This intervention seeks to improve sanitation infrastructure in Goa, India to address high rates of maternal and child mortality caused by unsanitary conditions and diseases like diarrhea. The program will focus on improving access to toilets and hygiene education for women and children, who make up about 285,000 of Goa's 1.5 million population. Methods will include oral rehydration therapy for treating diarrhea, and ensuring local participation and addressing myths to effectively implement and sustain the interventions. Previous similar programs in Afghanistan, Bolivia and Kenya that utilized integrated, community-wide approaches saw reduced disease rates and long-term maintenance of sanitation practices.

1. Carlos Morales & Jameson Hollis
SAR HS 430
4-9-16
Intervention
Problem: Issues of sanitation in parts of India inhibit efforts to effectively address maternal
and infant mortality. Our interventions seek to address determinants that lead to negative
maternal and child health outcomes and also the negative effects of unsanitary behaviors on the
affected population, like diarrheal disease which, in 2015, was the third leading cause of death in
children in India.i
Problem Context: India is the second most populated nation in the world. As of March 2,
2016, India had a population of 1,236,344,631 people.ii India’s population is only increasing,
growing bigger day after day. That population is scattered throughout all of India, as evidenced
by the fact that the six major indigenous ethnic groups of India find home in various parts of the
country.iii The massive population of the nation also has its wealth gaps. In late 2014, the richest
10 percent of all people in India held 75 percent of all wealth; the richest 1% of that 10% held
nearly half of that.iv In 2011, approximately 259,500,000 people in India were living off of just
$1.90 daily.v In 2014 alone, approximately 62 million children had their growth stunted
(inhibited);vi 50 percent of malnutrition in India pertains to diarrheal and intestinal worm
infections that come from dirty water, and bad sanitation and hygiene.vii Part of that 50 percent is
the 162 million children who suffer from malnutrition because of poor sanitation.viii Infectious
diarrhea is a nasty disease, as it kills 4.6 million children less than five years of age annually.ix
Part of that comes from the fact that people in India lack access to toilets; in lieu of using
restrooms and toilets, people there publically defecate to remove excrement from their system.
Research shows that there is a link between massive amounts of public defecation and the nearly
50 percent of children under five years of age who suffer from growth stunting problems in the
country.x Children there who have been exposed to public defecation and dirty water supplies
can “…ingest bacteria, viruses, fungi, or parasites that cause intestinal infection,”xi which can
ultimately lead to the growth stunting. To prevent public defecation from occurring to avoid such
problems, there have been programs whose goal has been to increase the number of toilets for
villagers to use; one such program occurred between 2001 and 2011. It ultimately reduced the
number of households without toilets by seven percent.xii The problem with these programs is
India’s population growth rate; it grew from 2015 to 2016 grew by 17,206,607 people; by 2017,
the total population is expected to become 17,436,659 people.xiii While proportionally the
population percent increase is growing smaller, each year, more and more people are being born
there.
The same efforts previously mentioned to increase the number of toilets in households
between 2001 and 2011 ultimately did nothing because of how fast India’s population is
growing.xiv One study conducted by The Lancet actually verified this; economic growth does
nothing in preventing early childhood growth stunting for middle-income and low-income
countries (India was one of the low-income countries researched in this investigation) because of
how rapidly their nation-wide population is growing.xv Greater food distribution from
governmentally based programs has also failed to reduce how problematic improper hygiene and
sanitation are in India’s malnourishment problems.xvi Public defecation is even more of a
problem because of the lack of waste management systems within the nation. Even in modern

2. cities in India today, there are no sewage systems to properly manage wastes that come from
practices like public defecation.xvii Even cities that have sewage systems still are in massive need
of repair, as they are currently severely malfunctioning.xviii Delhi and Mumbai have 40 percent of
all of India’s sewage management programs, but still generate 20 percent of the whole country’s
sewage.xix The sewage treatment plants do nothing to actually remove the contaminants in water
to purify it for human consumption.xx In addition, The Lancet found that 41.5% of urban houses
and 60% of rural houses in New Delhi and Uttar Pradesh, different cities in India, had
contaminated water supplies.xxi As long as there is a lack of a proper sewage to handle materials
like human feces, water will become contaminated, and people of all ages will continue drinking
it. Because of the fact that the immune system is initially weak when developing while children
are young, the kids will be more drastically affected by contaminants that find their way into the
water.
Women in India are also in need of toilets to not have to publically defecate. Worse, they
are also only allowed to relieve themselves at certain times of day; according to Indian tradition,
women must either defecate before sunrise or wait until nightfall.xxii The fact that sometimes
women have to wait for darkness to come is a problem. Snakes are more likely to bite women at
nighttime, and sexual predators are more likely to take advantage of vulnerable, isolated women
under darkness’ veil.xxiii In Uttar Pradesh, two teenage girls were raped and murdered while
attempting to relieve themselves at nighttime.xxiv In 2013, in Bihar, India, 400 women would
have avoided rape if there had simply been access to a toilet in their home.xxv Aside from issues
pertaining to safety because of cultural practices, sanitation among women in India is not good.
One-estimate states 65 percent of all women in the country practice open defecation; another
estimate claims that, in 2014, approximately 300 million women and girls practice open
defecation in the nation.xxvi One report found that the main to motivators for women to have
household toilets are primarily for safety reasons and convenience; a mere one percent of all
women asked about why they would want a personal toilet said it would be to maintain proper
hygiene and sanitation practices.xxvii
Even houses with toilet access still have problems. One study found 40% of houses with
properly functioning toilets still have at least one person in them who still openly defecates.xxviii
Individuals who still do so claim that publicly defecating is “…pleasurable, comfortable, and
convenient.”xxix There needs to be some means of making using toilets more appealing for
persons than publicly defecating. There also needs to come to light some means of educating
people the importance of practicing proper hygiene and sanitation, if more good women and
children (even India as a whole here) outcomes are to occur. There also needs to be some means
of incentivizing individuals into not publicly defecating when they have the knowledge of and
access to facilities to prevent the diseases that can result from unhygienic and unsanitary
practices. For the record, lacking toilets is not a new problem. Gandhi, during his time in guiding
India to being the independent nation it is today, had this to say with respect to toilets in the city
known as Rajkot: “[They are] dark and stinking and reeking with filth and worms.”xxx Toilets,
even if present, are not managed in such a way that they are good for frequent use among India’s
masses. Gandhi also found that untouchables, the lowest persons in India with respect to the
Hindu based caste system, had no access to toilets;xxxi there are currently more than 100 million
untouchables in India.xxxii

3. Intervention: This intervention program seeks to provide changes in Goa, India in the
hopes of changing sanitation infrastructure from a grassroots level. Ultimately, we believe that
infrastructural intervention would be a more comprehensive solution to the sanitation problem.
Program Context: This intervention seeks to develop modern infrastructural approaches
to improve sanitation outcomes and to lessen the burden of dysentery, cholera, and other similar
diarrheal diseases. The same dilemma exists in Afghanistan where there is such a high burden of
sanitation related diseases. Fortunately, intervention policies have been implemented and have
proven to generate positive externalities. The Afghan Ministry of Health and Ministry of Rural
Rehabilitation and Development is joining forces with UNICEF and other partners to launch a
new nationwide campaign to tackle water-related disease in Afghanistan.xxxiii This joint effort
with UNICEF has helped to provide a more cohesive integrated campaign, ensuring maximum
effectiveness in its design. The campaign launched in 2004 and combined numerous initiatives
such as “hygiene education, health promotion and the physical safeguarding of the water
supply.”xxxiv Afghanistan has proven to have similar maternal and child health statistics in India.
UNICEF estimates that up to half of the deaths of all children under the age of five are related to
diarrheal disease, caused by inadequate sanitation, lack of clean drinking water and poor hygiene
practices.xxxv Population density also proves to be a challenge. The concentration of people in
one setting who have been accustomed to unsanitary practices compromises the integrity of
ground water and sanitary systems. The significant increase in urban populations brought about
by high numbers of returnees in the last two years has placed particular strain on the water and
sanitation systems in Afghanistan's major cities, with households increasingly using
contaminated ground-water from shallow wells for drinking and food preparation. xxxvi The
campaign has specifically targeted school and community hygiene education starting by the
“chlorination of shallow wells and the social marketing of safe water and sanitation systems. xxxvii
These integrations are however not merely enough to ensure positive results. Physical
improvements are essential beginning with adequate food preparation, hand washing, and other
sanitary requirements. The integrated outreach approach has proven some success. As a follow-
up to the 2008 International Year of Sanitation, UNICEF has initiated clean village projects
promoting sustainable behavior changes on key hygiene practices among families. To date, 1,000
schools with a total of about 320,000 students in total benefit directly from this intervention.
xxxviii
In Bolivia, sanitary interventions were underway to improve health statistics. A mixed-
method (qualitative-quantitative) study was conducted in 14 rural intervention and control
communities throughout Bolivia in November 2008, six years after the completion of
interventions designed to improve knowledge and practices related to maternal and child health,
nutrition, community water systems, and household water and sanitation facilities. xxxix This
study accessed the long term effects of sanitation intervention programs in the community, a
crucial element in the fight to foster sustainable community wide sanitary practices. Researchers
found “Six years post-project, participants remained committed to sustaining the practices
promoted in the interventions. The average rating for the functional condition of community
water systems was 42% higher than the average rating in control communities” xl and those who
received integrated intervention programs that included development and health system renewal
did significantly better than communities that only received assistance in one focus area.
Ultimately, the interventions proved to be beneficial long term. Infrastructure such as sanitation

4. facilities were maintained and modernized. This study also utilized community wide
participation to optimize intervention efficiency. Community wide intervention effectively
maximized more frequent use of sanitary practices by women and children.
In Kenya, a clustered randomized study was conducted to assess the impact of school
water, sanitation, and hygiene interventions on the health of younger siblings of pupils. These
interventions were spearheaded under the WASH program to reduce rates of diarrhea-related
outcomes among school-aged children. Researchers conducted, “a cluster-randomized trial
among 185 schools in Kenya from 2007 to 2009. We assigned schools to 1 of 2 study groups
according to water availability. Multilevel logistic regression models, adjusted for baseline
measures, assessed differences between intervention and control arms in 1-week period
prevalence of diarrhea and 2-week period prevalence of clinic visits among children younger
than 5 years with at least 1 sibling attending a program school.” xli The results are a positive
indication of the efficient results these sanitation programs deliver. Among water-scarce schools,
comprehensive WASH improvements were associated with decreased odds of diarrhea (odds
ratio [OR] = 0.44; 95% confidence interval [CI] = 0.27, 0.73) and visiting a clinic (OR = 0.36;
95% CI = 0.19, 0.68), relative to control schools. xlii Ultimately, WASH interventions can reduce
the burden of diarrheal related diseases.
Program Population: Implementing a program to help sanitation to ensure better health
outcomes for both women and children in Goa, India will by no means be an easy task. As
previously stated, this intervention will attempt to make a difference initially in Goa, India; if
successful, this intervention will continue to expand to other cities throughout India. The reason
why this intervention will first take place in Goa is because of how Goa is the smallest state in all
of India. Goa has a population of approximately 1.5 million people;xliii however, the intervention
will not need to focus on all 1.5 million of these people in the state. Data recently collected
shows that only 5.09% of all of the people who call Goa their home are impoverished.xliv Also
given that women comprise about half of the total population in the state,xlv and children aged
between zero and nine years of age make 14.21% of Goa’s total population,xlvi, the intervention
will only need to focus on approximately 19% of Goa’s complete population, or about 285,000
people. These 285,000 people will become the women and children on whom we will test our
intervention in our attempt to improve sanitation.
Methods: One means of dealing with infectious disease, should it have already occurred,
is oral rehydration therapy (ORT). ORT involves replacing bodily fluids lost because of
communicable disease like infectious diarrhea. Infectious diarrhea, as previously stated in the
problem context, is a terrible disease that claims the life of millions of children annually;xlvii
infectious diarrhea kills by purging essential salts and fluids from the body needed for metabolic
processes. ORT works to replace those lost fluids and decrease the amount of times individuals
afflicted with the disease need to poop.xlviii In reducing the number of times persons afflicted
need to poop, the fluids added to the body have time to allow the body to recover what they have
lost so the body can ultimately make a recovery from the disease. One potential problem with
administering ORT to individuals may include language barriers that impede individuals in Goa
from understanding what ORT is, or why it is important for them to take should they acquire
infectious diarrhea. One intervention that used ORT in Guatemala found that having workers
speak Spanish in a non-condescending manner allowed for a greater ability to distribute the ORT

5. to individuals afflicted by infectious diarrhea. As such, one solution that would allow for
ultimately a better outcome is to hire workers who are familiar with languages common to
Goa,xlix which include the primarily spoken Konkani, which is Goa’s official language, and
Marathi.l Other languages secondarily spoken around Goa include Kannad and Urdu.li Another
important matter with ORT (and all methods for this intervention in general) is to debunk any
myths associated with ORT; one study that implemented ORT in Ethiopia found that parents
who thought teething in infants caused infectious diarrhea were statistically significantly less
likely to use ORT than parents who did not thinking infant teething caused infectious diarrhea.lii
Local individuals are going to be an invaluable asset to ensuring the intervention works.
If locals fail to understand the purpose of an intervention, or if an intervention is pitched to them
in a way that makes absolutely no sense to them, then the intervention will ultimately fail. One
study looked into why fishermen were using bed nets as fishnets.liii The study found that bed nets
intended for malaria accounted for up to 83.8% of the total amount of nets used on beaches to
catch fish.liv When asked why they were using the bed nets as fish nets, fishermen typically
responded with how the nets dried the fish faster, and because various NGOs were just handing
them out to anyone who wanted them, at no charge;lv the fishermen did not view the nets as
means of preventing malaria, but rather, a means of making their living easier at no extra cost to
them. Bed nets also were not used for their proper purpose because, initially, people just viewed
them as a means of simply ruining their night’s sleep; sleeping underneath bed nets, while
providing great protection from malaria containing mosquitoes, tends to result also in “protection”
from a night’s cool breeze, which results in sleeping in a hotter environment, which can
potentially ruin a good night’s sleep.lvi People who live around malaria also just view it as part of
the cultural norm; initial efforts to use bed nets failed because locals just perceived malaria, no
matter how dangerous of a disease it is, to just be a normal part of life. In believing this deadly
disease to just be part of the daily grind, they did not use the bed nets they were given because
they would rather simply have a good night’s sleep than prevent themselves from becoming
infected.lvii Local aid and understanding will be essential in getting people to follow through with
sanitation procedures so that way people will both initially follow them and encourage others to
follow through with them too.
In March 2015, the WHO and UNICEF found that among 66,000 health facilities from
“low- and middle-income countries,” more than a third did not contain soap for hand washing,
and a fifth of that 66,000 lacked toilets.lviii One important means of this intervention will be
bringing toilets and soap to the people of Goa to ensure they stop infectious disease from even
having a chance of occurring, a means of primary prevention. Currently, access to sanitation via
means such as a toilet or latrine is lacking in about a quarter of India.lix By adding toilets and
latrines to even just a quarter of Goa, because of our previously established fact that women and
children in Goa make only 19% of the total population,lx lxi the intervention will already have
supplied more than enough toilets and latrines for all of the women and children in the state to
use. One study found before it started attempting to implement toilets around India that some
areas already had toilets.
However, even when there are toilets available, the toilets themselves typically are in
horrible condition; the intervention coordinators noted public toilets “…are often in serious
disrepair within three months of being constructed, leaving people with little or no alternative but
to [publically defecate.]”lxii The coordinators also found a topic already discussed in this

6. intervention. Women suffer the most from their inability to access safe toilets.lxiii Women can
suffer from gastrointestinal problems from having to wait either until early dawn or late dusk to
relieve themselves because of cultural practices,lxiv but also can find that wildlife and sexual
predators can harm them as well when they attempt to go to the bathroom during these relatively
light-absent hours.lxv lxvi Ultimately, we seek to curb the rate of sexual assault by adding
protective personnel to defecation sites. These protective entities will be in the form of law
enforcement (police officers) stationed at select known defecation sites in Goa. To figure out
how many officers to place around these defecation sites, this intervention’s coordinators
compared Goa to the US state Maryland. Maryland is a state in the U.S. with a similar area per
square miles as Goa. In Maryland, there are approximately five officers per 1,000 local
residents.lxvii We propose to put 100 additional law enforcement personnel in Goa to act as
escorts for women to and from these defecation sites, and to protect them as they relieve
themselves. There will be 20 different stations and five enforcement officers at each station.
Some possible sites may include those in Panaji, Goa’s capital and Vasco da Gama, Goa’s
largest city.
In addition, we propose an implementation of heavy fines. This legislative initiative is
key to tackling the sanitary burden of public defecation. Fines paid in lieu of public defecation
will be allocated towards all legislations concerning sanitary initiatives in Goa. This money will
be used to fund law enforcement salaries, toilets, sanitation station implementation, and
infrastructural adjustments. The fine will provide incentive means to curb the influx of diarrheal
related sickness. In 2015, at a bus stand in the city of Panaji, “people urinate and defecate at the
bus stand despite [two sanitation officials] in the premises. Dry and wet wastes from shops are
dumped around the [bus stops], and heaps of paper and plastic are burnt every day causing air
pollution.”lxviii Participants who choose to publically defecate will be ticketed. Ultimately, these
measures will prove to curb the incidence of illegal defecation and the expansion of disease in
the region.
In the mid-1960s, the people of Mumbai fought for a better sewage system, and
ultimately got approximately $200,000,000 in US dollars in order to be able to construct it.lxix
The problem with this loan was that, because of how Mumbai’s population at the time (again,
mid-1960s) was approximately 4,854,000 people,lxx which is more than triple of what Goa is
currently today. Concurrently in Mumbai (also known as Bombay at the time) at the time was the
problem that most of the population did not in sanitary conditions; more than half of Mumbai’s
citizens at the time lived in slums, which ultimately led to a greater emphasis on improving
toilets there.lxxi If this intervention uses the logic that the reason then that public toilets were
emphasized much more in Mumbai was because of poverty, then because only 5.09% of Goa’s
residents are considered impoverished,lxxii then there can be a much greater emphasis on
implementing a better sewage system and less of a need to implement public toilets in the region.
Budget: Included here is a budget of all materials this program will need to have a real
chance of being effective and making a difference in preventing poor sanitation from causing
more death and disease spread. Please note that each dollar translates to 66.55 Indian Rupees.
The total cost for this whole program should ultimately come to between $7,269,754 and
$7,349,151.20 USD.

7. Budget
Items
Specifics
Quantity/Tools
Needed
Total
Cost
(US
Dollars)
Total
Cost
(Indian
Rupee
(INR))
Additional
Notes
Programs WASH
Inspection
Tests
2000 10,000 665494.54
Soap
Dispensers
10,000 20,000 1330989.08
Liquid Soap -
Each kilo
1000 USD
30 330,000 1996483.625
Each
Kilogram
Should Cost
$1,000 USD
Waterholes 1000 10,000 665494.563
Toilets 10,000 50,000 3327472.7
Boreholes 6 60,000 3992967.25
ORT
Each small
packet of
salts costs
~$1 USD
285,000 $285,000 18966593.25
Sanitary
Defecation
Sites
Cubic Yards 592.592 Yards
Between
1,689.60
and
3,119.60
Between
112441.95
and
207607.66
Each cubic
yard should
cost between
$84.48 and
$155.98 USD
Labor 5 Workers A Site
Between
27,939.40
and
66,956.60
Between
1859351.70
and
4455924.90
Each site's
labor should
cost between
$1,396.97 and
$3,347.83
USD
Debris
Disposal
Costs
Tools to Remove
Disposable
Materials
Between
18,900 and
20,900
Between
1257784.60
and
1390883.50
Each site's
disposal costs
should be
between
$945.00 and
$1,045.00
USD
Excavation
Equipment
Demolition,
Loading, &
Excavation
Equipment
Between
3,225 and
4,575
Between
214621.98
and
304463.73
Each site’s
excavation
costs should
be between
$161.25 and
$228.75 USD
Sewage
System
10
Throughout
Goa
Installation
Between
$15,000
and
$50,000
Between
9982417.50
and
332747255
Each
installation
should cost
between
$15,000 and
$50,000

8. Maintenance &
Septic Tanks
300,000 19,964,835.00
Funding for
this will come
from World
Health
Organization
Signs to
State How
Public
Defecation's
Illegal
Should Look
like Stop
Signs
1,000 511 34,006.77
Advertising
Materials
Handwashing
Cards
10,000 $1,000 66549.454
Personnel Police
Officers
Escort to And
from And
Protect
Women at
Defecation
Sites, Patrol
Streets to
Ensure No
Public
Defecation,
Fining Public
Defecators,
Ability to
Speak Local
Language(s)
to Effectively
Communicate
with Locals
100 $5,626,000 374407205.7
Annual Salary
should be
$56,250 USD
per officer
Appendix: Included are sample materials that this program will use during its implementation
throughout Goa.

9. This card will be placed at all authorized defecation sites. The card promotes hand washing with
soap in Hindi. The card is legible appealing to populations that are illiterate in the rural areas of
Goa.lxxiii
This card will be placed in front of every wash station. It is a reminder to wash hands before
doing daily duties.lxxiv

10. This diagram simplifies how to administer Oral Rehydration Salts to make and ORS solution.
This is key to administer in the midst of a diarrheal epidemic.lxxv
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Retrieved from http://www.prb.org/Publications/Articles/2014/india-sanitation-malnutrition.aspx
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india-rural-women-toilets
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xxvi Biswas, S. Why India’s Sanitation Crisis Kills Women. British Broadcasting Corporation.
xxvii Tewary, A. & Bihar, P. India Bihar Rapes ‘Caused by Lack of Toilets.’ British Broadcasting Corporation.
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