How Dhaka won the fight against open defecation and improved public health

A child recovering from diarrhoea at a hospital in Dhaka. Diarrhoea is no longer the leading killer of Bangladeshi kids, in part due to the success in ending open defecation. (icddr,b)

DHAKA, Bangladesh — The notorious Gabtoli bus terminal here can be jam-packed with passengers, clogged with vehicles, or stricken with civil unrest. But it’s a very good place to use the restroom.

The facility comes with amenities that aren’t always easy to find in South Asia: Standard flush toilets; urinals in the men’s room and sanitary napkin dispensers in the women’s; sinks with faucets and mirrors; electric hand dryers and lockers. The stalls are contiuously cleaned by a professional crew, while a closed-circuit TV camera watches over the common areas.

“Money well spent,” Golam Rabbi Prince tells me after using the men’s room, on his way to catch an inter-city bus. Use of the restroom costs 5 Bangladeshi taka, or about USD 6 cents.

This restroom is a collaboration between the local government and a pair of non-government organizations. The restroom opened almost four years ago and runs profitably. More than two dozen toilets have opened across Dhaka on this model — and the two local authorities that govern this megacity hope to add six more by the end of December.

It’s all part of a push in Dhaka and across the country that has yielded a remarkable result: Bangladesh has almost entirely eradicated the practice of open defecation. As recently as 2003, according to the government, some 42 percent of Bangladeshis relieved themselves along roadsides, behind bushes, aside homes or wherever they could find a place to go. Open defecation is linked to transmission of many diseases, such as cholera, diarrhoea and dysentery. Eradicating the practice is one of the key targets of the Sustainable Development Goals agreed to by all 193 countries at the United Nations.

A public restroom at Dhaka’s Gabtoli bus terminal is continuously cleaned.  (DSK)

By 2015, the country’s rate of open defecation was down to just 1 percent and the rate in urban areas was zero. Last month, a report from UNICEF and the World Health Organization called Bangladesh “open defecation free”. To put that feat in context, consider that in neighbouring India, 620 million people, or about half the population, still defecate in the open. According to the WHO, open defecation remains the norm for almost a billion people worldwide.

Sustained effort

Bangladesh’s success with sanitation is due to a deep political commitment from government at all levels, as well as collaboration from donors, NGOs and the U. N.

The government’s “sanitation for all” campaign began in 2003, following the shocking results of a baseline survey conducted by the government and UNICEF. The national strategy mobilized external funds as well as 20 percent of the government’s development budget, which was set aside for improving sanitation coverage in both big cities and small towns.

The strategy also created a more positive enabling environment. For example, a key feature allowed for provision of sanitation services in urban slums despite the fact that many residents lack land titles. Successive governments took sanitation seriously, and at least on this issue, didn’t scrap the policies of the previous administration.

Latrines in the Sattola area of Dhaka. (AZM Anas)

NGOs, which operate in every corner of the country, also played a critical role. The groups worked closely with the government and used their grassroots networks to build sanitary latrines and educate residents about using them, turning sanitation into something of a social movement. “Bangladesh has one of the highest concentrations of NGOs,” says Mohammad Shofiqul Alam, a water and sanitation specialist with UNICEF. “In every slum, you find two to three.”

Communications also played a role. The government put out advertisements in print and electronic media to encourage toilet use, and journalists reported extensively on the efforts of NGOs and donor agencies. In rural areas where literacy rates are low, folk songs and plays were developed to get the message across.

But the biggest change is the availability of toilets. In rural areas and many slums, this typically means sanitary latrines or pit toilets, often shared by a number of families. The government offered incentives to sanitation entrepreneurs, seeding a growing business in latrines and driving down the cost of installation. Local governments were also given budget allocations on a competitive basis for promoting sanitation; many local leaders were given trips overseas as a reward for making their jurisdiction “open defecation-free”.

“People used to defecate in the open because they didn’t have facilities,” says Khandker Mosharraf Hossain, the national minister who oversees local governments. “How can people change habit unless you give them opportunity?”

Hardware and software

A good place to see these efforts in action is the sprawling slum known as Sattola, not far from some of Dhaka’s wealthiest areas. The settlement houses more than 50,000 people, most of whom migrated from coastal areas after being displaced by flooding or land erosion. Many of the residents now work in textile mills, or serve as domestic help, day labourers and small traders.

Along Sattola’s narrow lanes is evidence of what Water and Sanitation for the Urban Poor, a British NGO, calls “hardware” and “software”.

The hardware is the latrine blocks scattered throughout the area, with spare but private and clean pit toilets. The NGO, commonly known as WSUP, has built or repaired 70 shared latrines in the neighbourhood and divvied up soap, buckets, bins and other hygiene materials among the residents under a project bankrolled by UNICEF.

The software is the numerous interventions aimed at changing behaviour. For example, the white walls of the latrines are plastered with pictures showing men and women taking good care of the latrines, using the waste bins, washing their hands and cleaning up for the next user. One sign says, in Bengali: “We’ll dispose waste into the basket.” Another says: “We’ll clean toilet after defecation by pouring water into the pan.”

Pictures on latrines in Sattola encourage users to wash hands and keep the facility clean. (AZM Anas)

Another example of software is the work of volunteers like Sharmin Akter. Born and raised in Sattola, Akter attends a private college and volunteered as one of WSUP’s “youth champions”. In that role, she used group discussions, home visits and one-on-one discussions to spread the gospel of healthy hygiene.

In household sessions, Akter would show residents pictures of good hygiene practices such as hand washing. She also handed out rewards such as buckets, brushes, hand wash, soap and toilet cleaner as rewards for keeping toilets clean. “Initially, it was tough,” she told me, describing a family that didn’t want to engage with her at first. “It took a while to win their trust.”

Residents I spoke with recalled the days not long ago when neighbours relieved themselves deep in the bushes or precariously straddling a bamboo pole over a swamp. They suffered much more frequent bouts of diarrhoea, stomach aches and worm infections then. Women who could recall the humiliation of defecating in view of boys peering from nearby high rises sounded grateful they and younger girls have privacy now, especially during their menstrual periods.

Most toilets in slums remain ‘unimproved’ facilities such as pit latrines.  (AZM Anas)

Trends are going in the right direction in Bangladesh. Dr. Mahbubur Rahman, a coordinator with the International Centre for Diarrhoeal Disease Research, Bangladesh, says diarrhoea is no longer the number one killer of Bangladeshi kids, in part due to the success in ending open defecation. Mortality for children under age 5 has been cut almost in half.

But challenges remain. Most toilets in slums remain “unimproved” facilities — pit latrines shared by many people. Many people still lack access to flush toilets and toilets connected to a septic system. Further, slums are often located in low-lying areas and there is a need to make latrines more able to withstand flooding and waterlogging.

Proper management and disposal of faecal sludge is another second-generation sanitation challenge to contend with. Still, Ashekur Rahman, a sustainable urban development specialist with UNDP Bangladesh, calls the country’s achievement a “milestone change” and says Bangladesh is “well ahead of” targets under SDG 6, the goal related to water and sanitation.

After the success in Sattola, WSUP closed its operations in the neighbourhood, but it remains active elsewhere in the city. “Sanitation is a human right,” says Habibur Rahman, WSUP’s head of sanitation in Dhaka. “As long as these people are here, our responsibility is to provide this right.”

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AZM Anas is an economic editor at The Financial Express, a Dhaka-based business newspaper.  Full bio

LEARNING FROM DHAKA

  • NGOs worked closely with the government and used their grassroots networks to build sanitary latrines in infomal settlements like the Sattola area of Dhaka. 
  • Volunteers work with community members one-on-one and in groups to encourage healthy hygiene. 
  • The efforts have helped reduce incidence of diarrhoea and mortality for children under age 5.

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