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Indian Toilet Pioneer Champions Good Ideas

By David SouthDevelopment Challenges, South-South Solutions

SOUTH-SOUTH CASE STUDY

Access to adequate sanitation and toilet facilities is critical to making development gains. Yet this simple fact of life often gets overlooked, especially in fast-growing cities where populations are on the rise or in transit. Out of an estimated 2.6 billion people in the world without toilets, two-thirds are in southern and eastern Asia (World Toilet Organization).

It is easy to take toilet technology for granted in developed countries, but in the fast-growing urban world of the global South, increasing access will be the dividing line between a future of good human health and dignity, or misery and poor health. The biggest gains in human health always come about once people have access to clean water and sanitation. Yet this proven fact gets lost in many places for a wide variety of reasons.

One country currently failing to meet the needs of its population is India. According to the McKinsey Global Institute, by 2030, 70 percent of India’s jobs will be created in its cities, and 590 million Indians will be city-dwellers. An enormous infrastructure task lies ahead for India: a city the size of Chicago needs to be built every year. But so far this challenge is not being met, leaving the country with the largest number of urban slum dwellers anywhere in the world. Housing is just not keeping up with populations’ needs.

As K.T. Ravindran, a professor of urban development, told the New York Times: “We require radical rethinking about urban development. It is not that there are no ideas. It is that there is no implementation of those ideas.”

It is this ability to act that makes the Sulabh International Social Service Organization stand out. The Indian non-governmental organization (NGO) sees itself as a movement and is a passionate advocate for toilets and toilet innovation for the poor and underserved.

Sulabh was founded in 1970 by Dr. Bindeshwar Pathak, who saw the vast task ahead. “I thought the challenges to provide toilet facilities have been overcome in rich countries; it has still to be met in developing countries like India,” he said.

So far, Sulabh has brought together 50,000 volunteers across the country to build toilets and sanitation facilities.

The organization’s success flows from understanding that it needs to do more than supply the ‘hardware’ of the toilets; it also needs to address the ‘software’: ideas and innovation and concepts.

The organization has directly built 1.2 million household toilets – but the government of India has built a further 54 million toilets based on the designs made by Sulabh. It’s an example of a good idea multiplying its impact when picked up by others.

While 10 million Indians use a Sulabh-built sanitation facility each day, according to the group’s website, an estimated 300 million are using a toilet based on Sulabh’s designs.

Most influential is Sulabh’s two-pit, pour-flush toilet (www.sulabhenvis.nic.in/Sulabhtechnology.htm). It consists of a toilet pan with a steep slope using gravity to flush the pan. Water is poured in to the pan to flush the toilet and the waste goes into either one of two pits. As one pit fills up with waste, waste is diverted to the second pit. After around 18 months, the first, filled pit’s waste becomes a safe, organic fertiliser suitable for agriculture and the fertiliser’s value covers the cost of emptying the pit. The successful design has been evaluated and approved by UNDP and the World Bank.

Sulabh has also been designing ways to get power and energy from toilets, building 200 biogas plants that turn the gas generated from the human excrement deposited in the toilets into a source of energy. Biogas (http://en.wikipedia.org/wiki/Biogas) is a clean-burning gas that can be made from animal, plant and human waste with the right technology and is a green solution to the need for gas to cook and run electricity generators.

Pride of place for the NGO is its vast toilet and bath complex at the holy shrine of Shri Sai Baba in Shirdi, Maharashtra (http://en.wikipedia.org/wiki/Maharashtra). Millions flock to the shrine every year, but it lacked proper sanitation facilities. To solve this problem Sulabh’s local branch has built a vast complex occupying two acres. The brightly coloured and palace-like facility has 120 toilets, 108 bathing cubicles, six dressing rooms, and urinals and can serve 30,000 people a day. There are telephones and 5,000 lockers for tourists to keep possessions safe.

There are also three biogas plants connected to the facility, generating electricity and hot water for bathing used by the toilet and bath complex. This solves the puzzle of how to fund the utilities. Water discharged from the facility is used to irrigate the surrounding green spaces.

Sulabh has also built a museum dedicated to toilets and toilet technology (http://www.sulabhtoiletmuseum.org). The museum places the toilet as a critical part of human civilisation and shows how it fits in with the cultural context of India. Toilets and toilet designs from around the world and throughout history are gathered together and make a fascinating journey through this essential human need.

Published: May 2011

Resources

1) World Toilet Organization: World Toilet Organization (WTO) is a global non- profit organization committed to improving toilet and sanitation conditions worldwide. Website: http://www.worldtoilet.org

2) World Toilet Day: On November 19 every year, this event draws attention to the lack of access for 2.6 billion people. Website: http://www.worldtoilet.org

3) Dirt: The Filthy Reality of Everyday Life: An exhibit by the prestigious Wellcome Collection on the human relationship with dirt and hygiene in history. Website:http://www.wellcomecollection.org/whats-on/exhibitions/dirt.aspx

4) World Toilet College: Established in 2005, the World Toilet College (WTC) started as a social enterprise, with the belief that there is need for an independent world body to ensure the best practices and standards in Toilet Design, Cleanliness, and Sanitation Technologies are adopted and disseminated through training. Website:http://worldtoilet.org/ourwork3.asp

Development Challenges, South-South Solutions was launched as an e-newsletter in 2006 by UNDP’s South-South Cooperation Unit (now the United Nations Office for South-South Cooperation) based in New York, USA. It led on profiling the rise of the global South as an economic powerhouse and was one of the first regular publications to champion the global South’s innovators, entrepreneurs, and pioneers. It tracked the key trends that are now so profoundly reshaping how development is seen and done. This includes the rapid take-up of mobile phones and information technology in the global South (as profiled in the first issue of magazine Southern Innovator), the move to becoming a majority urban world, a growing global innovator culture, and the plethora of solutions being developed in the global South to tackle its problems and improve living conditions and boost human development. The success of the e-newsletter led to the launch of the magazine Southern Innovator. 

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Health Care In Danger

Worrying breakdown in Ontario reforms

By David South

This Magazine (Canada), October-November, 1992

The Senior Citizens’ Consumer Alliance for Long-Term Care’s report on the Ontario New Democratic government’s health care reforms, released in July, documents what many people suspected: the much-needed reforms are mismanaged and dangerously close to chaos.

The report compares the present crisis to the failed attempt in the seventies to move psychiatric care out of institutions and into communities by closing 1,000 beds. Patients were left with inadequate community services, resulting in many homeless and jailed former patients. The alliance fears seniors – the biggest users of health services – could fall victim to reforms in the same way.

According to many health care reformers, Bob Rae’s government seems to have lost control of the issue, resulting in massive job losses and a worrying breakdown in services.

The NDP’s health care document “Goals and Strategic Priorities” reads like a wish list for progressive health care reformers, ranging from disease prevention programmes to improved access to health care for minorities, natives and women. To many, the debate isn’t over these goals but how they are achieved and what the government’s true motives are. Under pressure from big business and its lobby groups, the NDP is desperate to save money where it can, and as Ontario Health Minister Francis Lankin says, “not disrupt or destroy business confidence.”

Emily Phillips, president of the Registered Nurses’ Association of Ontario, is blunt: “The NDP’s plans sound good on paper, but they can’t give a budget or direct plan on how they hope to carry out reforms. They are going about things backward. They cut hospital beds and lay off staff without having community health care services ready.”

The national trend in health care is to deinstitutionalize and bring services to homes and communities. It is hoped that emphasizing prevention and healthy living will significantly reduce the need for hospitals, expensive drugs, surgery and high-tech equipment. The NDP has pledged to spend $647 million to reform long-term care services by 1997 – creating services that will allow seniors to stay in their own homes.

Problem is, the NDP has embarked on radical down-sizing of hospitals – closing beds and laying off thousands of health care workers – right now. Lankin claims that in the worst-case scenario, layoffs this year wouldn’t exceed 2,000, but the Ontario Hospital Association claims 14,000 jobs are in jeopardy. Phillips believes it will be hard to estimate job loss: “It is hard to even record the number of nursing jobs lost, because for every full-time job cut many part-time and relief positions go with it.”

Chaos will result when people who depend on hospitals have nowhere to turn but the inadequate community health care services, which are uneven and narrowly focussed. To make things worse, the same funding restrictions placed on hospitals have also hit the services that are supposed to save the day.

“I haven’t heard of any change in the quality of care. It is just too early,” says Phillips about the effect of layoffs on hospitals. “Right now the nurses are picking up the slack, but soon they will burn out. I don’t feel confident this government has the management skills to do this. I’d like to see a plan in place before moving people into the community.”

Training for laid-off hospital workers will have to come from the $160-million allocated for retraining workers laid off by cities, universities and school boards – all of whom are coping with record-low budget increases.

In February, Lankin appealed to hospitals to do everything in their power to make layoffs painless and to trim doctors and administrators first. But the NDP has yet to pass legislation that would bind hospital boards to make the right cuts. The boards operate at arm’s length from government and continue to make unnecessary decisions, ignoring the NDP’s moral pleas.

Rosanna Pellizzari, a member of the Medical Reform Group and chair of the Ontario Association of Health Centres, wants better community accountability for hospitals before they lay off staff and cut services: “Sometimes it makes sense to bring people to hospitals. Planning must be at the community level and open and democratic. Health care workers, who are mostly women, should not be scapegoated for financial problems. Doctors and management should go first. Physicians experience very little unemployment.”

Carol Kushner, co-author of the book Second Opinion, which evaluates the country’s medical system, sees chaos resulting from the conflicting agendas of governments and health care reformers: “Will the tremendous contradictions of institutions be transferred to the community? The federal government is rapidly draining money from medicare while provincial governments are having a hard time. This hasn’t produced extra funds for re-allocating services to the community – which was recommended by reformers. You have to ask: who is going to fall through the cracks?”

Find in a library:

Worldcat.org: Health care in danger: worrying breakdown in Ontario reforms, This Magazine, 26, Oct-Nov 1992, 6

ISSN: 1491-2678

OCLC Number / Unique Identifier: 8250614985

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Taking Medicine To The People: Four Innovators In Community Health

Preventing and treating illness at home or in small local clinics makes financial sense. It also makes patients a whole lot happier.

By David South

Canadian Living (Canada), January 1993

Your health is your wealth, my grandmother used to say. It certainly is our most valuable resource – and when its caretaker, universal health care, is under attack, people take notice.

Provincial health ministries across Canada are scrambling to find new cost-efficient ways to deliver health care, and community health care is an increasingly talked-about option.

“Every royal commission has suggested we need to shift resources to community care and stop focusing on institutions,” says Carol Kushner, co-author, with Dr. Michael Rachlis, of Second Opinion (HarperCollins, 1990), a blockbuster book that challenges the way we approach health care in Canada. According to Rachlis, health care nationally cost more than $60 billion in 1992 and is primarily delivered through hospitals and doctors’ private practices. Yet 20 per cent of all patients in acute care hospitals don’t belong there, and about five per cent of hospital admissions for people over age 65 are the result of improper use of prescription drugs.

One study of the Toronto Health Unit found that as many as 50 per cent of seniors residing in nursing homes who were admitted to hospitals with pneumonia had contracted it through mouth infections. If they had received regular dental check-ups in the community or at institutions, these unnecessary and costly admissions could have been avoided.

Increasing numbers of people see community health care as the way of the future. In this model, health care providers – doctors, nurses and support staff – work as a team, and users of health care are involved in making important decisions. Community-based care supplements a medical approach to illness, with emphasis on social and environmental factors like work-related stress. Its advocates say community care can wean us off our addication to expensive hospitals (where one bed costs at least $100,000 a year), drugs and surgery – and make us all healthier.

“Fee for service” encourages doctors to see as many people as possible, emphasizing quantity over quality. In community health centres, doctors are put on a salary and encouraged to give as much attention as necessary to each patient. By simply spending more time with each patient, and by taking into account factors such as illiteracy and cultural differences, community clinics can cut down on misuse of medication.

Jane Underwood, director of public health nursing for the regional municipality of Hamilton-Wentworth in Ontario, says we have reached the limit of what hospitals can do to improve health. “Other factors are now more important than a strictly medical approach, which was the foundation of the old health care system. In 1974, a Health and Welfare paper urged a behavioral approach – stop smoking, get more exercise. Now we are moving to a socio-environmental approach, looking at poverty, social isolation, and unemployment, and their effects on health.”

“Community health care is inevitable because we can now do many procedures on an outpatient basis. With the new technology, all kinds of things can be done outside institutions,” says University of Toronto professor Raisa Deber, co-editor of the recently released book Restructuring Canada’s Health Services System (University of Toronto Press, 1992).

“Just as people can work out of their homes because of computers and faxes, technology can take medical care to the home.” This trend can already be seen in the treatment of cancer. Many patients now receive their chemotherapy at home, with the help of computerized IV pumps.”

If the debate over community health care often seems confusing, it may be because of the haphazard patchwork of programs across Canada. Quebec is the only province that took community health care seriously enough to set up clinics across the province in the 1970s and make those clinics an integral part of the provincial system. Elsewhere in Canada, programs sprang up in the ’60s and ’70s at the initiative of community activists but were met with indifference or hostility from government.

The challenge for community care advocates is to educate both the public and governments. Jane Underwood admits it will be a tough struggle. “Governments are beginning to understand, but the public still has reservations. They panic when there are fewer surgeries and feel that lots of high tech will provide a safety net for health. In fact, it is more scientific to probe for the true causes of illness and not think that just taking a pill will make us better.”

Four Innovators in Community Health

South Riverdale Community Health Centre, Toronto

This fully functioning health centre opened in 1976 in Riverdale, a multicultural and economically diverse neighborhood. The staff consists of doctors, nurses, chiropodists, social workers, health promoters and a nutritionist. Innovative in taking on economic concerns of the community, the centre has set up a community food market to provide cheap and healthful food and recently started workshops with business and community members to come up with strategies to recover jobs lost during the recession. “We consider ourselves part of a movement,” says executive director Liz Feltes. And this is played out in projects with local groups and citizens on a variety of issues – from wife assault, drug abuse and sexually transmitted diseases, to medication literacy for seniors. 

Victoria Health Project, Victoria

Originally started in 1988 to tackle the problem of poor communication between hospitals and community health providers, the project first targeted Victoria’s large senior citizen population. Twelve programs were launched, including Wellness Centres, palliative support teams for patients dying at home and elderly outreach service focused on mental health. The project has been successful at getting local services to cooperate and eliminate duplication. “There are 500 different agencies for seniors in Victoria, so we linked up with them and increased cooperation,” says Susan Lles, excutive coordinator of the project.

It was such a great success that the minister of health created the Capital Health Council to expand the program to the rest of the community. Now, for example, in hospital emergency rooms, quick response teams of nurses assess whether a patient would be better served by other services in the community or by being admitted to hospital. 

Centres locaux de services communautaires (CLSC), across Quebec

Started in 1972 as part of province-wide health reforms, these comprehensive health centres now number 158, with more than 500 satellite offices all over Quebec. Every citizen is guaranteed access to a CLSC, even in remote areas. With five per cent of the provincial health budget, they are able to serve 41 pr cent of the population. They also involve the community through elected boards. “We think it is a unique model in that it integrates health and social services in the same place – both prevention and cure,” says Maurice Payette, president of the federation of CLSCs. Because CLSCs are close to the community, governments, schools, community groups and other organizations have turned to them for advice during the last five years. In rural areas, CLSCs have been crucial in reducing the number of farm accidents. 

Canadian Healthy Communities Project (CHCP), across Canada

Started in 1989, the program is aimed at municipalities and gets them to pledge that they will review all their actions with community health (including impact on the environment and economy) in mind. CHCP is part of an international movement linked with the World Health Organization’s Healthy Cities movement. With more than 150 participating programs, it is an innovative attempt at getting the powers that be to plan for overall health. “We bring together community leaders to make a list of top 10 health problems and then decide what can be done with the existing budgets and staffing,” says David Sherwood, project director. The city of Sherbrooke, Que., is a classic example. Facing reduced funds for road and sidewalk repairs, the city concentrated on repairs in neighborhoods with hig numbers of the disabled and elderly, thereby reducing the number of accidents. Unfortunately, funding was recently reduced dramatically by Health and Welfare Canada, but programs in Ontario, British Columbia and Quebec continue with the help of their own provincial government. 

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“… in recent years it has become a pursuit for a growing number of researchers. … Behind much of this growth has been the Hannah Institute for the History of Medicine …” 

Read more about Canadian innovation in healthcare and medical education here: Take Two Big Doses Of Humanity And Call Me In The Morning

Read more on my work promoting Canadian medical history scholarship here: Hannah Institute For The History Of Medicine | 1992 – 1994

Read more on my work leading on innovation and modernisation in the UK’s NHS here: CASE STUDY 5: GOSH/ICH Child Health Portal | 2001 – 2003

ORCID iD: https://orcid.org/0000-0001-5311-1052.

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