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Reference: Rural Sanitation in India: The Poo Party

This weeks paper of the week is brought to you by Dr Anant Jani, 3V Executive Director.

Bottom line

“Transforming the behavioral norms of rural populations is a particularly challenging task, and it will only work if rural communities change from within…much depends on the extent to which civil society takes up the call, and whether and how the government pitches in to sensitize and support the fight….The other half of the challenge is uprooting deep-seated beliefs and taboos…Success will require long-term campaigns to spread awareness, the development of regionally contextualized innovations, focus-group discussions, and women’s empowerment.”

Implications for value improvement 

Getting people to change is not easy.  Habits, beliefs and norms will always get in the way and not having a clear understanding of why people behave in the way they do means that our structure-focused interventions will always be destined to fail.

India has tried for many years to decrease open defecation because of the serious public health and safety issues it poses.  In 2014, the Indian government launched the Swachh Bharat Mission (Clean India Mission (Rural)) to stop open defecation over 5 years.  They took a, largely, structural approach by installing more than 200,000 subsidised toilets across the country.  There has been some success – there are now over 300 out of 644 districts that are Open Defecation Free (ODF).  But there is only 1 year left for the Swachh Bharat Mission to get the over 300 remaining districts ODF; how will it achieve this?

What is clear is that installing more toilets is necessary but not sufficient to drive change.  Toilets have also been installed in the over 300 districts that are not ODF but people in these districts aren’t using the toilets even though they are there.  This article highlights the variety of reasons why people are not using them – superstitions, habits/norms, religious beliefs, etc.  To get people to change their behaviour requires that:

  1. We first understand why they behave the way they do
  2. We design approaches, using techniques like human centred design, to actually get people to change within the norms and contexts that they understand
  3. We allow sufficient time for change to occur

Thinking that we can introduce structural changes to drive people to quickly change their behaviour has never worked nor will it.  Yet, that is exactly what we continue doing in systems across the world in a variety of sectors including health, education, transport, etc.

The NHS certainly isn’t immune to this folly.  It is constantly trying to convince NHS professionals to adopt new structural changes and pledge allegiance to new acronyms without actually understanding how these structural changes may or may not fit within their context/culture.

As the authors of this piece highlight, “it will only work if rural communities change from within”; this applies to healthcare systems as well and this is why at 3V we bypass ephemeral changes to the structure and dive headfirst into working with our partners to understand and change their culture so that they drive change from within.