 69th (2012) and 76th (2018) round; CGWB annual report 2016–2017 and 2018-2019; NARSS (2019–2020); SBM-Grameen (2020). To understand overall achievement towards SDG 6 in the 2030 agenda, the goal score (arithmetic mean of normalised value) has been calculated.

Major findings

According to NSS data, 88.7% of Indian households had enough drinking water from primary drinking water sources throughout the year, while 79.8% of households had access to toilet facilities in 2018. As per the 2019–2021 goal score for States and UTs in rural India based on SDG 6 indicator, SDG 6 achiever States and UTs (100%) are Sikkim, Himachal Pradesh, Andaman and Nicobar Islands.

Drinking water and sanitation for all ensure a healthy life. It is a matter of concern for the government, policymakers, and people to improve the condition where the goal score and indicator value of SDG 6 are low.

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Clean Water and sanitation are global public health issues. "Water collected from sources like—piped water into dwelling, piped water into yard/plot, household connection, public standpipes/tap, boreholes/tube well, protected dug wells, protected springs and rainwater collection and bottled water are considered as improved sources of drinking water. Drinking water collected from improved sources located on-premises, available when needed and free from faecal and contamination is known as safely managed drinking water" [ 1 ]. "Hygiene refers to conditions and practices that help maintain health and prevent the spread of diseases” [ 2 ]. Water, sanitation and hygiene are known as WASH. WASH includes the use of safe drinking water; safe disposal and management of human faecal matter, human waste (solid and liquid). Open defecation is much more common in rural India than in urban India. About 70% of the Indian population lives in rural areas. In fact, 89% of households without toilets were in rural areas, according to the 2011 census. Although the Indian government has spent decades building latrines and the country has had consistent economic progress, rural open defecation statistics have remained stubbornly high [ 3 ].Control of vector-borne diseases, handwashing practices. Open Defecation Free (ODF) is the termination of faecal-oral transmission in an open space or ending open defecation using a toilet. India has progressed in access to safe drinking water (tap/hand-pump/tube well) in the household from 38% in 1981 to 85.5% in 2011. Water, sanitation, and hygiene-related diseases are Infectious Diarrhoea, Typhoid and paratyphoid fevers, Acute hepatitis A, Acute hepatitis E and future F, Fluorosis, Arsenosis, Legionellosis, Methamoglobinamia, Schistosomiasis, Trachomaa, Ascariasis, Trichuriasis, Hookworm, Dracunculiasis, Scabies, Dengue, Filariasis, Malaria, Japanese encephalitis, Leishmaniasis, Onchocerciasisa, Yellow fever, Impetigo and Drowning [ 4 ]. The United Nations General Assembly declared 2008 the International Year of Sanitation to recognise the critical need for increased political awareness and action on sanitation. The purpose is to promote awareness and speed up progress toward the Millennium Development Goal of decreasing the proportion of people without access to basic sanitation by 2015. Due to poor sanitation, people suffer from bad health, lost income, inconvenience, and indignity. Despite this, billions of people worldwide do not have access to basic sanitation [ 4 , 5 ]. According to WHO (2015), 2.4 billion people lack sanitation facilities, and 663 million people still lack access to safe and clean drinking water facilities [ 6 ]. WHO (2019) state that 3.3% of global death and 4.6% of DALYs is attributed to inadequate water, sanitation and hygiene condition. "Unsafe sanitation is responsible for 775,000 deaths per year, 5% death in low-income countries due to unsafe sanitation, 15% of the world still practising open defecation [ 7 ]. "Age-standardized death rate attributable to unsafe water, sanitation, and hygiene (WaSH) (per 100,000 population) 268.587 in 1990, 239.719 in 1995, 210.642 in 2000, 180.757 in 2005, 143.453 in 2010 and 104.202 in 2016″ [ 7 ]. So safe drinking water and sanitation are essential, especially for children, to prevent acute and chronic illness death and sustain a healthy life. After the Millennium Development goal, on 25 September 2015, in UN general assembly 17th sustainable development goal (SDG) and 169 targets set up for 2030 agenda [ 8 , 9 ]. "SDG 6 is essential because it affects other SDG (1 – poverty eradication, 2 – ending hunger, 3 – healthy life and well–being, 4 – quality education, 5 – gender equality, 11 – inclusive cities, 14 – life below water and 15 – terrestrial ecosystem)" [ 10 ]. The present study deals with the national and state-wise analysis of current status and to access deficiency of India's Achievement towards SDG 6 (clean water and sanitation for all) for the 2030 agenda based on targets 6.1, 6.2, 6.4, 6.6 from 2012 to 2020. In this study, special focus is given to rural India.

Census of India continuously collecting data about drinking water and sanitation from all households in house listing and housing. “The National Statistical Office (NSO) Ministry of Statistics and Programme Implementation” (MOSPI), Government of India has been collecting data on housing condition, drinking water, sanitation and hygiene; those were collected by NSO from NSS 7th round (October 1953—March 1954) to NSS 23rd round (July 1968—June 1969), 28th round (October 1973—June 1974), 44th round (July 1988—June 1989), 49th round (January—June 1993), 54th round (January—June 1998) 58th round (July—December 2002), 65th round (July 2008—June 2009), 69th round (July—December 2012), and latest NSS 76th round. The Indian government has undertaken attempts to enhance drinking water and sanitation.

1949: The Environment Hygiene Committee advises that a clean water supply be provided to 90% of India's population within a 40-year timeframe.

1969: The National Rural Drinking Water Supply Program was initiated with UNICEF's technical assistance, and Rs.254.90 crore is spent on 1.2 million bore wells and 17,000 piped water supply systems during this phase.

In 1972–73, the Government of India launched the Accelerated Rural Water Supply Programme (ARWSP) to assist states and union territories in expanding drinking water supply coverage.

1986: The National Drinking Water Mission (NDWM) was established. The National Drinking Water Mission was renamed the Rajiv Gandhi National Drinking Water Mission in 1991 (RGNDWM). The 73rd Constitutional Amendment mandates the provision of drinking water by Panchayati Raj institutions (PRIs).

In 1986, the Central Rural Sanitation Programme (CRSP) was established to provide safe sanitation in rural regions. The Total Sanitation Campaign (TSC) was launched in 1999 to promote local sanitary marts and various technical choices to develop supply-led sanitation.

1999: The Total Sanitation Campaign (TSC) was launched in 1999 as part of the reform principles to provide sanitation facilities in rural regions to eliminate open defecation. Swajal Dhara, a national scale-up of sector reform, was launched in 2002. All drinking water programmers were placed under the RGNDWM's umbrella in 2004.

2005: The Indian government begins the Bharat Nirman Programme, aiming to improve housing, roads, power, telephone, irrigation, and drinking water infrastructure in rural regions [ 11 ].

In 2009, the ARWSP was renamed the National Rural Drinking Water Programme (NRDWP). One of the goals was to allow all households, to the extent practicable, to have access to and utilise safe and adequate drinking water inside the premises.

In 2012, The Nirmal Bharat Abhiyan was reformed and renamed (rural sanitation).

The Swachh Bharat Mission was launched across the country on 2 October 2014 to achieve the objective of a clean India by 2 October 2019. (PM India).

The current National Rural Drinking Water Programme (NRDWP) was reformed and incorporated under Jal Jeevan Mission (JJM) on 15 August 2019 to provide Functional Household Tap Connection (FHTC) to every rural household, i.e. Har Ghar Nal Se Jal (HGNSJ) by 2024. Jal Jeevan Mission (JJM) is a non-profit organisation.

The goals of SBM(Gmain) are to enhance the general quality of life in rural areas by fostering cleanliness, hygiene, and the elimination of open defecation. The Individual Household Latrines (IHHL) unit cost was increased from Rs. 10,000 to Rs. 12,000 rupees to accommodate for water availability. To meet the Swachh Bharat aim, improve rural sanitation coverage by 2 October 2019. Raising awareness and providing health education encourages communities and Panchayati Raj institutions to adopt sustainable sanitation practices and infrastructure. Encourage the use of cost-effective and suitable sanitation methods that are environmentally safe and long-lasting. Develop community-managed sanitation systems in rural regions, concentrating on scientific Solid and Liquid Waste Management systems for overall cleanliness [ 11 , 12 ].

In New York in 2000, 189 nations approved the Millennium Declaration for 2015, promising to work together to create a safer, more prosperous, and equal world. There are eight objectives, seven of which deal with sanitation and hygiene (target 7. C – Reduce the share of the population without sustainable access to clean drinking water and basic sanitation by 2015). (Millennium Development Goal of the United Nations) Following the millennium development goal (SDG), the United Nations General Assembly approved 17 sustainable development goals and 169 targets for the 2030 Agenda for Sustainable Development on 25 September 2015. Out of 17 SDGs, SDG 6 ensures availability and sustainable water and sanitation management. SDG 6 has different target for the year 2030—6.1: Achieve universal and equitable access to safe and affordable drinking water for all; 6.2: Achieve access to adequate and equitable sanitation and hygiene for all and end open defecation, paying particular attention to the needs of women and girls and those in vulnerable situations; 6.3: Improve water quality by reducing pollution, eliminating dumping and minimizing release of hazardous chemicals and materials, halving the proportion of untreated wastewater and substantially increasing recycling and safe reuse globally; 6.4: By 2030, substantially increase water-use efficiency across all sectors and ensure sustainable withdrawals and supply of freshwater to address water scarcity and substantially reduce the number of people suffering from water scarcity; 6.5: Implement integrated water resources management at all levels, including through transboundary cooperation as appropriate; 6.6: Protect and restore water-related ecosystems, including mountains, forests, wetlands, rivers, aquifers and lakes; 6.a: Expand international cooperation and capacitybuilding support to developing countries in water- and sanitation-related activities and programmes, including water harvesting, desalination, water efficiency, wastewater treatment, recycling and reuse technologies; 6.b: Support and strengthen the participation of local communities in improving water and sanitation management [ 8 ].

As the nodal institution for SDGs, NITI Aayog, the Government of India has striven to provide the necessary encouragement and support to forge collaborative momentum among them. Since 2018, the SDG India Index & Dashboard has worked as a powerful tool to bring SDGs clearly and firmly into the policy arena in our States and UTs [ 13 ]. Ministry of Statistics and Programme Implementation (MoSPI), Government of India developed a National Indicator Framework (NIF), which is the backbone for facilitating monitoring of SDGs at the national level and provides appropriate direction to the policymakers and the implementing agencies of various schemes and programmes [ 14 ].

The main objective of this study is to find out the status of SDG target 6.1, 6.2, 6.4 and 6. towards the achievement of SDG 6 in the 2030 agenda in India (National and State level) and to assess deficiency towards the Achievement of clean Water and sanitation for all in 2030 agenda India (National and State level).

The present study is based on seven indicators of SDG 6;

a: those are % population having improved source of drinking water- SDG 6.1,

b: % of individual household toilets constructed against target (SBM(G))- SDG 6.2,

c: % of districts verified to be ODF (SBM(G))- SDG 6.2,

d: % of school has a separate toilet for boys and girls- SDG 6.2,

e: % of households having safe disposal of liquid waste- SDG 6.a,

f: % of blocks/ mandals / taluka having safe groundwater extraction—SDG 6.4, and.

g: % of blocks/ mandals / taluka over-exploited- SDG 6.4. Data of those indicators are collected from the following secondary sources:

The present study is based on percentage distribution, normalization and arithmetic mean methods. The percentage of groundwater extraction from extractable groundwater resource annually is calculated by the formula: \(\left(\frac{\mathrm{total}\;\mathrm{annual}\;\mathrm{groundwater}\;\mathrm{extraction}}{\mathrm{annual}\;\mathrm{extractable}\;\mathrm{groundwater}\;\mathrm{resource}}\times100\right)\%\) . And goal score for SDG 6 indicators is calculated by target setting, followed by normalizing the raw data of indicator arithmetic mean of the normalizing value of indicators. The methodology of goal score calculation was developed by the Ministry of Statistics and Programme Implementation (MoSPI) in 2019. The target of those indicators was set by United Nations at the global level. The national target value for indicator a:100%, b:100%, c:100%, d:100%, e:100%, f:100% and g:0%. The next step is normalizing the raw data. It is important to maintain a standard indicator value between 0 and 100. An indicator higher value = lower performance, following formula, was used – the normalized value of an indicator \(({N}_{V})=\left(1-\frac{\mathrm{Actual }\;\mathrm{value}\;\mathrm{of}\;\mathrm{an}\;\mathrm{indicator}\;\left(\mathrm i\right)-\mathrm{target}\;\mathrm{value}\;\mathrm{of}\;\mathrm{the}\;\mathrm{indicator}\;(\mathrm i)}{\mathrm{maximum}\;\mathrm{value}\;\mathrm{of}\;\mathrm{the}\;\mathrm{indicator}(i)-\mathrm{Target}\;\mathrm{value}\;\mathrm{of}\;\mathrm{the}\;\mathrm{indicator}\;\left(\mathrm i\right)}\right) \times100\) . Normalization does not require for indicators a, b, c, d, e & f because values of that indicator are already in percentage and g have been done using the above formula. The goal score for all indicators of SDG 6 for each state and UTs have been done by the arithmetic mean of normalized value, using the following formula- Goal score of indicator(GSI) = ( \({\sum }_{i=1}^{Ni}Nv\) and \(Av\) × \(\frac{1}{\mathrm{Ni}}\) ). Whereas Ni means = the number of non-null indicators and \(Nv\) means the normalized value of the indicator and Av means the actual value of the indicator.

Result and Discussion

Result of households having access to Drinking Water (SDG 6.1) in India (National level and state level) as per National Sample Survey (NSS) data. Figure  1 depicts the sources of safe drinking from households accessing the drinking water throughout the year.

Percentage of households with access to principle sources of safe drinking water in India with resident type, 2018. Source: NSS 76th round (July—December 2018), graph prepared by the author. Notes: 0.0% indicate the least or negligible Percentage of household

In India 2018, most of household collect safe drinking water from hand pump (30.5%) followed by piped water into dwelling (21.4%), piped water to yard / plot (12.3%), tube well (10.7%), public tap / standpipe (9.2%), bottled water (6.8%), protected well (2.5%), piped water from neighbour (1.0%), private tanker truck (0.4%), public tanker truck (0.3%), protected spring (0.2%) and rainwater collection (0.2%). In urban areas, a higher percentage of households use piped water into the dwelling (40.9%), piped water into yard/plot (16.0%), bottled water (12.2%), public tanker truck (0.8%), private tanker track (0.5%) than a rural area. In rural area higher percentage of household using hand pump (42.9%), tube well (10.9%), public tap / standpipe (10.3%), protected well (2.9%), protected spring (0.3%) and rainwater collection (0.2%) [ 14 ].

"Bottled water, piped water into dwelling, piped water to yard/plot, public tap/standpipe, tube well/borehole, protected well, protected spring and rainwater collection are considered as improved sources of drinking water" [ 15 ]. As of 2018, 88.7% of households have access to drinking water from principal drinking water sources throughout the year, but 95.5% of household’s access improved drinking water sources in India. In contrast, the urban area has a higher percentage of access to principle (90.9%) and improved (97.4%) drinking water sources throughout the year than the rural area 87.6% and 94.5%, respectively. In India, 1.7% of principle sources and 4.9% improved drinking water sources increased from 2012 to 2018. As of 2018, 11.3% of households have a deficit in case of access principle sources of drinking water, and 4.5% of households have an obligation in case of access to improved sources of drinking water throughout the year for achieving safe and affordable drinking water for all (SDG 6.1) in 2030 agenda. Table 1 showing the percentage of households with access and deficit to drinking water with resident type in India.

From Fig.  2 , we can say the performance of states and UTs in India towards the Achievement of SDG 6 of target SDG 6.1 by using the percentage of households having access to improved sources of drinking water indicator. As per 2018, SDG 6.1 target achiever ( 100%) states and UTs are Chandigarh, Daman and Diu, Sikkim; Front Runner (65%– 99%) States and UTs are Bihar, Haryana, Punjab, Delhi, Goa, Tamil Nadu, Dadra and Nagar Haveli, Puducherry, Group of UTs, Uttar Pradesh, Gujarat, Telangana, Arunachal Pradesh, West Bengal, Andaman and Nicober Islands, Himachal Pradesh, Andhra Pradesh, Uttarakhand, Mizoram, Maharashtra, Karnataka, Chhattisgarh, Rajasthan, Madhya Pradesh, Assam, Odisha, Jammu and Kashmir, Meghalaya, Jharkhand, Group of NE States, Tripura, Nagaland, Lakshadweep and Manipur; performer state (50%—64%) in Kerala. Kerala has lower access to improved safe drinking water sources. Deficit of performance to achieve SDG 6.1 target based on the above indicator for states and UTs in India are Bihar 0.1%, Haryana 0.1%, Punjab 0.1%, Delhi 0.2%, Goa 0.2%, Tamil Nadu 0.2%, Dadra and Nagar Haveli 0.4%, Puducherry 0.6%, Group of UTs 0.7%, Uttar Pradesh 0.8%, Gujarat 0.9%, Telangana 0.9%, Arunachal Pradesh 1.2%, West Bengal 1.8%, Andaman and Nicober Islands 1.9%, Himachal Pradesh 1.9%, Andhra Pradesh 2.6%, Uttarakhand 2.8%, Mizoram 3.7%, Maharashtra 3.8%, Karnataka 4.6%, Chhattisgarh 4.8%, Rajasthan 7.4%, Madhya Pradesh 8.5%, Assam 8.6%, Odisha 8.8%, Jammu and Kashmir 9.1%, Meghalaya 9.1%, Jharkhand 12%, Tripura 12.2%, Nagaland 15.5%, Lakshadweep 24.1%, Manipur 25.1% and Kerala 43.3%. Although Kerala has a higher socio-economic development performance, Kerala faces a water crisis. "Urbanisation, modernisation, increasing material prosperity, the disintegration of traditional joint family structure, pressure on land, replacing open dug well with bore well, overexploitation of groundwater contribution to the water crisis in Kerala" [ 16 ]. "Kerala received 80% less rainfall than normal after a flood. So more dry spells and drops in groundwater levels are one of the reasons for the water crisis." (V P Dineshan). In terms of households having toilet facilities, all northeastern states exceed the national average. However, except with Arunachal Pradesh and Sikkim, all northeastern states are below the national average regarding access to improved drinking water sources.

Percentage of households having access to improved sources of drinking water in states & UTs in India, 2018. Source: NSS 76th round (July—December 2018), graph prepared by the author

Similarly, the percentage of villages in Arunachal Pradesh, Assam, Manipur and Meghalaya where the “Village Health and Sanitation Committee” exist is less than the national figure. Efforts should be made to form a "Village Health and Sanitation Committee" in an increasing number of villages. Financial assistance should promote family toilets and provide safe drinking water [ 17 ].

Result of households having access to latrine facility (SDG 6.2) in India (National level and state level) as per National Sample Survey (NSS) data.

As per 2018, in India, 79.8% of households have access to latrine facilities, whereas urban area has a higher percentage of household having access to latrine facility (96.2%), than rural areas (40.6%) given in the Fig.  3 . From 2012 to 2018, India had a 23.2% improvement in accessing latrine facilities, where the urban area has 5%, and the rural area has 30.7% improvement. As of 2018, in India, 20.2% of households have a deficit in accessing latrine facilities towards achieving SDG 6.2 in 2030, whereas in an urban area, it is a low deficit (3.8%) and in rural areas, it is a higher deficit  (28.7%).

Percentage of households having access to latrine facility with resident type, 2012 & 2018. Sources: NSS 76th round (July—December 2018) & 69th round (July—December 2012), graph prepared by the author

As per NSS 76th round, it is seen that in 2018 in India, 2.8% of the population never used a toilet. Although households have latrine facilities, it is higher in rural areas at 3.5% and lowers in an urban area at 1.7%. The various reasons behind not using the toilet are that 2.8% there is no superstructure, 8.2% impure unclear and insufficient water, 3% malfunctioning of the latrine, 0.5% deficiency of latrines, 1.3% lack of safety, 6.3% personal preference, 0.6% cannot bear the charge of the paid latrine, and another reason is 76.9%. It is also observed that the female population uses toilets more than the male population. 74.1% of households washed their hands with water and soap/detergent, and 13.4% washed their hands with water only after defecation [ 14 ]. Infrastructure is inadequate in the rural sanitation sector that must be addressed through immediate legislative reforms and government subsidies to develop appropriate and adequate facilities [ 18 ].

Figure  4 showing the Percentage of households having access to latrine facilities. A higher percentage of households having access to latrine facilities is found in Manipur, Mizoram, Nagaland, Sikkim, Lakshadweep, etc. A lower percentage of households below the national level are found in Odisha, Uttar Pradesh, Jharkhand, Bihar, Rajasthan, Madhya Pradesh and Tamil Nadu. Inadequacies in rural infrastructure are undoubtedly a significant source of the 'failure.' It has multiple causes, which can be baffling at times. Government-subsidized latrines in rural areas are often inappropriate, especially for women, due to a lack of roofs, doors, walls, buried pits, and adequate spatial dimensions, each of which depends on the convenience of latrine usage and, more crucially, privacy [ 18 ]. Performance of states and UTs in India towards the Achievement of SDG 6 of target SDG 6.2 by using the percentage of households having access to latrine facility indicator.

Percentage of households having access to latrine facilities in states & UTs in India, 2018. Source:NSS 76th round (July—December 2018), graph prepared by the author

As per 2018, SDG 6.2 target achiever (100%) states and UTs are Manipur, Mizoram, Nagaland, Sikkim, Chandigarh and Lakshadweep; front runner ( 65%– 99%) states and UTs are Daman and Diu, Kerala, Delhi, Tripura, Meghalaya, Uttarakhand, Assam, Himachal Pradesh, Haryana, Andaman and Nicober Islands, Punjab, Goa, Chhattisgarh, Dadra and Nagar Haveli, Jammu and Kashmir, West Bengal, Arunachal Pradesh, Puducherry, Telangana, Maharashtra, Gujarat, Andhra Pradesh, Karnataka, Tamil Nadu, Madhya Pradesh, Rajasthan, Bihar and Jharkhand; performer (50% to 64%) states are Uttar Pradesh and Odisha. As per 2018, deficit of performance towards achievement of SDG 6.2 target in 2030 agenda in States and UTs in India are Daman and Diu 0.1%, Kerala 0.2%, Delhi 0.5%, Tripura 0.6%, Meghalaya 1.5%, Uttarakhand 2.1%, Assam 2.2%, Himachal Pradesh 2.6%, Haryana 2.7%, Andaman and Nicober Islands 3.4%, Punjab 3.9%, Goa 7%, Chhattisgarh 7.4%, Dadra and Nagar Haveli 7.7%, Jammu and Kashmir 11.7%, West Bengal 11.9%, Arunachal Pradesh 12%, Puducherry 12.5%, Telangana 12.7%, Maharashtra 12.8%, Gujarat 14.2%, Andhra Pradesh 16%, Karnataka 18.5%, Tamil Nadu 21.5%, Madhya Pradesh 22.5%, Rajasthan 26.3%, Bihar 32.8%, Jharkhand 33.6%, Uttar Pradesh 37.7% and Odisha 45.1%. The result of the Percentage of blocks/mandals/talisie safe extraction of groundwater (SDG 6.4 and 6.6) in India (National level and state level) as per NSS 76 th round data. Infections and illnesses tend to be exacerbated by a lack of latrine facilities. Women and girls are usually disadvantaged due to several socio-cultural and economic factors that deny them equal rights with males. They have distinct physical needs from males, but they also have a greater need for privacy and safety regarding personal cleanliness. Actions such as going long distances in search of a good defecation site and carrying water are a sign of added load, which may be physically unpleasant and hard for women, particularly pregnant women [ 19 ].

Figure  5 showing the Percentage of blocks/mandals/talisie safe extraction of groundwater. As per 2017, the performance of States and UTs in India towards the Achievement of SDG 6.4 and 6.6 in 2030 agenda based on indicator percentage of blocks/mandals/taluka are safe extraction of groundwater (groundwater extraction does not exceed the total annual groundwater recharge, which is below 70% extraction) shows achiever (100%) States and UTs are Arunachal Pradesh, Assam, Goa, Jammu and Kashmir, Manipur, Meghalaya, Mizoram, Nagaland, Sikkim, Tripura, Dadra and Nagar Haveli; Front Runner (65%-99%) are Andaman and Nicobar Islands, Odisha, Jharkhand, Total UT's, Chhattisgarh, Bihar, Gujarat, Kerala, Madhya Pradesh, Maharashtra, Andhra Pradesh, Uttarakhand, West Bengal, Lakshadweep, Uttar Pradesh; performer (50%-64%) are India, Karnataka, Daman and Diu, Puducherry; aspirant (0%-49%) are Telangana, Himachal Pradesh, Tamil Nadu, Haryana, Punjab, Rajasthan, Delhi and Chandigarh. InIndia 63% blocks/mandals/taluka are safe extraction of groundwater.

Percentage of blocks/mandals/taluka are safe extraction of groundwater in States & UTs in India,2017. Source: CGWB annual report 2019–2020, graph prepared by the author

Result of the percentage of groundwater extraction (SDG 6.4) in India (National level and state level) as per 2017:

As per the "National Compilation on Dynamic Ground Water Resources of India (2017)" report by the CGWB, groundwater extraction below 70 per cent is considered a Safe extraction. Over extraction of groundwater annually (groundwater extraction exceed extractable groundwater annually) is found in Punjab (165.80%), Rajasthan (139.87%), Haryana (136.91%) and Delhi (120.00%); safe groundwater extraction is found in Karnataka, Telangana, Gujarat, India, Uttarakhand, Madhya Pradesh, Maharashtra, Kerala, Daman and Diu, Lakshadweep, Bihar, West Bengal, Chhattisgarh, Andhra Pradesh, Odisha, Goa, Jammu and Kashmir, Ladakh, Dadra and Nagar Haveli, Jharkhand, Assam, Tripura, Mizoram, Andaman and Nicobar Islands, Manipur, Meghalaya, Nagaland, Arunachal Pradesh and Sikkim. In India, 63.33% of groundwater is extracted annually as per 2017. The States and UTs with safe groundwater extraction achieve the SDG 6.4 target based on the indicator – the annual percentage of groundwater extraction from extractable groundwater resources. Figure  6 showing the Percentage of groundwater extraction from extractable groundwater resource annually in States and UTs.

Percentage of groundwater extraction from extractable groundwater resource annually in States & UTs in India,2017. Source: CGWB annual report 2019–2020, graph prepared by the author

"In India as per 2017 Total Annual Groundwater Recharge is 431.86 billion cubic meters (bcm) out of which Annual Extractable Ground Water Resource is 392.7 bcm and Current Annual Ground Water Extraction is 248. 7 bcm" (CGWB annual report 2019–2020).

Result of the overall performance of SDG 6 in India (National level and state level) 2019 – 2021.

Table 2 shows the achievements towards SDG 6 of all States and UTs. Overall goal score of the indicator—Percentage of the rural population having improved source of drinking water (SDG 6.1), percentage of individual household toilets constructed against target (SBM(G)) (SDG 6.2), percentage of districts verified to be ODF (SBM(G)) (SDG 6.2), the school has a separate toilet for boys and girl (%) ( SDG 6.2), percentage of Household Safe Disposal of Liquid waste (SDG 6.a), percentage of blocks/ mandals/ taluka having safe groundwater extraction (SDG 6.4) and percentage of blocks/ mandals/ taluka over-exploited (6.4) reveal that states and UTs belonging in achiever stage are Chandigarh, Dadra & Nagar Haveli, Ladakh, Lakshadweep, Sikkim and Goa. The states and UTs belonging to front runner stage (66–99%) are Mizoram, Andaman & Nicobar Islands, Jharkhand, Odisha, Kerala, Gujarat, Chhattisgarh, Jammu & Kashmir, Meghalaya, Arunachal Pradesh, Maharashtra, Uttarakhand, Assam, West Bengal, Nagaland, Tripura, Bihar, Andhra Pradesh, Madhya Pradesh, Uttar Pradesh, Daman and Diu, Puducherry, Telangana, Karnataka, Manipur, Tamil Nadu, Himachal Pradesh, Haryana, Rajasthan and Punjab. Delhi is the only Union Territory belonging to the aspirant stage.

As per January 2021, the performance of States and UTs in Rural towards Achievement of SDG 6.1 based on indicator Percentage of the rural population having improved source of drinking water shows achiever States and UTs are; Ladakh, Sikkim, Goa, Mizoram, Andaman & Nicobar Islands, Gujarat, Meghalaya, Nagaland, Telangana, Karnataka, Manipur and Himachal Pradesh; front runner are Jammu & Kashmir, Andhra Pradesh, Jharkhand, Madhya Pradesh, Haryana, Chhattisgarh, Uttar Pradesh, Kerala, Tamil Nadu, Uttarakhand, Odisha, Bihar, Puducherry, West Bengal, Arunachal Pradesh, Punjab, Rajasthan, Maharashtra, Tripura and Assam.

From Fig.  7 , we can see that most of the states and union territories belong to the green colour shade. That means all these states and union territories are in the Front Runner (65–99%) stage as per the Goal Score Indicator (GSI). Andaman & Nicobar Islands, Chandigarh, Dadra & Nagar Haveli, Ladakh, Lakshadweep, Sikkim and Goa are all states and Union Territories observing blue colour shade, indicating that all these states and union territories have reached the achiever stage as per the Goal Score Indicator (GSI). Delhi is the only union territory where orange colour is observed, indicating that the union territory is still at the performer (50–64%) stage.

Overall performance of different indicators of SDG 6 (Goal score of the indicator). Sources: Department of Drinking Water and Sanitation, Ministry of Jal Shakti, January 2021; Swachh Bharat Mission Gramin Dashboard,2020; NARSS round 3, 2019–2020; map prepared by the author

Figure  8 shows the spatial distribution of households having access to improved sources of drinking water and Fig.  9 shows the spatial distribution of households having access to latrine facilities in States and UTs in India.

Spatial distribution of households having access to improved sources of drinking water (%) in states & UTs in India, 2018. Source: NSS 76th round (July—December 2018), map prepared by the author

Spatial distribution of households having access to latrine facility (%) in states & UTs in India, 2018. Source: NSS 76th round (July—December 2018), map prepared by the author

From Fig.  8 , light green indicates states and union territories with 95–99% coverage of improved drinking water sources. Moreover, deep green indicates those states and union territories with more than 99% coverage of improved drinking water sources. The red colour indicates below 90% coverage of improved drinking water sources. Furthermore, orange indicates those states and union territories with 90–95% coverage of improved drinking water sources. All South Indian states except Kerala fall into more than 95% coverage of improved drinking water sources. Almost all States and Union Territories above and near the Tropic of Cancer have < 95% coverage of Improved Sources of Drinking Water except Chhattisgarh and Gujarat. Almost all states of North India except Jammu and Kashmir have more than 95% coverage of improved drinking water sources.

From Fig.  9 , light green indicates states and union territories with 80–90% coverage of access to latrine facilities. Moreover, deep green indicates those states and union territories with 90–100% coverage of access to latrine facilities. The red indicates below 50–60% coverage of access to latrine facilities. Furthermore, pink indicates those states and union territories with 60–70% coverage of access to latrine facilities. Whitish Grey indicates states and union territories with 70–80% coverage of access to latrine facilities. Delhi, Uttar Pradesh, Bihar, Jharkhand, and Odisha fall into less than 70% coverage of access to latrine facilities. Rajasthan, Madhya Pradesh and Tamil Nadu are found to have 70–80% coverage of access to latrine facilities. The rest of the states and union territories have found more than 80% coverage of access to latrine facilities.As per NSS data in 2018, 30.5% of households collect safe drinking water from the hand pump; in the case of urban areas 40.9% of households use piped water into the dwelling; and in rural areas 42.9% of households use the hand pump. 88.7% of households have access to a principle source of drinking water, and 95.5% use improved drinking water sources throughout the year. 100% of households having access to improved sources of drinking water (SDG 6.1 target achiever) in Chandigarh, Daman and Diu, Sikkim and Kerala has the lowest percentage 56.7%. In India, 79.8% of households have access to latrine facilities, whereas urban area has a higher percentage of household having access to latrine facility 96.2%, than rural areas (40.6%). The female population are more using toilets than the male population. 100% of households have access to latrine facilities (SDG 6.2 target achiever) in Manipur, Mizoram, Nagaland, Sikkim, Chandigarh, Lakshadweep; and the lowest found in Odisha 54.9%. Safe groundwater extraction from extractable groundwater resources annually (SDG 6.4 target achiever) in States and UTs in India, 2017 are found in Karnataka, Telangana, Gujarat, India, Uttarakhand, Madhya Pradesh, Maharashtra, Kerala, Daman and Diu, Lakshadweep, Bihar, West Bengal, Chhattisgarh, Andhra Pradesh, Odisha, Goa, Jammu & Kashmir, Ladakh, Dadra and Nagar Haveli, Jharkhand, Assam, Tripura, Mizoram, Andaman and Nicobar Islands, Manipur, Meghalaya, Nagaland, Arunachal Pradesh and Sikkim. In India, 63.33% of groundwater is extracted annually as per 2017. As of 2020, all the States and UTs in Rural India 100% individual household toilets constructed against target (SBM(G)) and 100% districts verified to be ODF (SBM(G)) (SDG 6.2 target achiever). As per January 2021, 100% rural population has improved source of drinking water (SDG 6.1 target achiever) in Ladakh, Sikkim, Goa, Himachal Pradesh, Gujarat, Karnataka, Mizoram, Andaman and Nicobar Islands, Telangana, Meghalaya, Nagaland and Manipur. As per 2019–2020, 100% school having a separate toilet for boys and girl (SDG 6.2 target achiever) in Dadra and Nagar Haveli, Sikkim, Himachal Pradesh, Andaman and Nicobar Islands and Puducherry. Goa achieves 100% safe disposal of liquid waste. Overall goal score expresses all the states belong to front runner stage (65% to 99%). Based on SDG 6.1 and SDG 6.2, it is observed that in Rural India achiever (100%) state is Sikkim, Himachal Pradesh, Andaman and Nicobar Islands in 2019–2021.Since the population is increasing, the number of sustainable water resources is not. Future population expansion will likely result in further reduced renewable water available per capita. Most changes in India's overall and rural regions, moderate changes in the world's overall and rural areas, and very little change in both India's and the world's urban areas have been seen in terms of access to essential drinking water services [ 20 ]. The top eight states are Gujarat, Jammu & Kashmir, Madhya Pradesh, Andhra Pradesh, Odisha, Maharashtra, Karnataka, and Telangana; the bottom eight are Delhi, Uttarakhand, Haryana, Uttar Pradesh, Bihar, Kerala, and West Bengal. Due to their location in the Ganges basin, most of the eight lowest performing states have abundant water resources, in contrast to the higher performing states, which are comparatively water scarce. Severe droughts have recently affected Gujarat, Maharashtra, Madhya Pradesh, Andhra Pradesh, Karnataka and Telangana. From an endowment standpoint, this focuses the attention of water concerns in India toward improved management and control of water resources. The top five states in terms of performance are Goa, Delhi, Kerala, Gujarat, and Telangana, whereas the worst five are Chhattisgarh, Bihar, Odisha, Andhra Pradesh, and Jharkhand. In Jharkhand, Bihar, and Uttar Pradesh, childhood malnutrition and stunting have increased due to poor sanitation services. Individually, these indices point to significant disparities in access to sanitary facilities and clean water throughout the states. Few states have been able to implement comprehensive planning to meet the key objectives [ 21 , 22 ].

The WHO/UNICEF, joint monitoring program estimated in 2012 that 60% of the world's open defecation occurs in India. While this trend is declining rapidly in other countries, it continues stubbornly in India. According to the 2011 Census of India data, about 90% of rural people in India defecate in the open. Social context always plays a vital role in countries like India, where households with higher income and better education are more likely to use latrines and toilets. Previous research has shown that Muslims are 25% less likely to defecate in the open than Hindus. Although Hindus have 6% more per capita consumption than non-Hindus, Hindus are less likely to use latrines [ 23 ].

Open defecation at the individual level is a more accurate reflection of the disease environment than latrine ownership at the household level. It is particularly true in rural India, where earlier research has shown that many residents of homes with latrines do not use their latrines. The literature indicates that the Indian government's policy of subsidizing pit latrines has not achieved large-scale behaviour change and may still represent a misguided focus. This policy has continued mainly under the current Swachh Bharat Mission (2014–present). Despite the evidence, understanding latrine demand is critical to understanding latrine uptake [ 24 , 25 ]. Sanitation practices and social norms receive minimal consideration in sanitation programmes. Sanitation policy would probably be more effective if it addressed the underlying social environment in which judgments about where to defecate and what kind of latrine is socially acceptable since even the well-educated and wealthiest households adopt latrines at such a slow pace [ 26 ].

After lunch of Swachh Bharat Mission and other programmes related to sanitation and drinking water, sanitation coverage and accessibility of drinking water rise which has reinforcement substantially in accelerating the Achievement of Sustainable Development goal 6. States and UTs having the lower status of sanitation, drinking water, groundwater and hygiene need to improve those condition by increasing availability, accessibility and affordability of the WASH facility. Localisation or bottom-up approach by giving responsibility to rural and urban local body enforced Achievement of SDG 6. Total water withdrawal per capita was 576.96 m 3 in 1975, which was 602.3 m 3 in 2010. Total water withdrawal has increased by about 3.07% in these few decades. From 1962 to 2014, 64.29% per capita of total internal renewable water resources decreased. From 1979 to 2011, 18.4% increase in water stress. To fulfil essential human needs and attain sustainable development aims, central and local governments must collaborate. These initiatives and actions for recyclable and reusable, sufficient, and treated water, as well as enhancing sanitation and hygiene infrastructure, are linked to creating opportunities that improve economic sustainability. Additionally, establishing sanitation, hygiene and drinking water infrastructure in households grants social dignity, which can assist in social sustainability.

Those States and Union Territories that have not achieved the goal of 100% overall SDG-6 should fulfil the goals through a specific regional development approach. If successful locally, it will help the country's overall progress on a large scale. India and other underdeveloped and developing countries need to fulfil the goals of SDG-6. If successful in achieving the target, it will accelerate overall health improvement and help reduce regional disparities. Developed countries need to help developing and underdeveloped countries. Finally, the various organizations of the United Nations should try to solve the problems at the local level through each country-specific regional approach that will accelerate the overall achievement.

To prevent and reduce acute and chronic illness death and sustain a healthy life, we need to increase awareness and facilities to access safe and adequate drinking water, sanitation and hygiene. For raising awareness, different days are celebrated on 22 March as World Water Day for Water, 19 November as World Toilet Day for sanitation and 15 October as Global Handwashing Day for hygiene. Still, we need to maintain safe drinking water, sanitation and hygiene all day. 

Availability of data and materials

The study is based on secondary data analysis. No data was collected for this study. The datasets generated and/or analysed during the current study are available in the NSS (Download Reports | Ministry of Statistics and Program Implementation | Government Of India), Central ground water control board (Department of Drinking Water and Sanitation, GOI (jalshakti-ddws.gov.in)), NARSS (Department of Drinking Water and Sanitation, GOI (jalshakti-ddws.gov.in)) NITI Aayog (Reports on SDG | NITI Aayog) repository.

Abbreviations

National Sample Survey

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Acknowledgements

The authors are grateful to NSS and NARSS for making the data available for this study.

We did not receive any grants from any funding agency in public, commercial, or non-profit sectors for conducting this study.

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Biswajit Dandapat

Department of Geography, Serampore Girls’ College, University of Calcutta, Serampore, 712201, India

Asraful Alam

Professor of Geography & Director, UGC-HRDC, University of Calcutta, Kolkata, 700019, India

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Biswas, S., Dandapat, B., Alam, A. et al. India's achievement towards sustainable Development Goal 6 (Ensure availability and sustainable management of water and sanitation for all) in the 2030 Agenda. BMC Public Health 22 , 2142 (2022). https://doi.org/10.1186/s12889-022-14316-0

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Urban Sanitation in India: Past, Present, and Future

• Written by Ankitha Gattupalli
• Published on October 24, 2023

With large populations come formidable challenges, particularly in the realm of health and hygiene. In the last century, upholding sanitary conditions in urban areas has remained a persistent challenge, particularly in a nation that houses over 1.5 billion people . India grapples with a myriad of issues- inadequate infrastructure for sanitation, lack of public toilets, and poor waste management practices. In densely populated cities, the struggle intensifies as sanitation and cleanliness management falters. India's rapid urbanization has outpaced the development of sanitation infrastructure and cleanliness issues have deeply entrenched in the nation's built environment.

Historical, social, economic, and infrastructural factors have collectively influenced significant shifts in India's urban sanitation landscape. Indian cities - especially those dealing with high population density, poverty, and inadequate sanitation - have long been susceptible to diseases . Dense urban centers breed diseases at an accelerated pace, generate substantial waste and sewage, and contaminate shared resources, resulting in unhygienic living conditions.

The purpose of urban sanitation is to mitigate health risks by managing factors within the urban environment that can contribute to health problems. The significance of urban sanitation in India is diverse - it profoundly impacts public health, environmental sustainability, and quality of life. As India's urban population grows and urbanization progresses at full tilt, ensuring clean and hygienic living conditions becomes challenging. Inadequate urban sanitation can propagate waterborne diseases, inflate healthcare costs, and deteriorate the quality of life for millions. It also poses severe environmental threats like water pollution and ecosystem degradation. In countries with massive populations, the existing infrastructure is often overburdened, leading to frequent breakdowns and escalating maintenance costs.

Related Article

More Indians have mobile phones than toilets

Urban sanitation hasn't always been a challenge in India . The nation boasts the legacy of one of the world's first civilizations that developed a sophisticated water supply and sewage system —the Bronze-age Indus Valley Civilization. This ancient civilization demonstrated a deep understanding of sanitation and urban planning. Its towns exhibited meticulous grid-like layouts with well-planned drainage systems that efficiently directed wastewater and rainwater away from residential areas. Homes featured private bathrooms and drainage systems, while public wells and bathing platforms were ubiquitous, revealing a community-oriented commitment to cleanliness and health.

A pivotal phase in India's sanitation history evolved during its colonial rule. From the mid-nineteenth century, public health gained prominence in Western European cities. British India mirrored this concern, resulting in the large-scale demolition of overcrowded and substandard housing in cities like Delhi. While purportedly driven by public health interests, it's believed that over a third of Delhi's transformation was a British tactic to assert control.

Before imperial rule, indigenous principles guided sanitation, health, and environmental practices in Indian settlements. Traditional infrastructure and healthcare systems played an integral role in shaping the built environment. With the onset of municipalization, British administrators embraced sanitary reform and the overhaul of infrastructure, including drainage, water supply, and waste disposal, in their quest to transform Indian cities into Western-style modern metropolises. Urban sanitation efforts in India largely reflected the principles of the British public health movement. Indian cities were reshaped, shifting away from existing localized sanitary infrastructure in favor of Western solutions.

The Present

Today, Indian cities continue to rely on modernized urban sanitation infrastructure but are unable to scale to meet the needs of a rising population. Rapid urbanization has strained existing urban infrastructure and sanitation facilities. The nation's cash-strapped municipalities, along with a shortage of trained urban managers, remain ill-equipped to confront this problem. Census data reveals that about 46 percent of Indian households lack indoor toilets , with 49 percent of the population resorting to open defecation. The remaining population depends on public toilets. Forty percent of India's waste remains uncollected and untreated, with human sewage directly flowing into rivers in many cities.

Income inequality in India exacerbates these issues, with poorer communities often lacking access to basic sanitation facilities. This, in turn, leads to unregulated waste disposal and unsanitary living conditions. While Indian society upholds strong values of cleanliness in households, most public spaces suffer from poor civic cleanliness as they are considered non-personal spaces.

The COVID-19 pandemic in 2020 drove urban sanitation to the forefront of public discourse. India's densely populated urban regions posed unique challenges in combating the virus, exposing the shortcomings of the sanitation systems and practices. The pandemic also highlighted the inequality and unsustainability inherent in the country's urbanization process . It was a stark reminder of urban dwellers' vulnerability to respiratory illnesses caused by the country's high levels of air pollution.

Government reforms have delivered positive outcomes in the advancement of urban sanitation facilities. The COVID-19 pandemic expedited the adoption of technology in urban sanitation. Contactless sanitation facilities, automatic sensors in public restrooms, and the use of data analytics for monitoring and maintaining sanitation infrastructure became prevalent.

In 2014, the Indian Government launched a $10 billion campaign, the Swachh Bharat Abhiyan (Clean India campaign), intending to improve sanitation facilities across the country. The campaign sought to eliminate open defecation by installing more toilets, improve waste disposal practices, and educate citizens about the relationship between sanitation and public health. As the world's most extensive sanitation drive, the campaign sparked a revival of indigenous understandings of health and sanitation that had been overshadowed during colonial rule. Behavioral change is a pivotal aspect of urban sanitation in India. The campaign's localized approach was successful on this front.

A critical aspect of the future of urban sanitation in India revolves around behavioral change, an area where localized strategies have proven effective. Government data reveals significant progress in sanitation across India, including the construction of over 100 million individual household toilets in rural areas, an additional 6 million in urban areas, and nearly 6 million community and public toilets in urban regions. This collective effort has led to more than 4,234 cities and over 600,000 villages achieving open defecation-free status .

Sanitation is more important than political independence - Mahatma Gandhi

While India's strides in the area of sanitation are undeniable, the path forward remains tough. Public funding is often directed toward Class I cities , partly due to their visibility. In regards to sanitary issues, the country requires an approach that caters to urban and rural areas contextually . At present, India exhibits a drastic improvement in terms of urban cleanliness and sanitation facilities as awareness and interest spread.

In an urbanized world, cities play a key role in shaping healthy futures. Better-managed cities, equipped with improved services, contribute significantly to health, governance, environmental cleanliness, dignity, and economic growth. Apart from benefitting health and the environment, urban sanitation aids urban development and planning by attracting investments and fostering a sense of well-being among the urban population. Government initiatives such as the Swachh Bharat Abhiyan emphasize the importance of urban sanitation in the national policy agenda and its critical role in ensuring citizens' quality urban life.

India's ongoing battle with urban sanitation stems from a complex combination of historical, economic, social, and environmental factors. Confronting these multifaceted issues demands an all-round approach comprising of infrastructure development, awareness campaigns, community engagement, and governmental initiatives.

This article is part of an ArchDaily series titled India: Building for Billions , where we discuss the effects of population rise, urbanization, and economic growth on India ’s built environment. Through the series, we explore local and international innovations responding to India ’s urban growth. We also talk to the architect, builders, and community, seeking to underline their personal experiences. As always, at ArchDaily, we highly appreciate the input of our readers. If you think we should feature a certain project, please submit your suggestions .

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Article Contents

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Water, Sanitation, and Hygiene Practices in Urban Slums of Eastern India

S. K. and P. C. contributed equally.

• Article contents
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Suman Kanungo, Pranab Chatterjee, Jayanta Saha, Tania Pan, Nandini Datta Chakrabarty, Shanta Dutta, Water, Sanitation, and Hygiene Practices in Urban Slums of Eastern India, The Journal of Infectious Diseases , Volume 224, Issue Supplement_5, 15 November 2021, Pages S573–S583, https://doi.org/10.1093/infdis/jiab354

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The Sustainable Development Goals identified universal access to water and sanitation facilities as key components for improving health. We assessed water, sanitation, and hygiene (WASH) practices and associated determinants among residents of urban slums in Kolkata, India.

Information on WASH practices was collected in 2 surveys (2018 and 2019) from participants of a prospective enteric fever surveillance conducted in 2 municipal wards of Kolkata. A composite WASH practice score was computed and a hierarchical stepwise multiple linear regression model constructed to identify key determinants of improved WASH score.

Over 90% of households had access to piped water; 6% reported access to continuous supply. Adult women (61% in 2018; 45% in 2019) spent 20 minutes daily to fetch water. Access to improved latrines was almost universal, although 80% used shared facilities. Unhealthy disposal of children’s stools was reported in both rounds. Food hygiene practices were high, with most (>90%) washing uncooked items before eating; frequent consumption of street food items was reported.

The study area reported high WASH coverage. Unhygienic behavioral patterns predisposing to food- or water-borne diseases were also noted. Awareness building and sustainable community mobilization for food hygiene needs to be emphasized to ensure community well-being.

Water, sanitation, and hygiene (WASH) remain critically important to public health. Lack of access to safe water, proper sanitation, and inadequate hygiene practices have been linked with the increased risk of transmitting infectious diseases like cholera, typhoid, hepatitis A, and many other water-related diseases [ 1 , 2 ]. Updated analysis of World Health Organization (WHO) data indicate that globally an estimated 8 29 000 deaths and 49.8 million disability adjusted life years, with a mortality rate of 11.7 deaths per 100 000 population in 2016, could be attributed to unsafe WASH practices [ 3–6 ]. The highest mortality rates associated with inadequate WASH are seen in low- and middle-income countries of South-East Asia and Africa, with 15.4 and 45.8 deaths per 100 000, respectively [ 7 ].

India has an enormous burden of enteric infections such as diarrhea and enteric fever, as a result of unabated population growth, high levels of poverty and illiteracy, and inequity in access to safe drinking water and sanitation services [ 8 ]. However, the provision of safe water and adequate sanitation does not always ensure hygienic use or adoption of other sanitary practices, as it has been demonstrated that point-of-use contamination of drinking water, obtained from safe, municipal sources, is a major determinant of diarrheal disease occurrence in children in urban slums of India [ 9 ]. The Swachh Bharat Abhiyan (Clean India Mission) has resulted in major improvements in access to safe potable water, sanitation, and hygiene facilities, especially in urban India. According to the statistics released by the Joint Monitoring Program for Water Supply, Sanitation, and Hygiene in December 2019, between 2000 and 2017, access to basic safe water has gone up from 94.7% to 96.3%, access to basic sanitation facilities has gone up from 49.3% to 72%, and around 80% of the urban population have been covered by basic hygiene services since 2012, when these estimates were first reported [ 10 ]. However, despite incremental access to improved WASH amenities, thanks to the Swachh Bharat Abhiyan, pockets of inequity still remain [ 11 ]. These inequities are especially pronounced in urban slums, where population densities are high, access to services are low, and as a consequence of poverty, adverse social determinants, and biological factors playing synergistic negative roles, the levels of morbidity and mortality are unacceptably high.

Enteric fever is a condition that imposes a significant public health burden and is a cause for concern in India, with varied geographic heterogeneity across the country [ 12 ]. Typhoid causes an estimated 235 cases per 100 000 persons per year in Kolkata, as reported from cohort studies in urban slum dwellers [ 13 ]. To generate evidence and current estimates of enteric fever burden in India, fever surveillance was conducted in Kolkata as a part of the National Surveillance System for Enteric Fever in India (NSSEFI) [ 14 ]. Individual household WASH services and practices were assessed at baseline and at 1 year of follow-up. This study reports on the gaps in WASH conditions in urban slums of Kolkata to inform and augment appropriate future interventions in the region.

Study Area and Population

Kolkata is one of the most populous cities of India, with 19 million people living in its central and suburban areas, which consists of 144 administrative wards. The study area consisted of 2 such wards, numbers 58 and 59, in the eastern part of the city. A large proportion of the residential areas in these localities are densely populated urban slum settlements. These are officially recognized and registered slums, with narrow streets and lanes characterized by overcrowding, shared intermittent water supply, shared community latrines, and inadequate sewage disposal through open drains.

Study Process

A community-based prospective enteric fever surveillance was initiated in November 2017 and it continued up to December 2019, recruiting children aged 6 months to younger than 15 years residing in the area. Five field health outposts, staffed by physicians and health workers, were set up in the 2 wards for enteric fever surveillance. Eligible children were enrolled prospectively following appropriate consent/assent processes. All enrolled children underwent active weekly inspection either through personal home visits or through telephone interviews for 24 months or until they attained 15 years of age, whichever was earlier. Any episode of fever (≥38°C/100.4°F) among the children included in the cohort was reported to the study team by the caregiver, and details recorded in the fever case report form. A blood sample was collected for culture from every subject with a history of fever for 3 consecutive days. Detailed methodology of the study has been reported previously [ 14 ].

A pretested questionnaire was administered to collect information on demography, assets, socioeconomic status, cooking fuel, access to safe water, sanitation, and hygiene practices from the households at the baseline (March to September 2018) and again 1 year later (March to September 2019). We followed the Joint Monitoring Program 2017 definitions for improved sources of drinking water and sanitation [ 15 ].

Data Analysis

A custom-designed data collection application, developed by the central data management team, was used for coded digital data collection in the field using an android-based handheld tablet computer. Rigorous checking and verification of the collected data, including quality control of the data, were carried out on a regular basis through the central data management team. All the recorded information was compiled and managed in a database locally at the Indian Council of Medical Research (ICMR)-National Institute of Cholera and Enteric Diseases (NICED). All data analysis was done using Stata version 16.1 (Stata Corp). The characteristics of the households being surveyed and reported WASH practices were described by the 2 rounds of the survey. The WASH information was used to develop a composite WASH score to summarize the WASH risks of the households and the difference in the score between the 2 rounds was also computed. Univariable linear regression analyses were conducted to identify the factors that were statistically significantly associated with the difference in WASH score. The factors that were found to be significantly associated with the WASH score were entered into a hierarchical stepwise multiple linear regression model to identify the factors associated with an improved WASH score.

The study was approved by the Scientific Advisory Committee and Institutional Ethics Committee of ICMR-NICED and the Institutional Review Board of Christian Medical College, the central coordinating institution.

Between November 2017 and December 2019, 5991 children were under active surveillance; 258 children were lost to follow-up during the study period. In the first round of the survey, 4104 households were included and 3906 were surveyed in the second round. Because several families contributed multiple eligible children to the study cohort, the number of households under observation was lower than the number of children enrolled in the study.

The sociodemographic characteristics of the study population are presented in Table 1 . We stratified the characteristics by the 2 rounds of the survey. In both rounds, a large proportion of the participating families were nuclear in nature, with a median family size of 5 (interquartile range [IQR], 4–6). Most of the families resided in single-room households, as is normal for the area under study. The median monthly family income was slightly higher in round 2 (median Indian rupee [INR] 9000; IQR, INR 8000–12 000) than in round 1 (median INR, 8000; IQR, INR 7000–10 000). A large proportion of the families resided in houses that were mixed kutcha-pucca in construction. Less than half of the households had a separate kitchen and most cooking activities were conducted inside the house. A very small proportion reported to have backyard poultry rearing or cattle of any kind in both the rounds. For classifying houses, we followed the definition laid down in the Statistical Year Book of the Ministry of Statistics and Program Implementation of the Government of India [ 16 ]. A pucca house was a permanent one with walls made of burnt bricks, stones packed with lime or cement, cement, concrete, or packed timber, and roof made of tiles, galvanized corrugated iron sheets, asbestos cement sheet, reinforced brick concrete, or reinforced cement concrete. Kutcha houses had roofs and walls made from less-permanent materials such as unburnt bricks, bamboos, mud, grass, reeds, thatch, loosely packed stones, to name a few.

Characteristics of Families Surveyed in 2 Survey Rounds During 2018–2019

Abbreviation: IQR, interquartile range.

In both the rounds, a very high proportion of the respondents reported having access to improved, safe drinking water source, and details are provided in Table 2 . Around 1 in 10 households had piped water in the dwelling; the most common source of safe drinking water supplied by the municipal authorities were shared pipes, which ran into the residential yard or public taps used by a group of households. These were the primary source of drinking water for over 80% of the households in both the rounds of the survey. In the second round, an additional question was asked about continuous water access; less than 6% of households indicated that they had continuous access to drinking water. Most families reported having access to intermittent water supply delivered in a time-limited manner, in multiple time intervals each day. Although fetching water was the primary responsibility of the adult women in the households, fewer women reported fetching water in round 2 (45.31%) than in round 1 (61.06%). A median of 20 minutes was spent in fetching water in both rounds. In both the rounds, approximately 1 in 10 families (13.72% in round 1, 9.65% in round 2) reported using any form of home-based water treatment for purification of drinking water. In the second round of the survey, we enquired about the specific strategy being used; use of water filters (6.81%) was the commonest, followed by boiling (1.66%).

Drinking Water Source and Management in 2 Survey Rounds During 2018–2019

a This question was not included in the first-year survey.

Table 3 summarizes the sanitation facilities that were available to the study population. Over 95% of the households reported having access to some form of improved, flush, or pour-flush latrine. In the 2 rounds, a very small proportion reported using open defecation or hanging toilets. A majority of the sanitation facilities were shared between a median of 6 (IQR, 2–10) households. More households reported accessing sanitation facilities that were open to the general public in round 1 (12.04%) than in round 2 (4.84%). However, despite the almost universal coverage of the study population with improved and safe sanitation facilities, 14.3% of the households reported risky disposal of children’s stools in the community in round 1. In round 2, this proportion had reduced to 8.3%.

Sanitation Facilities Access, Use, and Practices in 2 Survey Rounds During 2018–2019

The reported food hygiene practices are summarized in Table 4 . A very high proportion of the respondents reported consuming ready-to-eat food from street vendors on a regular basis in both rounds. Over 41% of respondent households in round 1 and 47% in round 2 reported consuming such foods at a frequency greater than or equal to once a week. Similar proportions of the study population reported consuming breakfast or ice creams from such street vendors in both the rounds. However, over half of the respondents in both the rounds reported rarely or never eating uncooked foods, and almost all respondents reported washing such uncooked foods or peeling them before consumption.

Food Hygiene Practices Surveyed in 2 Survey Rounds During 2018–2019

A composite WASH score was developed using the reported practices in the 3 domains of water, sanitation, and food hygiene, as outlined in Table 5 . Presence of any of the factors mentioned within each of the 3 categories would accrue a point. The differences in the WASH score across the study households in the 2 rounds are summarized in Figure 1 and the distribution of the WASH score in the 2 rounds is provided in Supplementary Table 1 . None of the households reported achieving the lowest possible score of 0 in either of the 2 rounds. Only about a third of the households noted an improvement in the WASH score in round 2, with a third noting a reduction in WASH score, and a third showing no change. As noted in Table 5 , the maximum possible score on this scale was 10. No households reported receiving the highest WASH score in round 1 and only 1 household reported this score in round 2.

Indicators of Water, Sanitation and Hygiene Practices Used to Develop Composite WASH Score

Distribution of water, sanitation, and hygiene (WASH) scores in round 1 (2018) and round 2 (2019) surveys.

Unadjusted simple linear regression indicated that the baseline family size, completed years of education, monthly income, housing type, presence of a separate kitchen in the house, location of cooking, cooking methods used, minutes spent fetching water every day, and number of households sharing a toilet were significantly associated with the WASH score ( Table 6 ).

Results of Univariable Linear Regression Showing Unadjusted Regression Coefficients for Different Factors

Abbreviation: CI, confidence interval; Ref, reference.

These variables were then systematically entered into a hierarchical multivariable linear regression model. In the first model, we included the key proximate factors associated with a lower WASH score: years of completed education, family size, number of households sharing a toilet facility, minutes spent in fetching water every day, and public access to toilet used by the household. In the second model, we further added the variables related to housing, including poultry rearing and presence of a separate kitchen. The f test for change in R 2 indicated that there was a significant change ( P  = .043) from model 1 and model 2 was a better fit. We then added the variables of location of cooking and family type to construct model 3, but we observed that the change in R 2 was not statistically significant, indicating that model 2 is a better, more parsimonious fit than model 3. Table 7 provides the detailed information on each model. After adjusting for the years of completed education, family size, and public access to family’s toilet facilities, model 2 indicated that there was a significant improvement in WASH score when fewer households shared a toilet and less time was spent in collecting water. However, the model characteristics show a low R 2 value overall, which indicates that other explanatory factors, which were not observed as part of this study, could be associated with improved WASH scores in the households of urban slums in Kolkata.

Hierarchical Linear Regression Analysis of Factors Associated With WASH Score

Abbreviations: β, adjusted regression coefficient; 95% CI: 95% confidence interval.

Safe WASH practices prevent the transmission of water-borne infections in the community. Our findings mirror those of the National Family Health Survey-4 (NFHS-4), which indicated that 96% of families in the region had access to improved sources of drinking water. Notably, almost all families reported receiving intermittent water supply, and often, during scarcity of water—especially during summer months—local municipal authorities also deploy tanker trucks to meet water needs. A majority of the families believed that the water obtained is safe for drinking, and thus only about one-tenth of the households treated the water in any method before drinking. This is similar to a finding from a study conducted in urban slums of south Delhi [ 17 ], where a majority (75%) did not treat the water before drinking, as most of them thought the water was already clean and ready to drink. Almost all the households in the study area had been using a flush toilet, which is much higher than what was reported by NFHS-4. Again, it is worth mentioning that a large proportion had to share their toilet facility with many other local families.

Despite the high degree of coverage with adequate WASH facilities, we observe that most of the households failed to obtain a high WASH score on the composite summary score devised for this study. Although the generalizability of such a score may be in doubt, its internal reliability is assured because all families were measured on the same scale, using uniform methods for data elicitation. This low WASH score is indicative of the vulnerabilities in this area, especially affecting the health of children younger than 5 years. Previous surveys have found that slum-dwelling children younger than 5 years in Kolkata were 3.7 times more likely to suffer from diarrhea than any other age groups [ 18 ]. Cross-sectional surveys showed around 8% of children reporting diarrhea in the 2 weeks preceding the survey [ 19 ]. Another longitudinal survey showed that children younger than 2 years and between 2 and 5 years reported the highest levels of diarrhea as well as the specific diagnosis of cholera; the incidence of diarrhea in children younger than 2 years was over 270 cases per 1000 person-years, which was almost 5 times higher than the overall incidence rate of 58 cases per 1000 person-years [ 20 ]. As a result of these high levels of morbidity, there are long-term implications for children’s health. Surveys have noted high levels of stunting in children from urban slums of Kolkata. One estimate reported as many as 26% of children to be suffering from stunting [ 21 ]; another survey reported that 31% were underweight, and amongst them, 29% were stunted and 29% were wasted [ 22 ]. In yet another survey, 55% of children younger than 5 years were found to have anthropometric failure, with 48% reporting some form of additional comorbidity, the commonest of which were diarrhea (11%) and acute respiratory illness (9%) [ 23 ].

A considerable proportion of this burden of disease and ill health could be averted by improvement in the quality of drinking water along with access to improved sanitation and hygiene facilities in underserved locations. The introduction of clean water, well-designed sewerage systems, and adoption of hygienic practices, along with increased awareness in high-income countries, has led to a dramatic reduction of morbidity and mortality associated with fecal-oral transmission in these countries [ 5 , 24 ]. Also of interest is the fact that a large proportion of the study population do not undertake any method to purify drinking water. Although drinking water with sufficient residual chlorine is obtained from improved sources by these households, there remains the possibility that the water can be contaminated during storage for drinking, cooking, and other domestic use, as has been previously documented in similar urban slum settings [ 9 ].

The lower education level of the head of the household was significantly associated with poor WASH scores, indicating an improvement in WASH practices with increment in education. Similarly, a study conducted among households with children younger than 5 years of the Sugali Tribe of Chittoor, Andhra Pradesh, stated that parents’ higher levels of education were associated with improved WASH practices [ 25 ]. Another study conducted among slum-dwellers in Hyderabad, Andhra Pradesh reported that better caregivers’ knowledge was associated with higher odds of improved child hygiene practices [ 26 ]. Education level has a practical bearing on all the aspects of living, including hygiene, as this empowers one to accept and practice modern ideas, changing traditional beliefs, attitudes, practices, and augmenting WASH-related knowledge and perspective. However, the gaps between the need for, and access to, health care information and behavior modification still need to be considered in assessing the potential impact of education and awareness-oriented interventions [ 27 ].

Almost all of the study population was living in overcrowded conditions in these urban slums (bustees). Most of these families lived in rented structures with extended family members either in single or double rooms, sharing toilets and other necessary infrastructure. Historically, overcrowding has been associated with the spread of infectious diseases. Living in overcrowded households, that is an increase in family size, was significantly associated with unsatisfactory WASH practices in the current study. As reported in a WHO bulletin, a larger family incurs a disproportionately higher cost for practicing safe WASH habits like boiling water or adopting any other purification methods [ 28 ]. It is to be noted that overcrowded living situations impose a considerable strain on existing WASH facilities, and with a higher degree of usage and fewer breaks for maintenance, the infrastructure can weaken over time.

It must be noted that as an outcome of the Swachh Bharat Abhiyan, there has been major strides made in coverage of vulnerable areas with appropriate WASH services. Ensured access to a sanitary flush toilet has become a reality, although other essential infrastructure has failed to keep pace over the years, leading to poor drainage in the area, resulting in waterlogging during the monsoon months, along with fecal contamination of the piped water supply. This becomes an especial cause of concern because 1 in 10 families have reported disposing the stool of their children in such open environments, amplifying the threat of diseases that are fecal-oral transmitted. Further, the food safety risks of the area are significant, because a considerable number of children of these families reported frequent consumption of food, including breakfast, from street vendors. It needs to be emphasized that food prepared and sold by the local street vendors, especially in the slum areas, may propagate water-borne infections, owing to the lack of basic hygienic practices of the handlers while preparing and storing food.

There are multiple limitations to our enquiry. There is a chance of recall bias around the yearly data collection timeline. Information on hand hygiene, which is an important part of the WASH practices, was not collected directly in this survey. All data were self-reported, which increases the risk of social desirability bias. Further, there were no observational aspects of the study, which limits the possibility of verifying the reported practices. Thus, we cannot demonstrate the gap between the knowledge and practice in our current effort. In addition, because we depended on self-reported information, there was no scope to evaluate the cleanliness, hygiene, and appropriate use of sanitation facilities. Given the cultural mores around toilet use, qualitative participatory research methods could be employed in future efforts to study these specific attributes. Given the post hoc nature of the analysis and the limitations associated with such approaches, we lay more emphasis on the descriptive findings. Finally, we are conservative in interpreting the identified associations given these limitations, and our inability to ascribe temporality. However, the data for the present analysis were collected as part of a large, community-based surveillance for enteric fever, using well-trained data collectors and field staff, making it highly accurate and internally valid. The data were also scrutinized at multiple time points, ensuring high quality of the data as well as fidelity in the data collection processes. Further, this data will contribute to a deeper understanding of the epidemiology and burden of enteric fever in the community settings, as part of the larger NSSEFI study.

The current analysis finds that despite a high coverage of WASH services in the urban slums of Kolkata, there are gaps in the WASH practices in the population. Although there are limitations in a self-reported, cross-sectional, observational study design, we have noted significant gaps in behavioral patterns, which have remained in spite of the intense focus on improving WASH through the activities of Swachh Bharat Abhiyan in the country. The findings are indicative of the fact that, in addition to providing high-quality WASH services and facilities, there is a need to deploy awareness building and social mobilizing activities, which emphasize building community ownership of these programs. Considering that most of the WASH facilities are currently shared between multiple families, they are unlikely to be used in a safe and sustainable manner unless there is sustainable change in behavioral practices of the community, including contributing to the upkeep, maintenance, and upgrading of such community-owned facilities. More studies are needed to generate evidence useful for planning the most effective intervention to ensure appropriate hygiene practices in the community.

Supplementary materials are available at The Journal of Infectious Diseases online. Consisting of data provided by the authors to benefit the reader, the posted materials are not copyedited and are the sole responsibility of the authors, so questions or comments should be addressed to the corresponding author.

Acknowledgments . We are thankful to all the participants, project staff, and the community involved in the study. We are also thankful to the Central Coordinating team from Christian Medical College, Vellore for structuring and monitoring the data collection process.

Author contributions. S. K., P. C., J. S., and N. C. collected the demographic and clinical data. S. K. processed the data and conducted the statistical analysis. S. K., P. C., and T. P. drafted the manuscript. S. D. revised the final manuscript. All the authors have read and approved the final version. The corresponding author had full access to all the data in the study and had final responsibility for the decision to submit for publication.

Disclaimer . The funder of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report.

Financial support . The work was supported by the Bill and Melinda Gates Foundation (grant number INV-009497-OPP1159351) through the Christine Medical College, Vellore.

Supplement sponsorship. This supplement is sponsored by the Christian Medical College Vellore Association.

Potential conflicts of interest . All authors: No reported conflicts of interest. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.

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Author notes

• enteric fever
• linear regression
• participation in ward rounds
• potable water

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• Volume 4, Issue 5
• Explaining the outcomes of the 'Clean India' campaign: institutional behaviour and sanitation transformation in India
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• http://orcid.org/0000-0001-8994-2878 Val Curtis
• DCD , London School of Hygiene and Tropical Medicine , London , UK
• Correspondence to Professor Val Curtis; val.curtis{at}lshtm.ac.uk

Introduction Many less developed countries are struggling to provide universal access to safe sanitation, but in the past 5 years India has almost reached its target of eliminating open defaecation.

Objective To understand how the Indian government effected this sanitation transformation.

Methods The study employed interviews with 17 actors in the government’s ‘Clean India’ programme across the national capital and four states, which were analysed using a theory of change grounded in Behaviour Centred Design.

Results The Swachh Bharat Mission (Gramin) claims to have improved the coverage of toilets in rural India from 39% to over 95% of households between 2014 and mid-2019. From interviews with relevant actors we constructed a theory of change for the programme, in which high-level political support and disruptive leadership changed environments in districts, which led to psychological changes in district officials. This, in turn, led to changed behaviour for sanitation programming. The prime minister set an ambitious goal of eliminating open defaecation by the 150th birthday of Mahatma Gandhi (October 2019). This galvanised government bureaucracy, while early success in 100 flagship districts reduced the scepticism of government employees, a cadre of 500 young professionals placed in districts imparted new ideas and energy, social and mass media were used to inform and motivate the public, and new norms of ethical behaviour were demonstrated by leaders. As a result, district officials became emotionally involved in the programme and felt pride at their achievement in ridding villages of open defaecation.

Conclusions Though many challenges remain, governments seeking to achieve the sustainable development goal of universal access to safe sanitation can emulate the success of India’s Swachh Bharat Mission .

• environmental health
• public health

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https://doi.org/10.1136/bmjgh-2019-001892

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Key questions

What is already known.

At least 47 countries are not on track to reach the sustainable development goal of universal access to safe sanitation by 2030 and some 0.6 billion people are still defecating in the open.

It is not clear how governments in low-income countries can be galvanised to act to resolve this pressing public health problem.

What are the new findings?

The experience of the Clean India programme suggests that countries can almost eliminate open defaecation.

The success of the programme was due to the following factors: setting of ambitious targets; use of modern communications strategies and monitoring technology; and provision of visible reward and recognition for employees.

What do the new findings imply?

Disruptive leadership is needed to create working environments where, sometimes jaded, civil servants are given an opportunity to make a difference.

Politicians who embrace the cause of sanitation may find that there are votes in toilets.

In a country as powerful as India—dreaming of space conquest, building roads, development—the fact that the priority of the entire Indian administration is to end open defaecation is extraordinary. (Interview No 14)

Introduction

In 2007 readers of the BMJ chose the introduction of clean water and sewage disposal—'the sanitary revolution'—as the most important medical milestone since 1840. 1 Yet safe sanitation, essential for the prevention of infectious disease, for child growth, for gender equity and for human dignity, 2–10 has yet to reach a quarter of the world’s inhabitants. 11

Most countries of South East Asia and sub-Saharan Africa have struggled to improve their rates of toilet ownership. One country, however, has bucked this trend. Rural India, once responsible for 60% of the world’s open defaecators, 12 has over the past five years been transformed by a government-led programme named the Clean India Mission ( Swachh Bharat Mission (Gramin ) or SBM(G)). In 2014, fewer than four in 10 rural Indian households owned a toilet; by the middle of 2019, official figures put coverage at over 95%. 13 While it is hard to be certain of the actual numbers of toilets in such a vast and diverse country, it is clear that a major national transformation has taken place. This is an unlikely success story, both because Indian bureaucracy is not famous for its ability to create rapid change, and because ending open defaecation is a surprising target for a political campaign.

In this paper I aim to explain how this sanitation transformation happened. From interviews with national, state and district actors, I deduce a theory of change for the behaviour of government officials in districts and use this to draw lessons for other nations wishing to emulate the success of the Clean India campaign.

Study sample

I interviewed 17 people chosen to represent a range of types of SBM(G) actors operating at national, state and district levels. Participants came from the capital and four states, with varied performance on toilet coverage. Of the interviewees, six were career civil servants, five were assigned to work in SBM(G), four were employed by partner organisations outside of government and two were academics. Of the total, four worked in national government, four at state level and six at district level. The aim was to have approximately four people in each type of position (some interviewees represented several types) and to continue interviewing until saturation was reached. 14 Fifteen of the 17 interviewees were Indian nationals and seven were female. Eleven interviews took place face-to-face and six over Skype; each lasted for 60–80 min. Interviews took place between May and July 2018. All of the people approached agreed to take part, although one delegated the interview to a colleague. I also drew on my experience as an occasional adviser on behaviour change to the Indian Ministry of Drinking Water and Sanitation (MDWS).

Study ethics

Interviewees were supplied with an information sheet about the study, were informed that their participation would be anonymous and were asked to sign a consent form. Identifying information was removed before transcription of interviews. Ethical approval was granted by the London School of Hygiene & Tropical Medicine (no 15261) and permission to conduct the study was granted by the MDWS.

Patient and public involvement

No patients or members of the public were involved in the design, analysis or reporting of this study.

Data collection and analysis

The interviews followed a structured format that included a request to describe the SBM programme, questions about administrative structures, decision-making systems, programme financing, technical issues and specific challenges. I also asked participants about their own circumstances and their motives for working in SBM(G). I followed COREQ guidelines for the design, analysis and reporting of qualitative research. 15

Interviews were conducted in English and recorded. Following transcription, I employed the steps of framework analysis—namely, (i) familiarisation, (ii) identifying a thematic framework, (iii) indexing, (iv) charting and (v) mapping and interpretation. 16 I employed the framework of Behaviour Centred Design (BCD) 17 to index and chart the data using NVivo version 11. 18 Figure 1 shows the generic BCD theory of change framework, depicting how interventions perturb the physical, biological and social environment of actors. These changes affect their psychology (at an executive, motivated or habitual level), and lead to changes in their behaviour. These behavioural changes, when compounded, lead to changes in the state of the world—for example, better toilet provision in India. All these changes take place in a particular geographical, political, economic and cultural context.

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Generic Behaviour Centred Design theory of change.

Figure 2 shows the theory of change for SMB(G) constructed from an analysis of the interviews using the BCD framework. On the right are the observed changes to the state of the world (improved toilet coverage and use). Left of this, in grey, is the change in behaviour of district officials. In blue, are the psychological changes in these actors, brought about by changes in their operating environments, shown in green. The orange boxes are aspects of the intervention (ie, the activities of SBM(G) as led by the MDWS that caused this cascade of changes. Below I detail these changes, working from inputs to impact.

Theory of change for the Swachh Bharat Mission (Gramin) . MDWS, Ministry of Drinking Water and Sanitation; ODF, open defaecation free; SBM, Swachh Bharat Mission ; SDGs, sustainable development goals.

Interventions (inputs to SBM(G))

All interviewees ascribed the initial impetus for the Swachh Bharat Mission to the prime minister, Narendra Modi. In 2014, in his inaugural speech from the ramparts of the Red Fort in Delhi, Modi announced his plan for India to become free from open defection in 5 years, by 2 October 2019, in honour of the 150th anniversary of the birth of Mahatma Gandhi. The setting of this ‘big hairy audacious goal’ 19 made the need for radical changes in the government’s normal approach evident:

[We are in] mission mode delivery arrangement, where you have a sunset clause that you have to achieve in a given time period… …So, it's a very different working paradigm. (01) [In normal practice] the government might have said that we have 10 years to make India open defaecation free. So we might have done squat for 7 years and started working in the eighth year and then asked for a 5 year no-cost extension. (16)

Officials at all levels referred to the prime minister’s evident commitment to SBM:

The major change is that the political leadership came from the prime minister’s office… …to reach all the communities, civil societies, religious leaders, famous people of India, actors or people in sport. Involving everybody at the same time for a national cause under the lead of the PM. (14) …the fact that this is led by the prime minister – it is high on the agenda of every district collector. It has led to government functionaries being on their toes all the time and also reaching out to the people in a way that has never happened before. (12)

And the PM kept up pressure over the life of the programme:

So, it was not just a political announcement, but they backed it with serious attention over last 4 years, I think that’s quite dramatic. That’s one big game changer. (16) …the PM referred to Swachh Bharat in 35 of his 50 addresses to the nation on All India Radio between October 2014 and December 2018. (10)

Breaking with administrative norms to appoint staff on the basis of seniority, the prime minister sought out a technocrat to lead SBM(G) within the MDWS. The chosen secretary was a sanitation specialist and was also unusual in having worked both within the Indian administrative service, and outside of it in international bodies. This gave him the ability to navigate the government hierarchy, but also to see where it might be disrupted.

In terms of technical leadership, this time the people put in place to lead this campaign are people with global experience that have worked abroad. They are aware of what is happening in the world in terms of sanitation programming, successes and failures, so there is great openness to learning in this programme. (14)

The ministry team led a consultation exercise with states to gather lessons from a succession of previous sanitation campaigns, and to work out what it would cost to achieve the goal of an open defaecation free (ODF) India. The total bill was estimated at some US$20 billion over 5 years, or about US$4.00 per head of the population per year. 20 In addition, the team negotiated a loan of US$1.5 billion from the World Bank. 21 The ministry also asked the World Bank, UNICEF, WaterAid and other support agencies to augment their technical assistance to states, and asked philanthropic foundations (Tata Trusts and the Bill and Melinda Gates Foundation) to fund the recruitment of consultants to a project management cell:

The consultants have given a new dimension to the working of the ministry. Previously we were working like a government setup, but with the coming of this young blood… …they have given momentum to the programme. (02)

Unusually for India, the management cell was integrated within the ministry rather than sitting outside of it. The SBM(G) team thus had access to government communications channels and to the cabinet and prime minister:

What Modi has done is picked up these bureaucrats and said you have direct access to me… (09)

A further input that distinguished SBM(G) from standard Indian government programmes was a new strategy for communications. The team recognised early on that it was important to constantly communicate; downwards through the government hierarchy to programme actors, outwards to the population as a whole and to partners in the private and development sectors, and also, critically, back upwards to SBM’s political masters. Key influencers had to be kept on board:

We started delivering and then we started communicating that to the people who matter - like media, like the political masters, they need to feel that the thing is moving. Then there are academics, the international community, the sort of people who are influencers, who can spread the word. It's like chicken and egg: when you start doing well, then nothing succeeds like success, but it needs to be communicated… (11) So point is, if you want political leadership and you get it, then you have to nurture it… (14)

Mass media played a major role in keeping all these audiences supportive and involved:

…all of our communication has become much more world class. Indian government ads are [normally] easily identifiable from their look and feel -- they are dull, boring and preachy and nobody wants to watch them. But in this ministry the ads are very exciting and entertaining… (10) Honestly I don't know if promoting stuff on social media is leading to behaviour change in rural India, but it does make urban India more aware about what happening in rural areas, for that is also important. (12)

Changes to the environment in districts

The theory of change depicts how these inputs (disruptive leadership, mobilisation of human and financial resources, new modes of communication) changed the operating environment for staff working in India’s more than 600 districts. The new leadership team in the ministry recognised that the first barrier to overcome was widespread staff scepticism, engendered by the experience of having seen many previous campaigns falter. 22 They needed to make district officials believe that change was possible. One hundred districts were therefore targeted for an ‘early-win’ campaign. Their heads, the district collectors, were invited to national workshops, and were offered resources and, unusually, direct access to the leadership, to enable them to resolve any problems they encountered. By the end of 2016, most of these flagship districts had declared that they were ODF. This model was then duplicated across the country.

That is one of the great achievements (of SBM), they really have made sure that there is great support for any collector who wants to achieve this. (17)

The new leaders of SBM disrupted social norms in districts by modelling behaviour that was results-oriented and ethical. One interviewee recounted:

If the secretary is going to the field [normally], the collector’s job is to be the protocol officer, to receive him at the airport, ensure his dietary requirements, see his arrangements are proper. Your job is to carry his briefcase. But this secretary focuses on the task in hand, he asks the collector important questions, rather than where to buy this handloom saree for his wife… This changes the professional ethics. Then the administrators know that this guy will ask for results rather than where to go shopping. (09)

Several interviewees told of the surprise that they felt when they saw a photograph of a top ministry official climbing into a toilet pit to empty it in the national newspapers. 23 One top state official dug toilet pits herself. Another related her initiation to the SBM programme by a trainer which violated the norm :

’Tatti’[shit] is the most disgusting and vile word in Hindi. And he was just like: ‘tatti tatti’… …and I could not stop giggling. It is not even a word you may use, you may use this word at home, but not if there is a guest or someone. (10)

Many interviewees felt that such activities had caused a change of norms in society, and by extension, in districts:

So this is quite unique… …5 or 6 years back you could not even talk about defaecation. And now you see that the whole of India is expert on the issue of open defaecation. (14)

A further change to the operating environment of districts was the use of technology to monitor and encourage progress. Collectors were set targets by the leadership in Delhi and then, unusually, were held to account. They were expected to report on progress in face-to-face meetings, in regular multi-participant video conferences and online.

Video and satellite conferences were my two important communication tools to connect with people and officials from across all the districts. I used video conferences to get figures on how many toilets had been built and to hand out targets. (15)

District collectors were trained on, and encouraged to sign up for, social media, and to use email:

[It is] rare for a bureaucrat to reply within an hour to an email. That means he has got email on his phone. Babus [bosses] still don’t do it to this day. (10)

In addition, the MDWS created a live ‘dashboard’; a website displaying progress on sanitation coverage showing the number of toilets built and the percentage of households covered. 24 In many states this system worked automatically via a mobile phone app that was updated by village authorities in real time, as toilets were built and funds disbursed to householders’ electronic bank accounts.

These improvements in communications technology provided an environment in which districts knew they could be held publicly to account, but also gave them an opportunity to show off their success. Rather than being forgotten in remote corners of the country, those collectors and their staff who did well were held up as examples on social media, invited to receive awards at multiple ceremonies involving local, state or national dignitaries and some were given awards by the prime minister himself.

The secretary… …travels a lot to see what’s happening on the ground and he tweets almost every day about the good things that are happening. So, this provides a lot of motivation to the system. (08) We had this workshop to felicitate the spouses which really touched all of them. Many of these wives… …said that nobody has ever acknowledged the work that we do. (15)

A further means by which ‘business-as-usual’ in districts was disrupted was the introduction of ‘fresh young blood’. Aside from deploying technical consultants, development partners were asked to recruit a cadre of new, young and enthusiastic fellows. Five hundred preraks were hired and assigned to support districts, where they took on a variety of roles.

This is how the programme works: they take fellows from districts which have become ODF and put them in districts or states wherever it’s required according to the skills and the needs… (08) The preraks are an astonishing innovation… They have been terrific… (17)

Preraks described how they offered flexible support to districts, filling in where needed:

I had a collector who would call me pretty much on a daily basis. If I didn’t meet him, he would text me and ask about the update. Eventually, I would run a lot of workshops and he even sent me to different locations because [he said] ‘I can’t understand what the problem is there, why don’t you go and check out what the problem is and just address it…’ (07)

Preraks supported each other and shared solutions to problems, often using social media:

But in terms of everyday things that we needed to carry out, we were calling each other on WhatsApp or email… ‘I heard that you guys have a lot of dysfunctional toilets, how are you working on this?’ …that was on a WhatsApp group. (08)

Psychological changes

In figure 2 innovations that changed the social and technological environments in districts led to psychological changes (belief, motivation and habitual response) of the relevant officials. First, staff had to believe that change was possible. Officials repeatedly described how they had joined a civil service out of a desire to ‘serve’, but had been frustrated by bureaucracy and stasis:

It's just pushing up against the wall which is not going to move ever. So, why am wasting the good years of my youth and all my energy and ideas on this? (10)

But as they saw progress, staff begun to believe that the sanitation situation could be changed:

Because it gives you so much conviction, you know, what the world thought is impossible is being done in my time. (01)

As the results of their work became more visible, district officials related their pride at their achievements:

So now when I travel with my family they say: ‘see what is happening to your Swachh Bharat…’…I am ‘Swachh Bharat Champ’ they call me. (03)

Staff described their motivation for working in SBM using emotive terms:

There is a lot of passion for the first time in my sanitation business for many years. This is the first time that I have seen such a powerful country being mobilised in such a genuine and realistic way. (14) …it is glamorous (07) …disgust with the kind of situation people have lived in in our villages for such a long time… (06) I think this whole country has been amazingly galvanised [by this] compelling creation, amazing euphoria…, …the sanitation programme is a very adventurous, courageous and romantic venture. (01)

However, the motive that was most often mentioned by staff working in districts was the opportunity that working in the SBM had given them to ‘make a difference’:

It gives you satisfaction when you see that we are heading a programme that is being implemented and that is being successful and people are owning it. (03) Because here I think I can give my best output and can contribute in assisting my bosses so that they can do it well too. (02)

The new technological environment also changed the habitual responses of officials—for example, by making it easy for them to monitor progress closely:

So now when you are in a village you log into the app [and] all the Swachh Bharat mission toilets are mapped there with the beneficiary name, with the photographs, everything is there. (06)

Further, the new norms of behaviour set by national officials led to new working habits such as abandoning air-conditioned offices and spending more time in the field.

Changes in behaviour in districts

The cascade of changes in the operating environment and in the psychology of actors in SBM led to new behaviour in districts—the level at which staff have the mandate, operational staff and budgetary autonomy to organise development activities. Interviewees reported that the most important determinant of progress in latrine construction was the level of involvement of the district collector (DC). A DC who had taken on the challenge of SBM would typically move into ‘campaign mode’, making building toilets her/his priority, sometimes neglecting other activities to do so. The work comprised reviewing the sanitation status of blocks (administrative units) and villages, setting targets for toilet construction, organising payments to self-help groups and contractors, training masons and huge numbers of social mobilisers ( swachhagrahis ), organising mobilisation events, monitoring results and verifying the ODF status of villages.

DCs used a range of strategies to galvanise these activities: setting targets for blocks and villages to become ODF, arranging disbursement of funds, having weekly problem-solving meetings with block staff and sometimes, following up progress daily using social media.

The commitment of some of these collectors is quite extraordinary. Some use WhatsApp to call people at 4 in the morning to make sure they are up for the nigrani samiti [morning visit to open defaecation grounds]. Quite amazing! (17) So they [block coordinators] feel happy and motivated as there is regular follow-up. And as I call them almost every day, so they also hold meetings almost every 2 to 3 days. (03)

Perhaps the biggest change in the behaviour of district level staff was the move from ‘business-as-usual’ to a personal engagement with the cause:

If you are not out in the field, you are not present and people don’t see you, then people will not get excited. (11) Everybody was more excited about the mission, because the collector himself was sitting with us. (08) So you try to inspire people, motivate people, appeal to them, persuade them to do it fast, quickly and so on, in the mode of pulse polio [national eradication campaign], where in matter of a week or 10 days you can simultaneously start the work of construction and of triggering people. (15)

Change in the state of the world (impact)

What, finally, was the overall impact of these changes in the administrative system under the SBM(G)? The government of India has made repeated efforts to improve the sanitation conditions of its rural population; figure 3 shows the results. After the national census of 1981 put national sanitation coverage at only 1%, the Central Rural Sanitation Program was launched in 1986. This increased coverage to 9% and evolved into the Total Sanitation Campaign, which began in 1991. In the following 20 years, coverage improved by some 1% a year, reaching 31% by 2011. 25 Despite a relaunch of the campaign, as the Nirmal Bharat Abhiyan , India failed to meet its millennium development goal to halve the rate of those with no access to sanitation by 2015. 26

Household toilet coverage in India 1981–2018 according to surveys and the national monitoring system.

By contrast, 4 years after the 2014 launch of Swachh Bharat, official figures suggested that over 80 million toilets had been built; 500 districts and almost half a million villages had been declared free of open defaecation. 27 Figure 3 suggests that the rate of toilet building in rural areas was around 10 times that of previous campaigns. In tandem with accelerating increases in sanitation coverage, government figures suggest that open defaecation has also decreased, dropping by 3% a year between 2000 and 2014 and by 12% a year from 2015 to 2019. 11

A number of unpublished surveys suggest that the government monitoring system overestimates the true levels of toilet coverage. 28 29 Interviewees gave reasons for discrepancies between individual surveys and government figures that included inaccuracies in the original government baseline against which progress is reported, the omission from the SBM programme of households with old toilets which had fallen out of use, and systemic incentives to over-report results. Nevertheless, interviewees described exceptional progress in improving toilet coverage over the past 4 years, transforming India from a country where the majority defaecated in the open, to one where the majority of people have, and use, toilets.

I don’t think there is any historic parallel of any country anywhere in the world, shifting numbers on such a scale. That will change the global indicators. I think that the story is not whether it is 85%, right, or 90%, right, the story is the fact that there is a tremendous shift. (16)

While interviewees were positive about the gains made by the SBM, there were also worries about the sustainability of these gains over the long term:

we brought India from A to B which is an outstanding achievement but there is recognition that behaviour change is complex, there is unfinished business and there is necessity to invest beyond the campaign so that we have a real impact by the end of the SDG era. (14)

As the final deadline for SBM looms, political attention to the unfinished last mile on sanitation will inevitably shift to other pressing social problems, such as rural water supply. In the face of this the MDWS is trying to embed sanitation in national policy, and plans to continue to make funds available to complete and sustain the gains of SBM.

On sustainability, of course the ministry is also aware; they have started focusing on something called ODF Plus, which looks at the sustainability issue. (13)

Drawing transferable lessons from a programme’s theory of change requires understanding its particular context. 30 The SBM(G) programme took advantage of opportunities presented by the prevailing national political situation, of improvements in living conditions in rural India and of the proliferation of communications technology. It also drew on the experience of previous sanitation programmes, and on the global push to meet the sustainable development goals. Contextual factors that hindered progress, on the other hand, included a general scepticism of government-sponsored programmes, political division, where some states were not supporters of the current government, and the many other competing demands for social investment in India.

Interviewees pointed out how the political context was key in the launch of SBM, where a swing towards a nationalist and pro-Hindu party provided an opportunity to capitalise on the symbolism of purity, cleanliness of the mother country and the example of Gandhi. This was expected to translate into electoral support:

Sanitation is something each family needs every day. And through his programme, Modi is able to reach out to almost all the households in the country. And a toilet becomes synonymous with Modi. So, Modi is equal to Swachh Bharat and Swachh Bharat is equal to a toilet. So, this has given him immense visibility, immense publicity and immense connection with crores of households in India. (01)

Indeed, observers have suggested that the prime minister’s evident commitment to rural sanitation was a factor in the success of the ruling party at the 2019 general elections. 31 32

You see, good sanitation is good politics. (01)

The new SBM goals were set for a nation in the midst of modernisation, where millions have emerged from poverty, and most people have improved their housing and gained access to electricity, water, mass communications and education. 33 India was therefore ready for modern toilets, and had the communications networks necessary to spread the idea rapidly.

The SBM(G) programme did not emerge anew but was set up in the context of a long line of previous national sanitation campaigns. These had had limited success, but provided experience concerning what worked and what did not.

The Swachh Bharat Mission is preceded by several other missions; the Total Sanitation Mission, Nirmal Bharat Abhiyan and other campaigns. When the Swachh Bharat mission started we were very much aware of this. We can't say that those programme were a total failure, these contributed to building momentum and creating awareness, and some of these toilets are still in use. …definitely they left imprints. (05)

Both the national and international situation was favourable to SBM. International agreement to meet the sustainable development goals reminded Indian leaders that, though their country had made progress in many ways, sanitation conditions still lagged far behind those of countries with comparable levels of development.

Principal findings

While it will still take some time to completely realise the ambition for an ODF India, the country has made large strides in this direction over the past 5 years. In rural areas of other low-income countries, around 1.5 billion people still lack access to basic sanitation services, and 0.6 billion defaecate in the open. 34 This study offers insights and lessons for the governments of countries that are looking to improve the sanitation conditions of their populations:

There are votes in toilets . The Indian experience suggests that political commitment at the head of government can galvanise an administration to a goal as unlikely as ending open defaecation, and that this may be rewarded politically.

Disrupt institutional norms . From the outset, the leaders of SBM(G) set out to disrupt the bureaucratic norms of government. The leadership modelled ethical norms of commitment to progress, new enthusiastic young staff in districts helped to create norms of adaptive learning, enthusiasm and personal engagement and the norm of polite silence about matters faecal was repeatedly and deliberately violated.

Believe the impossible . A key driver of the success programme was the ‘big hairy audacious goal’ to make India ‘open defaecation free’ by 2 October 2019. Standard development programmes tend to be conservative, setting less risky, but more plausible, goals (for example, the Tanzanian government has set a target of 85% coverage with improved toilets by 2030). However, such targets neither provide a compelling vision nor a sense of urgency. SBM shows other countries that ambitious plans for sanitation transformation can galvanise behaviour change in institutions.

Set targets and monitor them . Many development programmes set targets, but few follow them up as relentlessly as did the Swachh Bharat team. Making use of electronic data gathering and real-time, public dashboards, the ministry team reviewed progress district by district, every month, sought to resolve any bottlenecks and held district collectors to account for their results.

Reward and recognition . Once districts began to meet their targets, their progress was deliberately and publicly celebrated. Officials from successful districts were lauded and presented with awards at national, state and local events, and they, in turn, gave awards to leaders and mobilisers in successful villages. Successful officials were praised in tweets and Instagram posts. As a result, officials were full of pride at their achievements and were motivated to make efforts that went well beyond their normal pattern of work.

Constant 360° communications . Unusually for a government programme, the SBM(G) embraced modern communication strategies and media technologies. The centre kept relevant stakeholders, such as MPs, journalists, academics, development partners and private sector players, informed and involved, using social media, mass media, high-profile events, conferences, teleconferences and personal visits. District officials learnt to use communications technologies such as email and social media to follow progress, to short-circuit sometimes cumbersome official channels and to encourage one another.

Focus on behaviour and sustainability . Learning from previous programmes in India an elsewhere, the SBM made major efforts to support behaviour change through mass training programmes and local innovation.

A passion for sanitation . A surprising finding from this research was the degree of emotion shown by the respondents when they described their engagement with the SBM programme. Motives driving their participation included justice, creativity, nurture, status and disgust. 35 From top to bottom of the hierarchy, almost every interviewee described the programme in emotive terms; whether as adventurous, glamorous, exciting, fulfilling, pride-generating, satisfying, or humbling. According to one interviewee:

I will be living testimony to the fact that India will become ODF and I will be making a huge difference in lives of millions of people, because I am associated. The difference that we will make in rural India, the profound impact it will have on the lives of poor people is very, very satisfying, inspiring, humbling. (01)

Much has been written about sanitation programming, such as the choice of technology, 36 motives for the adoption of toilets, 37 38 provision of subsidy, 39 40 community participation, 41 42 environmental factors 43 and health outcomes of sanitation programmes, 44–46 but only a few published studies have tried to unpick the successes and failures of government-led programmes.

A 2012 study of the of the previous Total Sanitation Campaign in India 22 blamed its poor results on a lack of political priority and leadership, a lack of confidence in the possibility of success, the misuse of subsidies, poor monitoring systems and a top-down supply-led approach. The results of the current study suggests that the leaders of SBM(G) had learnt how to resolve, at least some, of these problems, by capitalising on political support, broadcasting the successes of the programme, using electronic banking to pay subsidies directly to households, employing technological platforms for monitoring and by emphasising behaviour change. The use of electronic technology to monitor progress is not new to India; it has been employed successfully in sanitation programmes in Indonesia 47 and Zambia. 48 A lack of political will has long been lamented in the field of sanitation (for example, in India, 43 Nepal, 49 Tanzania 50 and Ghana 51 ), but the SBM example suggests a reason why politicians should become involved—there are votes in toilets!

The factors responsible for the success of SBM, to some extent, echo those identified as important for success in large-scale health programmes more generally. One survey of 20 proven programmes concluded that political will, technological innovation, expert consensus about the approach, effective use of information by management, and sufficient financial resources were critical. 52 It also pointed to the importance of government ownership of development programmes, if success is to be sustained.

The setting by the government of ambitious, ‘not-quite achievable’, big hairy audacious goals was undoubtedly one of the factors in the success of the SBM. Nevertheless, the pursuit of success can have what Rajkotia describes as an ugly side: “the high stakes, the ambition and the expectation can instil a fear of failure, stifle risk-taking and innovation, and lead to the fabrication of achievement.” 53 However, for SBM a high level of awareness of previous failures led to innovation—for example, an attempt to focus on behaviour change and on construction targets. The strategy has also undoubtedly led to inflated claims about SBM’s results. But, as Rajkotia also points out, aspirational targets are important because they can rally governments and civil society to focus their energies on social development. He suggests that it might thus be unfair to chastise them for failure to achieve their aspirations completely. Countries should recognise that there is a virtuous circle by which aspirational targets can drive success, both through success itself, and by the learning that accrues from acknowledging, accepting and understanding failure to achieve them, partially or completely. 54

Even when toilets have been built, and counted, people might still not use them. A study in Orissa suggested that while the sanitation campaigns of 1999–2012 increased latrine coverage substantially, over one-third of people with toilets were still not using them. 55 Obtaining good data on use is difficult, but there are indications that the longer people have toilets the more likely they are to use them. 56 Evidence suggests that of all the structural, cultural, psychological and material factors determining toilet acquisition and use, the most important seems to be the perceived social norm of not defaecating in the open. 38 Given the much wider presence of toilets and greater discussion of their use, it may be that toilet use has reached a tipping point, beyond which their use will only increase.

A novel aspect of this study was the attention paid to the settings and motives of civil servants. This study documented positive emotions associated with participation in SBM(G). In Bangladesh, Hanchett found that a factor in the success of the national sanitation programme was the enthusiasm and pride of union council chairmen and their shared experience. 57

Strengths and weaknesses of the study

Courtesy bias may be partially responsible for the almost unanimously positive response of interviewees about their experience of SBM, but the enthusiasm of the SBM participants was clearly genuine. Given the huge size and heterogeneity of India, a larger study with a broader range of interviewees from a broader range of states might have provided further lessons. However, data saturation was acheived early, with few new insights emerging after about 12 interviews. 14

This study was unusual in that it focused on the behaviour of district officials within government institutions, rather than on the effect of sanitation programming on villages and households. A more complete investigation might have analysed the factors leading to behaviour change at every level in the hierarchy, from leaders, through ministry, state, district, block and village, through to householders. A future analysis of the factors leading to behaviour change in households could be expected to provide further important information.

The study also focused purely on sanitation programming aimed at households in rural India. How to achieve universal access to sanitation in urban settings in low-income countries remains a large and largely unsolved problem.

It might be asked how far is India a special case, and can the achievements of the SBM be transferred to other countries? India is one country among many in which modernisation is proceeding rapidly. Tusting et al show that housing is improving across sub-Saharan Africa, 58 and our research in Tanzania suggests that toilet promotion can be linked to this process of modernisation. 59 India is also one of many countries in the global south with political leaders with ambitions for transformation, as was demonstrated when 53 government delegations attended a summit on SBM held in Delhi in October 2018. India differs from many countries with incomplete sanitation in its low level of reliance on external monetary help. Yet the, seemingly huge, amount it made available for toilet building amounted to only around US$4 per person per year, a sum that could be recouped in financial savings associated with lower healthcare and other costs. 60 Case studies suggest that poverty is rarely a barrier to the achievement of public health goals. 52 Hence it seems likely that other countries can - if they wish - emulate India’s sanitation success.

The theory of change perspective of Behaviour Centred Design was applied for the first time to behaviour change in institutions. It provided a new, relatively straightforward method to understand the behaviour of actors in government. A new aspect of the approach was its ability to investigate the role of psychological factors such as motives, and the social and physical factors in the operational environment of the key actors. It allowed the creation of a structured and plausible theory of change from which it was possible to derive lessons that should be of use to other institutions wanting to improve the quality of public services.

Future research

SBM measured its success against a baseline set in 2013, but interviewees pointed out that many families had been left out of SBM. The government will need to tackle the tough ‘last mile’ problem of remote and left-out rural households, and find better sanitation solutions for the urban poor, before it can fully claim to have met its objective to declare the country free from open defaecation. Questions remain about the sustainability of the achievements of SBM. Much could be learnt by studying the different experience and differing levels of success across India’s widely varied 600+ districts. Future studies, including the national census of 2021, will disclose the long-term trajectory of the gains claimed by SBM.

Finally, it is increasingly understood that people working in institutions are motivated to act by a range of factors beyond immediate financial advantage. 61 62 As one interviewee said:

All of us who are members of civil services, we joined the service with the vision for the betterment of society. (05)

A closer investigation of the motives of civil servants in national action programmes, such as the successful Swachh Bharat programme in India, might provide important lessons about how best to stimulate and reward such activity. This could have consequences for better public services beyond the urgent struggle to get the sanitary revolution to everyone on the planet.

Acknowledgments

I wish to thank Robert Aunger, Sarah Bick, Kavita Chauhan, Ian Ross, Astrid Thorseth and the interviewees.

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Handling editor Stephanie M Topp

Funding This study was funded by London School of Hygiene & Tropical Medicine.

Competing interests None declared.

Patient consent for publication Not required.

Provenance and peer review Not commissioned; externally peer reviewed.

Data availability statement Data may be obtained from a third party and are not publicly available.

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Reaching China’s fertilizer reduction goals through nitrogen and phosphorus recovery: a substance flow analysis case study

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• Published: 16 September 2024

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• Julia Santolin   ORCID: orcid.org/0000-0003-2642-8307 1 , 2 ,
• Oliver Christopher Larsen   ORCID: orcid.org/0000-0002-4361-100X 1 ,
• Albrecht Fritze   ORCID: orcid.org/0000-0002-2818-3246 1 ,
• Bing Xue   ORCID: orcid.org/0000-0002-7790-1216 1 ,
• Zheng Yang   ORCID: orcid.org/0000-0002-2176-6297 1 &
• Vera Susanne Rotter   ORCID: orcid.org/0000-0001-9300-7292 1  

Linear agricultural nutrient regimes are the principal cause for perturbation of the geochemical cycles for nitrogen (N) and phosphorus (P) and other planetary boundaries. Nutrient cycles are characterized by high spatial disparity and China is a hotspot due to high fertilizer application rates. Using substance flow analysis, this study identified and quantified nutrient flows from agricultural production to residue management of Huangyan tangerines ( Citrus reticulata ) and water bamboo ( Zizania latifolia ) in a case study of Huangyan district (Taizhou City, Zhejiang province). About 754 Mg/a of N and 105 Mg/a of P can theoretically be recovered in the tangerines and water bamboo systems from currently untapped material flows. This could replace 59% of the N and 15% of the P currently applied as chemical fertilizer, reducing environmental impacts. Combining the nutrient recovery of both systems and upscaling the results to Taizhou City, the goal from the 14th Five-Year Plan for Agricultural and Rural Modernization to save 1182 Mg of nutrients per year could be exceeded by almost 12 times. This study’s data have varying degrees of uncertainty. The analysis of data representativeness shows potential for improvements, especially in the agricultural production of water bamboo and the nutrient contents of material flows.

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Introduction

The biogeochemical cycles have exceeded the proposed safe operating space for humans [ 1 ]. According to Campbell et al., agriculture is the main driver for the transgression of this and other planetary boundaries [ 2 ]. Specifically, the production of nitrogen (N) fertilizer is linked to a high energy demand (the Haber–Bosch process for ammonia synthesis is responsible for 1–2% of the world’s total energy consumption) [ 3 ], it consumes 2% of the world’s natural gas as feedstock [ 4 ], and contributes to 1.4% of all anthropogenic CO 2 emissions [ 5 ]. Phosphorus (P) is a finite resource mainly mined in China, Morocco and the United States, making phosphate rock as well as phosphorus critical raw materials [ 6 ]. Apart from climate change and resource depletion, the high N and P application in agricultural regions leads to air pollution, soil acidification, and eutrophication of water bodies—which ultimately results in water dead zones, fish kills, algal blooms, and water contamination [ 7 ]. This unsustainable nutrient management attempts against the achievement the United Nations Sustainable Development Goals (e.g. 6—Clean water and sanitation, 12—Responsible consumption and production, 14—Life below water, 15—Life on land).

Industrial agricultural systems are commonly characterized by linear regimes. Since the nineteenth century, natural nutrient sources and recycled materials were no longer enough to cover the needs of the increasing population [ 7 ]. Therefore, the use of Haber–Bosch N and mined P started to increase rapidly, becoming the main nutrient input for crops—since the 1960s, the use of synthetic N fertilizers increased ninefold and the P fertilizer use tripled [ 7 ]. Although fertilizer production is concentrated in a few countries (mainly China with 25%, Russia with 10%, and United States and India both with 9%), its use is widely distributed globally, meaning that many countries rely on imports to cover their fertilizer demand [ 8 , 9 ]. After application, an important part of these nutrients (over 80% of the N and 25–75% of the P) gets lost to the environment, causing pollution [ 7 ]. The inefficient fertilizer use has been recognized as a global issue and the UN Environment Programme highlighted the need for coordinated policies to manage N and P pollution effectively at global, national, and regional levels [ 10 ]. Moreover, fertilizers are one of the carbon-intensive products covered by the EU’s Carbon Border Adjustment Mechanism (CBAM) to encourage global reduction of carbon emissions instead of moving their production to countries with less stringent climate policies [ 11 ].

China (in particular eastern China) is one of the few agricultural regions with very high P and N application rates that are the main contributors to the transgression of the biogeochemical flows boundary [ 1 ]. It is the world’s largest consumer of fertilizers (42.31 Mio Mg/a of nutrients) [ 12 ], and the country with the second highest greenhouse gas (GHG) emissions from agriculture after India (663 Mio. Mg of CO2 eq/a) [ 13 ]. The reason is that China’s agriculture has been transitioning from a self-subsistence extensive agriculture to an intensive industrial cash crop production system [ 14 ]. After the establishment of the People’s Republic of China in 1949, hundreds of millions of farmers were organized in collective agriculture communes, where all agriculture production decisions were made by local leaders following a higher level production plan [ 15 ]. This changed after the economic reform in 1978: collectively owned land was leased to individual farmers, who had to deliver a fixed quota of “strategic crops” to the state for a fixed price, but were also free to produce more and sell their surpluses in rural markets [ 15 ]. To increase the production on their small plots, farmers started to apply excessive amounts of chemical fertilizer—China’s yearly application per hectare of cropland is one of the highest of the world with 319 kg (for comparison, the world’s average is 119 kg and Europe’s average, 75 kg) [ 16 ]. This resulted in a series of environmental impacts, including groundwater contamination with nitrates, eutrophication of surface waters, soil acidification, greenhouse gas emissions, loss of biodiversity, and micronutrients deficiencies in feed and food [ 17 ].

The Chinese government has set goals and introduced policies to improve sustainability in agriculture. In 2015, the Ministry of Agriculture launched the “zero-growth” action plan, regulating fertilizer and pesticide use by 2020 [ 18 ]. Later, in 2021, the 14th Five-Year Plan for Agricultural Green Development was released, emphasizing the reduction of chemical fertilizer and pesticide use and the improvement of the utilization level of agricultural resources [ 19 ]. China wants to become carbon neutral by 2060, which requires a substantial transformation of the agricultural sector as well [ 20 ].

In addition, local governments are increasingly taking measures to promote agricultural practices that are more circular and sustainable. In Taizhou, a city in the Zhejiang province, the Bureau of Agriculture and Rural Affairs launched its own 14th Five-Year Plan for Agricultural and Rural Modernization to improve productivity and living standards in rural areas (its focus is slightly different of that of the national Plan for Agricultural Green Development mentioned above, which mainly aims at reducing environmental impacts). This action plan aims to increase the use of commercial organic fertilizer, digestate from anaerobic digestion, and green manure to improve soil structure and organic matter content. The utilization rate of manure (from livestock and poultry) and rice straw should also be improved to 92% and 95%, respectively, by 2025. Besides, chemical fertilizer use in the crop sector should be reduced with the help of soil testing and formula fertilization. In this way, Taizhou expects to save 0.6 kg of “pure nutrients” (N, P 2 O 5, and K 2 O) per Mu—or more than 1182 Mg per year—while reducing air pollution (mainly caused by straw burning), eutrophication of water bodies, soil erosion, and salinization. [ 21 ]

Implementing circular systems to achieve these goals requires the detailed study of locally available, potentially valuable organic material flows, which can be done by using Material Flow Analysis (MFA) [ 22 ]. This is a case study for Huangyan (黄岩), a district in Taizhou city (Fig.  1 ) [ 23 ]. Huangyan is a typical example of a region with a linear, cash-crop-oriented, agricultural system and a high demand for chemical fertilizers. While the majority of Taizhou’s economic activities take place in Luqiao district, the agricultural production is based in Huangyan. The agricultural sector, with a yearly contribution of over 10 billion yuan, plays an important role in the region’s economy [ 24 ]. In 2021, 1,918,000 Mu of agricultural land were sown in Taizhou, with a total output of 560,000 Mg of grain and 1,456,900 Mg of fruit [ 25 ]. By quantifying the nutrients that could be recovered in this region, the possible contribution to Taizhou’s goal can be assessed and additional measures can be taken (e.g. to effectively recover those nutrients, to formulate stricter goals if necessary, or to introduce new regulations).

Map of Huangyan, a district in Taizhou city, located in the Jiaojiang River Delta, southeast of Zhejiang Province. Huangyan has an area of 988 km 2 and a registered population of around 610,000

The study focuses on the two crops with the highest production amounts in the region, namely Huangyan tangerines ( Citrus reticulata, annual production in Taizhou reaches 546,000 Mg/a) and water bamboo ( Zizania latifolia, also called Manchurian wild rice, 77,000 Mg/a) [ 25 ]. Both species are native to China, which leads the global market—China produces 61% of the world’s tangerines, mandarins, and clementines, and 27% of the rice [ 26 , 27 ]. The goal of the study is to identify and quantify all the by-product flows in these agri-food systems, to later derive the amounts of N and P that could theoretically be recovered and recycled. These theoretical recycling potentials will then be related to the amount of nutrients that Taizhou expects to save according to its last Five-Year Plan for Agricultural and Rural Modernization. In this way, the potential contribution of nutrient recovery in these two agri-food systems can be measured.

Materials and methods

The methodology of material flow analysis, deeply described in Brunner & Rechberger’s Handbook of Material Flow Analysis , is defined as “a systematic assessment of the flows and stocks of materials within a system defined in space and time” [ 22 ]. MFA is an iterative method consisting of several steps, including goal and system definition (which lead to a qualitative model), determination of mass flows and stocks, and mass balance (resulting in a quantitative model). The quantified material flows can also be linked with the substances’ mass fractions to identify the substance-specific sources and sinks, allowing the development of specific recommendations to improve substance flows.

Goal and system definition

The goal of this substance flow analysis (SFA) is to quantify the amount of N and P that could be recovered within the agri-food systems of the two main agricultural products (Huangyan tangerines and water bamboo) in Huangyan district, Taizhou City, Zhejiang province, China, in 2019.

The system model was defined according to the material life cycle stages identified during the data acquisition, namely: agricultural production, manufacturing, distribution and sales, consumption, and waste treatment and disposal (Figs.  2 , 3 ). The processes shown in the SFAs represent the average and not the best available technology. All solid organic material flows were considered. Gaseous, water, and energy flows were not regarded due to a lack of data.

System definition for Huangyan tangerines

System definition for water bamboo

Data acquisition and uncertainties

The required data were acquired by both top-down (secondary data comprising statistical and aggregated data) and bottom-up (primary data from interviews) data collection.

For the bottom-up data collection, 25 relevant stakeholders from governmental institutions, educational organizations, agricultural and manufacturing sectors, markets, and waste management companies were interviewed between October and November 2019 (supplementary material, Figure a). The interview participants were selected through snowball sampling. Interview guides were prepared in advance to provide a framework of topics to be covered (see questions in supplementary material). However, the interviews were semi-structured, including open questions and allowing new ideas to be raised during the discussion. A translator was always present to translate from Chinese to English and vice versa.

Top-down data were collected through literature research, including statistical yearbooks (from Huangyan and Taizhou), scientific publications, and official reports. This secondary data were combined with the primary data from the interviews to have a solid foundation for the MFA modelling.

For the SFA, the material composition data was taken from FoodData Central, a data system launched by the U.S. Department of Agriculture (USDA), whenever available [ 28 ]. If the needed data were not available in that system, different sources were revised, and the average of various values was calculated.

To account for uncertainties and varying reliability, as well as the temporal and spatial representativeness of the collected data, four data representativeness levels [ 29 ] were defined to classify the quality of the gathered data (Table  1 ). Level 1 was assigned to educational organizations (interviewees were experts in their fields); level 2 to governmental institutions and waste treatment companies (statistical data derived from reports, measurements, and census in the study region); level 3 to farmers, food manufacturing companies and markets (specific information, not valid for the entire region); and level 4 to literature data (related to other geographic regions and/or periods).

Modelling and material balancing

Mass flows of fresh matter (FM) were determined using an Excel model. All the inputs and outputs of each process were related to a reference flow of 1 Mg of freshly harvested product (Huangyan tangerines or water bamboo). When a range of values was available, an average was used. The calculations to determine each of the FM flows and the assumptions made can be found in the supplementary material (Tables a, b).

The flows for the N and P SFAs were calculated by multiplying the FM flows by the N and P mass fractions of each flow. These mass fractions were obtained from secondary sources, except for a few cases, where the interviews revealed relevant data (supplementary material, Tables c, d).

The models for Huangyan tangerines and water bamboo were introduced in the MFA software e!Sankey to obtain a graphical visualization of the nutrient flows. Finally, the theoretical recycling potential of P and N was calculated by adding up all the by-product flows and compared to the amount of N and P already being recycled.

These results were compared with the goal set by Taizhou’s Five-Year Plan for Agricultural and Rural Modernization (saving 1,182 Mg/a of “pure nutrients”). To do that, the values for the P recycling potential were multiplied by 2.29 to account for P 2 O 5 and, hence, allow the comparison with the above-mentioned goal.

The results for Huangyan tangerines and water bamboo are described in this section (the graphic descriptions of the entire life cycles of the tangerines and the water bamboo can be found in Figs.  2 , 3 ). The SFAs for N are illustrated in Fig.  4 (tangerines) and Fig.  5 (water bamboo), and those for P are shown on Fig.  6 (tangerines) and Fig.  7 (water bamboo).

Nitrogen SFA for Huangyan tangerines. Values represent annual flows

Nitrogen SFA for water bamboo. Values represent annual flows

Phosphorus SFA for Huangyan tangerines. Values represent annual flows

Phosphorus SFA for water bamboo. Values represent annual flows

Huangyan tangerines

Agricultural production.

Around 4,200 ha in Huangyan are covered by tangerine orchards. This area is shared between almost 19,500 farms, i.e. the average area of a tangerine farm in Huangyan is only 0.2 ha [ 24 ]. Most of this area belongs to families who own a small piece of land for self-supply. Recently, the government is investing to improve the quality of Huangyan tangerines by funding large, modern tangerine gardens managed by just a few partners [ 30 ]. An average tree produces around 24 kg of tangerines per year [ 31 ]. Trees in their most productive phase, however, can produce up to 10 times more [ 32 ]. The young tangerine gardens in the district are the main reason for the low average [ 30 ].

Tangerine farmers apply 20–30% (relative to N) organic fertilizer and 70–80% chemical fertilizer (15% N, 15% P 2 O 5 , 15% K 2 O) [ 31 ]. In 2017, Taizhou launched a policy to promote the use of organic fertilizer: farmers who use at least 50% organic fertilizer can get access to subsidies [ 31 ]. Currently, there are less than 50 of these “green agriculture” farms in Huangyan—including but not only tangerine farms [ 32 ]. Since there is no fertilizer production in Huangyan, this product has to be imported from other regions [ 31 ]. Chemical fertilizers add 975 Mg of N and 426 Mg of P to the agricultural soils every year, constituting the largest nutrient input of this system. Common organic fertilizers include rapeseed compost, a mixture of sheep manure and mushrooms, compost made out of cassava and residues from alcohol production, and compost made out of water bamboo and sugar cane waste [ 31 , 32 ]. These organic fertilizers introduce 325 Mg of N and 195 Mg of P to the tangerine system.

Most of the tangerines produced in Huangyan (95%) are exported to other regions [ 24 ]. 173 Mg of N and 11 Mg of P leave the system in this way. From the rest, 95% is sold as fresh fruit directly on the farm or in markets and supermarkets (or grocery stores), and 5% serves for the further manufacturing of different products like canned tangerines, Chinese medicine, oil, or candies [ 33 ]. The largest by-product flow in the entire tangerine system comes from the agricultural stage. Every year, 16,140 Mg of by-products are produced in Huangyan’s tangerine farms. This agricultural waste, consisting mostly of pruning residues, contains 311 Mg of N and 20 Mg of P. It is partly used to make fire for heating and cooking [ 33 ], while the rest is either left on the ground, burned in open fires, or landfilled [ 30 , 31 ]. Farmers mentioned a lack of space (it is not permitted to construct buildings in agricultural areas) and a lack of animal manure as the main reasons why they do not compost or digest their waste [ 32 ].

Manufacturing

The biggest company for canned fruit in Taizhou City, “Yiguan Food”, contributes to 10% of China’s canned tangerines production [ 31 , 32 , 33 , 34 ]. The majority of their products are exported and only small amounts (5%) stay in Taizhou for supermarkets, cake and jelly production [ 35 ]. The tangerines for the manufacturing process are purchased from different cooperatives in Taizhou, Hubei, Hunan, and, mostly, Linhai [ 36 ]. The production process includes size separation (small tangerines are picked out), heating in water to facilitate the peel separation, and an acid–base treatment to separate the pith. Afterward, tangerines are separated into slices by hand, which in some cases damages them. Peels, damaged or rotten tangerines, pith, and wastewater are the major by-product flows in this production chain. The peels are sold to a company that produces spices. Wastewater is sent to an industrial treatment plant that processes wastewater from this and other companies, before going to the municipal wastewater treatment plant.

Distribution

Huangyan’s tangerines for fresh consumption are either sold directly from the farm (30%) or in markets and supermarkets (70%) [ 37 ]. Only 9% of the products in the market come from Huangyan, while the rest is imported from other regions, for example from the wholesale market in Luqiao [ 38 ]. Imported tangerines introduce 60 Mg of N and 4 Mg of P into the system. Around 5% of the products sold in the market get wasted [ 39 ]. A small part of these by-products is collected by people who use it to feed their animals, but most of it goes to Huangyan’s landfill [ 40 ]. In contrast, the wholesale market in Luqiao treats part of its by-products: the “clean” fraction (without plastic, paper, or other contaminants) is treated at high temperatures to produce fertilizer. The “contaminated” fraction is compressed. The wastewater then goes to the wastewater treatment plant and the compressed waste is incinerated at Luqiao waste to energy plant. [ 39 ]

Consumption

Around 6% of the produced tangerines, containing 50 Mg of N and 2 Mg of P, get wasted in households [ 41 ]. The consumed nutrients are excreted and leave the households with the wastewater (16 Mg of N and 2 Mg of P).

Waste treatment

Huangyan Waste Sorting and Treatment Centre is responsible for 20% (or 27 Mg per day) of municipal perishable waste. Well-sorted perishable waste from school and office canteens, as well as the “clean” fraction of the perishable household waste is composted. This accounts for 20% of the perishable waste treated by the company. The composting process is still being tested, and the compost quality is still not good enough for agricultural applications. The rest 80% of the company’s perishable waste, corresponding to the “polluted” fraction of the household waste, is treated anaerobically. This waste is first filtered, and then the oil is separated and sold to soap or biodiesel companies. The solid fraction is treated for three to seven days under anaerobic conditions and high temperatures (around 140 °C), while the liquid fraction goes to the wastewater treatment plant. Also this treatment is still being tested to improve the quality of the resulting fertilizer. [ 42 ]

Most of Huangyan’s municipal perishable waste (80%) ends up in the landfill [ 42 ]. 40 Mg of N and 2 Mg of P get lost in this way. At the time of the field trip, the landfill was almost full, and a new incineration plant was being constructed to replace it. During the interview at the landfill, it was stated that China would ban landfills in 2020. There was a project to use kitchen waste to produce biogas in the future, but there was still no estimated starting date. [ 43 ]

Wastewater treatment

Excreta is the main waste flow resulting from the tangerine consumption stage, and the second-largest waste stream in the entire system (12,009 Mg/a). Yuanqiao wastewater treatment plant in Huangyan District can treat up to 60,000 m. 3 per day. The site covers an area of more than 11 ha and applies Anaerobic/Anoxic/Oxic technology (AAO). The clean effluent is discharged into the river. [ 44 ]

Water bamboo

Manchurian wild rice ( Zizania latifolia ), or water bamboo, is a perennial plant native to China [ 45 ]. Its seeds have been consumed as a cereal for more than 3,000 years. When infected with the black smut fungus ( Ustilago esculenta ), the stem becomes bigger and tender, making it the second most-cultivated aquatic vegetable in China. Huangyan is one of the main producing areas in the country [ 46 ]. Wetland farms growing Z. latifolia in Huangyan cover a much smaller area than tangerine farms—around 800 ha [ 37 ]. However, this area is growing because producing this crop in paddy fields is more profitable than producing rice [ 30 ].

There are two harvest seasons for water bamboo: one from May to June and another one from October to December [ 47 ]. In the summer, the production (around 100 kg/ha) is twice as much as in autumn [ 48 ]. To produce 1 Mg of water bamboo, farmers use on average 50 kg of chemical fertilizer (15–15-15) [ 24 ]. In this way, 296 Mg of N and 129 Mg of P are added to the cropland every year. Apart from that, in the summer, farmers put compost from their farms back in the field (503 Mg of N and 19 Mg of P per year) [ 48 ].

During the harvesting, waste leaves (which represent 30% of the plant’s weight) are cut off and, in most cases, left on the field [ 47 ]. This is the heaviest by-product flow in the entire system, accounting for 25,200 Mg per year (437 Mg of N and 147 Mg of P). There are some farms using these leaves to cover the soil (e.g. in tangerine fields) to improve its quality, although the transport and labour is expensive [ 49 ]. Stems are collected for further processing [ 47 ]. In the next step, the stems are peeled by hand. Thus, the water bamboo shoots (representing 50% of the plant’s weight) are separated from the peels (accounting for the rest 20%) [ 47 ].

Around 20 kg/ha of water bamboo shoots are wasted every year because of diseases, bad quality, or bad appearance. This agricultural waste stream, containing 64 Mg of N and 14 Mg of P, gets landfilled [ 24 ]. After the peeling process, the majority of the water bamboo shoots are exported, along with 648 Mg of N and 137 Mg of P. This is the largest P export in the system.

Farm composting

The peels are cut into little pieces on site and mixed with urea—the largest nitrogen flow in the system, adding 3,091 Mg of N—and decomposing agent. After 20 days, the compost is ready to be put back on the field. This is done every year at the end of July. 70% of the compost (1173 Mg of N and 44 Mg of P) is sent to other fruit and vegetable farms, constituting the largest N export in the system. The rest 30%, containing 503 Mg of N and 19 Mg of P, is used in the farm itself. [ 48 ]

Most of the produced water bamboo shoots (95%) are exported to other regions. The part that stays in Huangyan gets sold in markets, supermarkets, and grocery stores [ 24 ]. As mentioned for the tangerine system, only 9% of the products in the markets come from Huangyan, and about 5% of the products sold in the market get wasted.

Consumption, waste treatment, wastewater treatment

The life stages consumption, waste treatment, and wastewater treatment are identical to the ones described for the tangerine system. Also in, this case, excreta constitutes the major waste flow coming from the consumption stage (16,032 Mg/a). 286 Mg of N and 61 Mg of P are lost through this route.

Recovery potentials

In the tangerine system, the by-product streams that could theoretically be recycled include agricultural waste; peels, damaged tangerines, and pith from the manufacturing process; and excreta, peels, and rotten tangerines from the consumption process. These flows amount to 38,870 Mg/a. The nitrogen content in those flows adds up to 382 Mg/a and the phosphorus content to 25 Mg/a.

Only the tangerine peels from the manufacturing process are currently being recycled to produce spices and a part of the rotten tangerines and peels from consumption are treated anaerobically or through composting. These account for 2,115 Mg/a or 5% of the total theoretical recycling potential. The nitrogen contained in the recycled flows accounts for only 11 Mg/a or 3%, and the phosphorus for 0 Mg/a or 2% (Fig.  8 ).

Tapped and untapped recycling potential for nitrogen and phosphorus in Huangyan’s tangerine and water bamboo systems. Solid color areas represent the amount of N (green) and P (orange) that is already being recycled. Dotted areas represent the amount of N (green) and P (orange) that is not yet recycled. t tangerine system, wb water bamboo system

Regarding the water bamboo system, the theoretically recyclable by-product streams include leaves cut and put back into the field while harvesting; peels and rotten water bamboo from the peeling process; rotten water bamboo from the markets; and excreta and rotten water bamboo from consumption. Together, these flows amount to 63,685 Mg/a. The nitrogen content in those flows adds up to 1,122 Mg/a and the phosphorus content to 292 Mg/a.

The materials that are already recycled include water bamboo leaves and peels in the field and rotten water bamboo shoots that are sent to composting or anaerobic treatment after consumption. These flows add up to 42,166 Mg/a, or 66%, of the theoretical recycling potential for fresh matter. The nitrogen contained in the recycled flows accounts for 738 Mg/a or 66%, and the phosphorus for 211 Mg/a or 72% (Fig.  8 ).

Contribution to Taizhou’s goal

Adding up the recycling potentials of the untapped N and P 2 O 5 flows results in 426 Mg/a for Huangyan tangerines and 570 Mg/a for water bamboo (Fig.  9 ). The goal of Taizhou’s Bureau of Agriculture and Rural Affairs is to save 1,182 Mg of “pure nutrients” (N, P 2 O 5 , K 2 O) per year. Hence, recovering all the N and P from the analysed systems would contribute 36% to the achievement of the goal in the case of the tangerines and 48% in the case of the water bamboo. Combining both systems would make a very high contribution to the goal (84%).

Contribution of the potentially recyclable N and P 2 O 5 in both Huangyan systems (Huangyan tangerines and water bamboo) to the goal set by Taizhou’s Five-Year Plan for Agricultural and Rural Modernization on the mass of “pure nutrients” (N, P 2 O 5 , K 2 O) to be saved

Data uncertainties of material flows

The basis for the N and P SFAs for tangerines and water bamboo presented in Sect. “Results” are MFAs conducted in the scope of this study. Data uncertainties for the corresponding material flows are discussed hereunder. The below-mentioned reference flows correspond to 1 Mg of fresh matter (tangerines or water bamboo).

Data uncertainties in the tangerine system

The data representativeness of all flows entering or leaving the agricultural production process in the tangerine’s SFA corresponds to the first or the second level. The “organic fertilizer” input and the “pruning residues and leaves” output account for 21% of the reference flow. The size of these flows combined with their very high data reliability form a good basis for the SFA. The flow “tangerines for export” is the largest of the system, accounting for 90% of the reference flow, and it is defined with high reliability. Due to the flows’ significance, it is recommended to further improve data representativeness and confirm flow quantities by published scientific data or an independent source such as producers or distributors. Most input and output data of the canned tangerines production process was provided by one factory owner ( Yiguan Food ) and therefore was classified as medium reliability data. It could be argued that in reality data representativeness is higher, since it is the largest company producing canned tangerines in Taizhou City [ 31 , 32 , 33 , 34 ]. Further research could be conducted by examining other similar factories or conducting own measurements. The largest flow related to this process, however, only accounts for 7% of the reference flow. Hence, efforts to improve the data quality of this process should be kept within reasonable limits. Three of the four flows of the distribution process correspond to the third data representativeness level. Due to the significance of the “imported tangerines” (31% of the reference flow) and the “tangerines for the markets” (33%) flows, it is suggested to verify the gathered information. More interviews with owners of various markets in Huangyan should be conducted. It was assumed that the consumers are “steady state” humans, i.e. the nutrients consumed in the food will end up in the excreta, based on the fact that the percentage of food retained by the human body for the synthesis of tissues can be considered negligible on average [ 50 ]. Since this data comes from literature, those flows were classified as level four. The “Excreta to wastewater” flow is the largest output (1% of the reference flow) of the consumption process. Its data with defined medium data reliability was obtained from scientific publications of other geographic regions and periods. Since this flow holds a significant nutrient recovery potential, it is recommended to reduce data uncertainty and contact Taizhou’s Environmental Protection Bureau. Unfortunately, during this study, the Bureau repeatedly refused to be interviewed. Requesting a reference letter from the Chinese government could help to obtain data from governmental institutions. All the flows entering and leaving the composting, filtration, and anaerobic treatment processes belong to the data representativeness level 2, which indicates that these flows can picture the real situation in Huangyan relatively well.

Data uncertainties in the water bamboo system

The outputs of the agricultural production, “stems” and “leaves” account for 140% and 60% of the reference flow, respectively. Both flows are based on data from one farmer and are, therefore, defined as the third data representativeness level. Roughly 29% of the stems become peels. Together with the amount of rotten water bamboo shoots, it makes ca. 53%, which corresponds with the information obtained from Huangyan Agricultural Bureau—according to which 50% of the vegetable is wasted [ 30 ]. The “leaves” and the “peels” flows are the largest by-product flows in the system and represent the highest nutrient recovery potential. Based on the statements of two farmers (third representativeness level) the leaves are left in the fields during the harvest and the peels are composted. It is recommended to approach water bamboo experts (equivalent to the scientists from the Institute of Citriculture for the tangerines), identify relevant scientific studies, or conduct surveys covering a representative number of farms, to reduce data uncertainty for these relevant material flows. The data employed to model the rest of the processes (distribution, consumption, composting, filtration, and anaerobic treatment) is the same as the one used for the tangerines. Hence, the data representativeness of those processes in both systems is similar and the same recommendations can be drawn (see “ Data uncertainties in the tangerine system ”).

Data uncertainties in both systems

The fresh matter flows served as a basis for the calculation of the N and P flows. During the SFA modelling, the uncertain material flow values were multiplied by estimates for N and P contents obtained from secondary sources. Firstly, the level of uncertainty rises with these mathematical operations. Secondly, the values from the literature refer to studies with different spatial scopes decreasing the accuracy of the calculated P and N flows in this study. To improve accuracy and reduce uncertainty, it is recommended to conduct a sampling campaign to measure the N and P contents of each flow as a basis for the SFAs, as was done in a Danish study [ 51 ]. Although this approach would have exceeded the scope of this study, it could have avoided the need for several assumptions (supplementary material, Tables c, d).

Methodological uncertainties of the material and nutrients SFAs

The inputs and outputs of the substance flow processes are not always balanced (see Δ MB flows in the SFAs), since data on energy, soil, water, and gas flows could not be gathered in the scope of this study. The following two paragraphs discuss nutrient imbalances. The mentioned values represent the real annual flows in Huangyan.

Methodological uncertainties in the tangerine system

The biggest N losses occur as agricultural waste during the tangerine production (311 ± 31 Mg/a) and as peels during the consumption phase (50 ± 10 Mg/a). The N mass fraction of the peels is higher than that of the rest of the fruit. Since most of the peels produced during the consumption phase (80%) are sent to the landfill, this organic material is lost from the system. 807 ± 161 Mg N/a are missing when comparing N from fertilizer application (inputs) and N contents in agricultural products and by-products (outputs). From the applied 1,300 ± 130 Mg N/a, only 13% (173 ± 35 Mg/a) end up in the tangerines. The findings align with previous research, which shows that agriculture is responsible for almost three quarters of all N losses (43% of those losses occur through nitrate leaching to ground and surface waters, 30% through denitrification, and 23% through ammonia emissions) [ 52 ]. Similarly, major P losses in the tangerine system occur during agricultural production. While 621 ± 62 Mg P/a are applied to the tangerine fields, 20 ± 2 Mg/a end up in agricultural waste and 12 ± 2 Mg/a (2%) in produced tangerines. The rest 589 ± 118 Mg P/a (95%) is lost. Prior research has also showed that more than half of the total P losses happen in agriculture, 88% of those losses through P accumulation in soils [ 52 ]. According to George [ 53 ], agricultural production has low P-efficiencies due to solubility and mobility interactions in soils and plants. Also, Golomb and Goldschmidt [ 54 ] stated that less than half (43.7%) of the P-uptake by the mandarin trees ends up in the fruits. The pruning residues and leaves to product ratio calculated in a Croatian study is much lower than the one resulting from this study (0.07 kg/kg versus 0.21 kg/kg) [ 55 ]. This can be explained by the new tangerine farms in Huangyan, since young trees have lower production rates leading to relatively higher amounts of residues [ 30 ]. The pruning residues and leaves to product ratios are expected to decrease in the future, with more mature trees. These are also possible reasons for the low N-uptake of tangerines in Huangyan. Furthermore, the export of tangerines implies N and P losses for Huangyan’s tangerine system, with 176 ± 36 Mg N/a (14%) and 12 ± 2 Mg P/a (2%). No information was found on the local wastewater treatment processes. The literature research indicated that wastewater treatment plants in China are still concerned about removal—and not recovery—of nutrients, and that landfilling is the main sludge treatment method [ 56 ]. Hence, the nutrients contained in excreta (16 ± 6 Mg N/a, 2.4 ± 1.0 Mg P/a) are not recovered. A study conducted in Vietnam quantified regional N and P flows from rice, fruit, and vegetable production. Major P losses modelled in that study also occur during the same life cycle stages and include leachate from agricultural production, solid waste, and excreta from households [ 57 ]. Analyses of soil, surface water, groundwater, and wastewater samples, as well as liquid and gaseous emissions, could provide details on the fate of N and P in the agricultural production and consumption phase.

Methodological uncertainties in the water bamboo system

The production of water bamboo is characterized by higher N and P recovery rates than that of tangerines. Assuming that all nutrients from the leaves, which are cut off during the harvest process, are absorbed by the crops in the wetland, a total of 29% N (550 ± 165 Mg/a) and 56% P (166 ± 50 Mg/a) of the applied nutrients would be recovered. The differences between added nutrients from fertilizer and leaves (inputs) compared to harvested stems (outputs) are 425 ± 127 Mg N/a (22% of applied N) and 73 ± 22 Mg P/a (20%). Other studies investigating flooded rice production systems, showed that the largest losses for P and N were caused by run-off, leaching and accumulation in the soil, as well as emissions to air [ 58 , 59 ]. These potential nutrient losses should be quantified in future studies for the water bamboo production system with leaves decomposing in anaerobic conditions in flooded paddies and peels further processed to compost (19 Mg P/a).

The nutrient losses during the peeling, distribution and consumption phase are 384 Mg N/a and 81 Mg P/a from rotten water bamboo and excreta, which end up in the landfill or the wastewater treatment plant. 50% of the N (1,821 ± 481 Mg/a) and 95% of the P (181 ± 41 Mg/a) entering the system as fertilizers are exported as water bamboo and composted leaves.

In summary, for the agricultural processes, nutrient fixation in soil and nutrient leaching in surface and ground water, as well as gaseous emissions, are assumed to be relevant contributions to the substance imbalances. For the remaining processes, data uncertainties are assumed to be the main cause for imbalances. The N and P SFAs presented in this study, as well as the derived recycling potentials, should be considered as estimates. It is strongly recommended to conduct a sampling campaign and use own measurements to correct these results.

Contribution to the Chinese national and regional political goals towards a sustainable agriculture

The results suggest that, combining the already recycled streams with the currently unutilized rotten tangerines and water bamboo as well as the resulting excreta from consumption, over 1,503 Mg N/a and 316 Mg P/a (725 Mg P 2 O 5 /a) could theoretically be recovered in Huangyan. Recovering these nutrients would allow a growth of agricultural production of 15% (based on N) and 13% (based on P), while fulfilling the zero-growth action plan of the Chinese government. Upscaling these results from Huangyan district to the region of Taizhou, 11,065 Mg N/a and 1,329 Mg P/a (3,043 Mg P 2 O 5 ) could theoretically be recovered (based on the production numbers for tangerines and water bamboo published in Taizhou’s statistical yearbook) [ 60 ]. Adding up the nutrient mass for N and P 2 O 5 then results in 14,108 Mg nutrients/a. This would exceed the goal of chemical fertilizer reduction (1,182 Mg of nutrients) by almost 12 times. It is worth mentioning that this result would be even better if potassium flows would have also been accounted for. Considering the negative environmental impacts caused by the utilization of chemical fertilizers [ 61 , 62 ], recycling activities can help to enhance environmental sustainability and support China in becoming carbon neutral in 2060.

Challenges and measures for practical implementation of nutrient recovery

While this study calculates the theoretical potential for nutrient recovery, several practical challenges must be addressed to enhance feasibility. Primarily, technical barriers exist, such as the efficiency of recovery technologies. For example, net losses of 18% of N were reported during anaerobic digestion [ 63 ], and for composting they can reach up to 50% [ 64 ]. Besides, the agricultural by-products analyzed in this study are from plant origin, and an addition of animal manure (which could imply a collaboration with other stakeholders) might be required to improve the efficiency of the recovery process. These technologies depend on (in some cases advanced) infrastructure and expertise, requiring investment in training and capacity-building for local technicians and farmers. Economic constraints also play a significant role: the initial investment costs for installing nutrient recovery systems can be a big barrier. As a reference, a household-scale biogas digester in China costs between 368 and 792 USD [ 65 ]. To encourage adoption, financial incentives such as subsidies or low-interest loans could be provided.

An important condition for stakeholders to adopt technologies to treat organic wastes for bio-based fertilizers’ production is that there needs to be a market for those fertilizers. Users of organic fertilizers have high quality expectations (nutrient content, nutrient release rates, risk) [ 66 ]. Moreover, a Chinese study on barriers to replace mineral fertilizers with manure showed that farmers have an overall negative attitude, lack of knowledge, and limited experience [ 67 ]. Targeted marketing strategies that provide information on the benefits and costs of implementation are needed, as well as regulatory tools that ensure price stability (to maximise the market share of these fertilizers, they should be 30–46% cheaper than equivalent mineral fertilizers) [ 68 ]. Sutton et al. [ 7 ] stress the importance of a holistic approach to nutrient management, advocating for improved nutrient use efficiency throughout the entire food chain to enhance food and energy production while minimizing losses that cause environmental impacts.

This study quantifies untapped theoretical recycling potentials for N and P throughout the tangerine and water bamboo life cycle in Huangyan, China in 2019 (370 ± 47 Mg N and 24 ± 3 Mg P for tangerines, and 384 ± 136 Mg N and 81 ± 29 Mg P for water bamboo). Hotspots for nutrient recovery include inefficient agricultural residue utilization, low recovery of nutrients from organic residues in municipal solid wastes (most N and P is landfilled), and missing recovery of N and P during wastewater treatment. N and P imports of 427 ± 128 Mg/a for tangerines and water bamboo production are contrasted by N and P exports of 2,189 ± 560 Mg/a. Such imbalances are symptomatic for cash crop producing regions and result in the need of chemical fertilizer imports. Implementing circular economy management approaches such as precision farming, source waste separation, composting, or anaerobic digestion, combined with advanced wastewater treatment concepts could improve N and P recovery.

The recovery of these nutrients could substitute 59% of N and 15% of P supplied by chemical fertilizers for tangerines and water bamboo production in Huangyan, contributing to the circular economy and the achievement of political goals in Taizhou and China. Using untapped nutrients enables further production growth while reducing chemical fertilizer application, contributing to the zero-growth action plan of the Chinese Ministry of Agriculture. The use of organic fertilizers from agricultural residues and municipal solid waste and wastewater allows low-carbon agriculture and improvement of the utilization level of agricultural resources in line with the 14th 5-year plan of the Chinese government, paving the path towards carbon neutrality in 2060. On a regional level, implementing these circular concepts would allow Taizhou to reach the goal of increasing the use of organic fertilizer, digestate from anaerobic digestion, and green manure; improving soil structure and organic matter content. Taizhou could exceed the expected nutrients saving of 0.6 kg (sum of N, P 2 O 5 and K 2 O) per Mu—or more than 1,000 Mg per year (worth over 5 million yuan)—reducing air pollution (mainly caused by straw burning), eutrophication of water bodies, soil erosion and salinization.

Reliable data are crucial for potential assessments, yet currently available Chinese data for regional material and substance flows stems from statistical yearbooks, which lack scientific basis. To address this uncertain data foundation, this study defines data representativeness levels. This enables a first quantification and visualization and supports the identification of data weak points for future studies to address. The study identified theoretical recycling potentials, but several challenges related to technology efficiencies, costs, and users’ acceptance need to be addressed to ensure feasibility.

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Acknowledgements

We gratefully acknowledge the support of the Open Access Publication Fund of the Technische Universität Berlin.

Open Access funding enabled and organized by Projekt DEAL. This research was funded by the German Ministry for Research and Education (BMBF) in the context of the research and development project Urban–Rural Assembly (URA)–Managing inclusive transformation-to-sustainability processes at the urban–rural interface of the Huangyan-Taizhou region in China (Grant No. 01LE1804A). Julia Santolin is a holder of a Ph.D. fellowship strategic basic research from the Research Foundation—Flanders (Grant No. 1S57222N).

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Santolin, J., Larsen, O.C., Fritze, A. et al. Reaching China’s fertilizer reduction goals through nitrogen and phosphorus recovery: a substance flow analysis case study. J Mater Cycles Waste Manag (2024). https://doi.org/10.1007/s10163-024-02067-6

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DOI : https://doi.org/10.1007/s10163-024-02067-6

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