The Wilson Center partnered with Banyan Tree Global to convene global experts on December 6, 2024 to discuss India’s Swachh Bharat Mission. Dr. Shamika Ravi was a panelist in the event. The full recording of the event can be found here.

Open defecation (OD) has been demonstrated to be a major contributing factor to poor health, resulting in adverse social and economic impacts due to work and educational disruptions. Despite various policy-driven efforts since 1954 to eradicate OD, it remains highly prevalent in India—especially in rural areas where there is a lack of toilets. A survey conducted in 2012 revealed that 60% of rural households (and 9% of urban households) had no toilet access. India’s open defecation rate of 40% was one of the highest in the world—more than three times the global average of 12%.

On the occasion of the October 2, 2014 celebration of the Gandhi Jayanti, Indian prime minister Narendra Modi launched the world’s largest sanitation program—the Swachh Bharat Mission (SBM). The goal of this efforts was to universalize access to toilets and making the country open defecation free (ODF) by 2019.

Within days of its launch, the SBM turned into a people’s mass movement mobilizing active participation from the nation’s government, corporate entities, and civil society organizations across all states of the country. Within 5 years, 100 million toilets were built, with an impact on the lives of 500 million people while sanitation coverage in rural areas improved from 38.7 to 100 percent.

The SBM also began actively focusing on encouraging behavioral changes aimed at health and hygiene practices at the grassroot level within months of its implementation. Public information and communication campaigns were disseminated across the country in all local languages and across all forms of media.

Figure 1: Cumulative district-level SBM coverage (2015-2020), illustrating the pace and scale of the toilet-building initiative across India. Chakrabarti, S. et al. Toilet construction under the Swachh Bharat Mission and infant mortality in India. Sci Rep 14, 20340 (2024).

Positive Impacts on Health, Dignity, and Safety

The connection between sanitation and improved health outcomes is well documented. Studies have outlined OD’s direct links to higher child mortality, malnutrition, and poverty. The pervasive presence of OD also explains a significant portion of the differences observed in child stunting (height-for-age) between India and sub-Saharan Africa, despite the former’s higher levels of income. Making greater provision of toilets is therefore an important policy tool to reduce OD and improve child health outcomes.

Since the launch of the program, areas with > 30% toilets constructed under SBM had 5.3 fewer infant deaths (IMR) and 6.7 fewer under 5 deaths (U5MR) per 1000. Research also shows that some 60,000–70,000 infant lives are saved annually due to the implementation of the SBM.

Figure 2: District-level infant mortality and toilet access in India, 2003–2020. Toilet construction under the Swachh Bharat Mission and infant mortality in India. Sci Rep 14, 20340 (2024).

Access to toilets has also improved other health indicators in India. The World Health Organization estimates that the SBM prevented 300,000 deaths and avoided 14 million DALYs (Disability-Adjusted Life Years) between 2014 and 2019 alone. A UNICEF study also showed significant benefits from improved sanitation levels through the SBM impacted water, soil and food quality in ODF areas that had significantly lower levels of fecal contamination. Further, households saw annual benefits of INR 50,000 (US $780), in the form of medical costs averted, as well as in the value of time and lives saved. With benefits of toilet-building exceeding the costs by 7 times, the initiative is delivering overwhelmingly positive outcomes for even the poorest Indian households.

And while the SBM was initially motivated by the goal of improving health and hygiene, it also has had unintended benefits, particularly in enhancing the safety and dignity of women and girls. An absence of toilets means that women are forced to use dark, and secluded open spaces, exposing them to both attacks by wild animals and violent crimes. One survey found the safety of women as the primary reason to increase toilet construction for both women (80%) and men (82%) (Figure 3). Following toilet construction, 93% of women reported no longer feeling afraid that they will be hurt by a person or attacked by animals. Another study found that a 10 percentage point increase in the proportion of households with a toilet, led to a 7% reduction in assaults in that same area.

Figure 3: Reasons for construction of toilets. Sambodhi Research and Communications. Access to Toilets and the Safety, Convenience and Self-Respect of Women in Rural India (2018).

Public Service Delivery: Management and Communications

Despite previous sanitation programs in India, coverage of in-home toilets moved sluggishly: from 24% in 1991 to 37% in 2001 and then 47% in 2011. The catalytic success of the SBM can be attributed to the leadership of Prime Minister Modi and an effective leveraging of resources from the public sector, private sector, media, and civil society. Theory of change research tracing the execution of the SBM found that high level political support, and disruptive leadership strategies (such as the appointment of technocrats and young officials) led to shifts in implementation practices. This dynamic triggered changes in the beliefs, motivations and habitual responses of officials, which combined to enable lasting policy impact.

The SBM also became a broader “Jan Andolan” (or “people’s movement”) by using improved living conditions and better communication networks to promote behavioral change. A rural Indian citizen was exposed to IEC messaging between 2500 – 3300 times over four years through various channels including door-to-door campaigns, wall murals, social media, and mass media such as TV and radio. The confluence of a clear political commitment to ambitious targets, a shift in the official attitudes, and the use of technology galvanized the mass sanitation movement throughout the country.

In ten years, the Swachh Bharat Mission has shown widespread and compelling evidence of its transformational impact. Research overwhelmingly documents the SBM’s positive contributions in achieving better health and gender outcomes alongside creating sustainable behavioral change for its improved implementation.

As India’s economy grows and the society urbanizes, the SBM has evolved in its core characteristics to meet health, hygiene, and management needs of a modernizing country. The scale and scope of this successful policy initiative serve as a blueprint for other countries that are faced with similar challenges.