Aleem Walji is chief executive officer at the Aga Khan Foundation U.S.A., expresses his opinion about the advantages of public-private partnership to wash away with poor sanitation in the country
Universal health coverage is part of the world’s movement toward improved quality of life. The Sustainable Development Goals embody that vision for a healthier planet, with SDG 3 looking to ensure healthy lives and promote well-being for all. There is also SDG 6, which looks to ensure availability and sustainable management of water and sanitation for all. These are connected. Children born into poverty are nearly twice as likely to die before their fifth birthday as children in wealthier families. Sanitation is key to a healthy environment, yet access to sanitation remains far from universal.
Unsafe management of fecal waste and wastewater is a major threat to public health for the nearly 2.4 billion people worldwide who lack a decent toilet. Achieving universal access to adequate health services including decent sanitation requires local action everywhere.
Such big vision improvements demand partnerships and the biggest advances demand partners from both the public and private sectors. Sometimes a small, local investment — such as a family’s investment to build a toilet — can leverage a government’s big vision, simply by bringing in a partner with on-the-ground credibility and flexibility.
For example, in 2015, India’s prime minister declared the country would eliminate open defecation by October 2019. To accomplish this, the Indian government aspires to build 120 million toilets across rural India. The government dedicated $29 billion to this vast initiative, known as the Clean India Mission.
However, to translate that funding into behavior change, the people of India need to alter long-entrenched habits and buy in to the vision. Moving the needle on such deeply ingrained practices requires a sense of ownership and a three-pronged solution of funding capital, raw materials, and human capital. India’s citizens need to feel fully engaged to create a successful movement for better health, cleaner water, and improved sanitation.
For communities to have ownership of the government’s plan, they need to manage the building of their own toilets. The government created a subsidy of $175 for each household to buy materials to build a toilet. One problem with this is cashflow: families get those funds only after the toilet is constructed. Low-income households don’t have the cash flow to be able to wait.
When it comes to tackling some of these problems and making moves toward improved sanitation — and with it improved health — public-private ventures can have a role to play.
Provision of financial mechanisms
First, partners need to be able to identify possible bottlenecks from a local perspective. If the challenge is financial, public-private partnerships are often able to alleviate that burden through innovative and creative financial solutions.
In this case, the bottleneck in helping families with the construction of a toilet was capital. To tackle this, the Aga Khan Development Network — of which the Aga Khan Foundation is a member — set up a revolving fund through local village institutions. Due to existing relationships with community-based savings groups and the fact that this grew from a source familiar to the community, the new approach had credibility from the start. Families can use the revolving fund to get an interest-free loan, buy raw materials, and pay masons. After their toilet is built, they then repay the loan using the government subsidy. Only families who qualify for the subsidy are eligible. As of August 2017, the fund has helped over 711 households in 20 villages to build toilets. That’s an impressive gain for public health in a poor, remote area, and a quick start for an innovative financial approach that shows the effectiveness a public-private venture can have in tackling improved health.
There are many other instances where similar partnerships can bring rapid change in public health. Two other microfinance institutions in India that are making a difference are Guardians in Tamil Nadu, and Grameen Koota in both Tamil Nadu and Karnataka. Both provide loans to beneficiaries to build toilets and access a clean drinking water supply.
Communicating the benefits
Governments often need partners to help communicate about a change, a new initiative, or an awareness program — and this needs to happen in a way that resonates with the local people. In India, making clear the benefits of having a toilet requires communication efforts. Local partners can help by organizing events such as street plays and wall paintings with messages about hygiene and sanitation.
Other behavior changers face somewhat lower hurdles. Dial 1298 Ambulance was established in 2005 in Mumbai and is essentially a ride-hailing partnership for emergency medical care. It aimed to get people to call an ambulance in emergencies rather than using conventional transport. Ambulances displayed the name brightly and the clever title communicated the desired change directly and the public responded. Due to demand, the service grew sixfold from 10 ambulances in early 2007 to 60 ambulances by 2009.
Providing training and building skills
Partnerships can strengthen the local supply of skills by helping to grow the capacity of local groups through training and access to resources, and ensuring the sustainability of those skills in the local culture and economy. In this case, rural masons can be trained in a three-day course that covers all the details of building toilets and why they are essential. More than 600 masons in four states in India have taken the courses so far, and trained masons are increasingly in demand. AKDN has since received requests to train new masons from two more states. These masons can then be linked with private entrepreneurs and vendors that run construction shops and sell the required construction materials. AKDN has promoted several such shops in parts of the state of Bihar to ensure beneficiaries have ready access to construction materials.
Partners bring incentives from the private sector together with public sector vision for big changes in health. As in the case of the Clean India Mission, the private sector is able to bring creative solutions to financial bottlenecks, provide means for growing local assets to support toilet construction, and execute effective communication campaigns.