EXAMINATION OF THE FACTORS IMPEDING THE IMPLEMENTATION OF OPEN DEFECATION LAW IN THE NORTH
CHAPTER TWO
LITERATURE REVIEW
2.1 Introduction
This chapter provides the documents literature related to the study and particularly focused open defecation practice, perceptions and factors influencing it practice among households and communities. Areas that would be covered include determinants of open defecation; latrine ownership and use; attitudes towards open defecation; beliefs and perfections on open defecation and the effects of open defecation.
About 2.9 billion people or 39% of the world population are reported to have used own (unshared) toilet or improved latrine facilities with proper excreta disposal or treatment also referred to as safely managed sanitation facilities in 2015 and 68% having at least basic facilities. Of 2.3 billion people who still do not have the basic sanitation facilities such as toilets or latrines, 892 million are reported to still defecate openly world over. These among others includes defecation in the bushes, street gutters, or openly in water bodies (WHO & UNICEF, 2017).
2.2 Overview of Sanitation
Sanitation according to the Millennium Development Goals (MDGs) as “access to facilities that hygienically separate human excreta from human, animal and insect contact. Facilities such as sewers or septic tanks, pour-flush latrines and simple pit or ventilated improved pit latrines are assumed to be adequate, provided that they are not public.” (UN, 2003). In 2005, the MDG Task Force on Water and Sanitation provided the following working definition of “basic sanitation” as “the lowest cost option for securing sustainable access to safe, hygienic and convenient facilities for excreta and silage disposal that provide privacy and dignity while ensuring a clean and healthful living environment both at home and in the neighborhood of users” (Lenton, Wright, & Lewis, 2005).
Also, in 2010, the United Nations documented the right to safe sanitation as a human right issue and therefore defined it as “access to, and use of, excreta and wastewater facilities and services that ensure privacy and dignity, ensuring a clean and healthy living environment for all” (WHO- UNICEF, 2015). COHRE, UN-HABITAT, SDC & WATERAID, (2008) added that these facilities and services must be safe, physically accessible, affordable and culturally acceptable. The Sustainable Development Goals has added further on this by looking to achieve “progressive realization” of the Human Right to Water and Sanitation by extending access to the “unserved”, “moving people up the service ladder” and “progressively eliminating inequalities in access” (WHO-UNICEF, 2015).
The Community Water and Sanitation Agency (CWSA) also defines sanitation as hygiene promotion and the disposal of faecal matter and solid waste. The provision and use of latrines is an important component of the strategy for breaking the cycle of transmission of excreta-related diseases. Sanitation interventions search for ways to promote improvements in environmental sanitation and living conditions of people so as to improve health and productivity of the people and the community at large (CWSA, 2004). People must be provided with toilet facilities that eliminates their contact with human excreta and wastewater by making available toilets that are convenient, clean, easily accessible and affordable by all. Meeting these basic needs and thus reducing the burden of disease related to their insufficiency should be the focus of raising the health status of vulnerable groups (UN-Habitat, 2003). Sanitation ladder is a new way of analyzing sanitation practices that highlights ways in using improved, shared, and unimproved sanitation facilities and the trend in open defecation.
Poor sanitation contributes to 88% of diarrhea incidences globally (Pruss-Ustun et al., 2008). Diarrheal diseases as a second leading contributor of global burden of diseases measured by the use of Disability adjusted Life Years (DALY) continuous to lead as a major cause of childhood death and illnesses (Black et al., 2010; Liu et al., 2012). It is being estimated that 1.5 million to 2.2million persons die of diseases associated with diarrhea and mainly the children (Robert et al., 2009). In Africa, many children have lost lives to diarrhea and it is the chief source of demise in children universally (DFID, 2013; UNICEF, 2012).
Toilet facility coverage is an indicator for improved sanitation and coverage. It is not the same everywhere and every time, that is to say toilet facility coverage changes through time and space. As reported by WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation in 2008, 62% of the world‟s population have access to improved toilet facility, 8% share an improved toilet facility with one or more households, and another 12% use an unimproved toilet facility, whilst the rest (18%) of the people practice open defecation (WHO/UNICEF, 2008).
2.3 Global burden of Open Defecation
Open defecation is the practice whereby people go out in fields, bushes, forests, open bodies of water, or other open spaces rather than using the toilet to defecate (Gupta el at, 2015). Two and a half billion people live without access to improved sanitation and hygiene facilities resulting in 1 billion (15%) people worldwide defecating in the open. Open defecation continues a vicious cycle of disease and poverty making sanitation and hygiene among the most important drivers of health, social and economic environments (Gupta el at, 2015).
The practice of open defecation adds more burden to the already strained health system. Poor sanitation is known to be associated with a number of disease transmission, these include cholera, diarrhea, dysentery, hepatitis A, typhoid and polio (WHO & UNICEF, 2017). Open defecation is responsible for about 58% of all diarrheal deaths. Up to about 842, 000 persons in Low middle Income Countries (LMICs) are reported to die due to inadequate water, sanitation, and hygiene annually
The United Nations call to action on sanitation included the elimination of open defecation (OD) by 2025 (UN, March 2013). The need to address this issue comes from the fact that “open defecation constitutes a health and human capital crisis” (Coffey et al., 2014) with implications that “keep(s) women under the threat of harassment, violence and rape. It forces girls to abandon education at puberty. It contributes to a cost of $260bn a year through death, ill health and loss of productivity.” (Excerpt from United Nations Deputy Secretary-General Jan Eliason‟s address at the campaign launch to end open defecation, May 28, 2014).
The global trends on open defection rates shows a declined from 24% in 1990 to 13% in 2015 (WHO/UNICEF, 2015). It has also been estimated that sixteen countries have reduced open defecation rates by at least 25 percentage points during the MDG period, with India (highest in the world) recording a sharp decline of 31% (WHO-UNICEF, 2015). However, a previous Joint Monitoring Program (JMP) estimate on “unfinished business” of the MDGs may offer some viewpoint on these gains. It proposed that until 2014, India was home to 597 million people practicing open defecation, making it the country with the highest number of open defecators globally (WHO-UNICEF, 2014).
Many countries have accomplished great progress in tackling the open defecation issues. For instance, in Vietnam and Bangladesh more than one in three people relieved themselves in the open in 1990, virtually engraved themselves out the practice entirely by 2012. This led to a decrease in the global number from 1.3 billion in 1990 to 1 billion today. 90% of societies living in rural country side still engage in open defecation. The practice is on the rise in 26 countries in Sub-Saharan Africa, with Nigeria the least compliant. Open defecation has risen in the Sub- Saharan region from 23 million in 1990 to 39 million in 2012 and 42 million in 2015 (Conant, 2005; WHO, 2012).
2.3.2 The practice of Open Defecation
Most of the open defecation practices are being carried out in rural settings by openly excreting in the open grounds, jungles, bushes and water bodies and it is mostly countries that earn low income. This is mostly associated with rural communities not having access to adequate sanitation (Robert et al, 2009).
Open defecation among children is a norm in most Asian countries (Bangladesh, Philippines, Indonesia, Sri-Lanka), and south east American country (Peru) and some African countries (Burkina Faso). The common practice of open defecation is by washing the faeces of babies in water bases such as river, canal and ponds. It is a tradition that babies are to defecate in beds, on the laps of their mothers such that the faeces can be absorbed in the clothes which later is to be washed. The faeces of the children are collected or picked using paper, straws, leaves and hoes (Sultana et al, 2013; Alam, et al., 2008; Majorin et al., 2014; Zeitlyn & Islam, 1991; Aulia et al., 1994; Tessema, 2017).
Open defecation in Ethiopia has significantly decreased from 1990 to 2015 that is 92% (44.3 million) to 29% (28.3 million) (Greeley; UNICEF, 2016) meanwhile large percentage still are involved in practicing open defecation (UNICEF; WHO, 2015). However, approaches like Community based participatory approach such as Community Led Total Sanitation have been put in place in order to fight diseases that result due to poor sanitation (Araya; UNICEF, 2016). This aims at empowering the community to take control of their own sanitation issues and its effects on open defecation (Robert, 2009).
In 2015, the UN general assembly recognized access to safe water and sanitation and sound management of freshwater ecosystems as essential to human right and to environmental sustainability for economic growth. Achieving the universal access to basic sanitation and ending the unsafe practice of open defecation will require substantial acceleration of progress (UN, 2017).
With Shared latrines as a contentious discussion area, LMICs have a bigger proportion of 16% for people sharing their toilet facilities with the highest in sub-Saharan Africa, where 19% of the population depends on shared sanitation with the rates of shared facilities increasing generally particularly in urban based environments, up to 33% in urban populations in the sub-Saharan (WHO, 2014). This situation is not any different in the four Asian countries namely Bangladesh, China, Mongolia and the Philippines, with over 15% of the population depending on shared sanitation.
2.4 Open Defecation in Nigeria
Access to proper sanitation is poor among many communities in Ghana. Report by Ghana Water Sector Restructuring Secretariat (WSRS) in 2005 put the percentage of the population with access to improved toilet facilities at approximately 40 percent in urban areas and 35 percent in rural areas. The country has also been performing poorly with sanitation coverage of only 15 percent, making the practice of open defecation a key sanitation challenge because people do not have access to key basic facilities (Connell et al. 2014).
Open defecation issues in Ghana is alarming and Ghana had been ranked second after Sudan in Africa for open defecation, with five million Ghanaians not having access to any toilet facility. The Chief Officer at the Water, Sanitation and Hygiene, WASH, Unit of UNICEF Ghana, David Duncan, notes that in the last 25 years, Ghana made one percent progress at eliminating the practice. According to him, though the current pace is nothing to write home about, he was hopeful Ghana could achieve an Open Defecation Free society within the four-year national target if actions are expedited on all fronts (www.pulse.com.gh-19/04/2018).
In has been highly argued that the use of shared sanitation should be regarded as unimproved. These are still a few steps away towards the achievement of access to private and improved sanitation. However, it‟s important to provide a sub-classification to way sharing is carried. Where household shared (sharing with a specific household number who are related in a way or know each other), public toilets (primarily intended for fleeting population, but most often the main facility used by poor neighborhood) and institutional toilets (school, church, workplaces, markets etc. (WHO, 2014).
About 60.6% of Ghanaians live in compound houses rather than self-contained houses; characterized by several households sharing an open area or yard hence share all utilities including water, electricity and sanitation. Originally, traditional living style common in rural but now in urban and peri urban settings (GSS, 2014).
It‟s however essential to interpret individually depending on each context studied, whether culturally acceptable or not for example experiences from Ghana and other sub-Saharan African countries illustrate how household shared sanitation may well fit with the sanitation choices of the households. A shared sanitation is considered as being at some point away from open defecation in the sanitation ladder. It contributed to a greater extent to the current achievements in sanitation in recent years. The use of shared sanitation increased from 29% in 1999 to 59% in 2012. About 19% of the population in Ghana still practices open defecation and the overall rate of improved sanitation use still stands at a low level of 14%, leaving Ghana far from reaching sustainable development goals target of ending of open defecation (WHO, 2014).
2.5 Factors contributing to Open Defecation
A number of factors have been found to contribute to the menace of open defecation. There are factors such as lack access to toilets and some toilets are weakly constructed and there are many blocked toilets. But the main issue is the mentality of the people both in the urban and rural areas. For example, parents and grandparents are seen by their children defecating openly and so they do. It is also a belief among the farmers that defecating in the gardens provides natural fertility to the soil and refreshes their minds. (WHO/UNICEF 2014).
Factors such as absence of money, shortage of land, tenants living in the houses of the landlords and intentional refusal to build latrines or toilets is a very huge promotion of open defecation. In a study conducted by Geeta (2014), these factors led to 33.1% of the people involved themselves in defecating in open meanwhile 62.5% used their household toilets and 4.3% used public toilets, (Geeta, 2014).
Globally there has been reduction in the percentage of open defecation performance from 1990 to 2008 that is from 25% to 17%. For the case of Sub-Saharan Africa, it was by 25% that open defecation practices dropped and in total the people performing open defecation rose from 1880 million in 1990 to 2008. Meanwhile in southern Asia, the number decreased from 66% to 44% from 1990 to 2008 (WHO/UNICEFJMP, 2010). According to Anata (2013), the total number of people who still cannot afford to access toilets or latrines is 2.5billion particularly in third world countries and out of this figure 1 billion go for open defecation. At least in four persons, one goes for open defecation which later leads to poverty and incapability to construct the toilets.
A study conducted in Odisha indicated accepting latrine use is poor and this is due to a number of factors such as rituals, gender differences, and the age of the people, marital status, social ways of living and the lifestyle of the people.
One third of population from Peri-urban communities in southern Ghana are reported to prefer the use of shared toilets compared to ownership of one due to issues related to land tenure, affordability of one as well as other biological and physical related barriers towards the ownership of a household toilet (GSS, 2008; Keraita et al., 2013; Spencer, 2012).
Issues related to Land and its tenure are particularly well-known barriers to achieve a required sanitation in many sub-Saharan Africa, those who do not own land legally including tenants and some traditional unclear ownerships have often to depend on the instructions of the right full land owner or care taker before building private toilets on land. Urban settings even find it more difficult to settle since such settlements are often temporary and the owners‟ plans may not necessarily include constructing a private latrine as rents are often income generating in nature (Spencer, 2012).
Proper disposal of faeces in their right places that is the toilet or latrine and adequate sanitation brings about significant changes in the area of health (Mara et al, 2010; Spears et al, 2013) and this leads to remarkable socio-environmental change (Pearson et al 2008; Jewitt et al, 2011; Kar et al, 2012; O‟Relly, 2014). However, in 2015 it was approximated that 2.4 billion persons did not have access to adequate sanitation and about 1 billion of the population do open defecation, the biggest number living in Sub-Saharan Africa and South Asia (WHO/UNICEF 2015).
Policy negotiations and media interpretations of open defecation in rural areas attribute lack of using latrine to inadequate access to water. This is due to the big quantity of water that is needed for better latrine maintenance (Coffey el at., 2014). However, with the current data, water is not an obstacle to adequate use of latrine. According to the India Human Development Survey in 2015, reports indicated rural homes that own piped water are just 9%, contributing to the percentage of reduction in open defecation compared to those who do not totally have piped water. The dissimilarity can entirely be accounted for statistically by feeding, earnings, household dimensions, and knowledge, proposing that purely reveals a false correlation with socio economic status, and is not a true effect of access to water on open defecation (Coffey el at., 2014). According to the SQUAT analysis outcomes, less than 1% of males and 5% of females who practice open is due to them not having access to water latrine use. Another connected study piloted on sanitation favorites and views in rural India and Nepal, water was hardly elevated as a limitation on latrine use in 99 in-depth semi-structured interviews (Coffey el at, 2014; Tarraf, 2016). Open defecation provisional on latrine possession paths the form of intra-household status.
Age and gender of people who practice open defecation is found by many studies to be associated with the habit of open defecation. Coffey el at, (2014) reported that excluding for among young children, it is mostly men who openly defecate compared to the women. It was also identified that throughout late infancy and youth years, there is lessening of open defecation in young females with entree to latrines. Two motives were given for the variances between females and males. First, a preference among young women to use latrines, or a north Indian cultural norm that keeps women in their reproductive years inside the home. Similar differences in open defecation was accounted among older people. Most people in the adult age range, open defecation increases with age. This perhaps mirrors mature persons, on typical and are capable of moving further easily than at homes and to endorse their favorites. Secondly, the study also indicated that, grown-up individuals are associates of previous cohorts, born into past years when defecating openly was common than it is today. However, open defecation falls faster among the oldest household members in the sample (Coffey, el at., 2014)
2.6 Attitudes towards open defecation
Open defecation and human excreta is regarded in difference ways by different cultures and it is interesting to know. Some tolerate it to a certain extend while for others the sooner it is out of sight, the better. Some cultures regard it as extremely repulsive and disgusting while others have tolerated the handling of human waste. In some parts of urban China, night soil workers cart away human waste in “honey carts” and in Vietnam there has been a long tradition of fertilizing rice fields with fresh human feces. (Jewitt, 2013). In many cultures, management of human excrete is regarded as unmentionable hence designated it as the work of the lower social status people (Mozaffar, 2014). It is interesting to note here how the indifference to public dirt and filth is contradicted with private cleanliness, emphasis being placed on the purity of the body. Therefore, “when waste is taken out of the home compound, it becomes “public” dominion, so everyone is fit to scrapheap garbage as well defecate in it” (Jewitt, 2013). Similarly, it is paradoxical how Indians are very particular about the removal of filth from their homes but indifferent to what happens to it afterwards (Mozaffar, 2014).
2.7 Beliefs and perceptions on open defecation
A study conducted in India found that of people who might offer their descriptions of good and bad regarding defecating openly and use of latrine. 47% of those who openly defecate say it‟s for pleasurable, provides comfort and for convenience. Those who openly defecate even though they are able to have latrine facility at their homes, at least 74% of them cited unchanged explanations (Coffey el at., 2014). In that same study, other Participants stated that open defecation provides them a chance walking in the morning, visit their gardens and enjoy the cool air which is fresh in the morning. A study conducted established universally-believed views on the paybacks of open defecation, noticeably related to what is reported above (Jenkins & Curtis, 2005). A number of individuals look at open defecation as part of good, healthy and worthy life.
2.8 Effects of Open defecation
Open defecation in whichever way and form, its practice poses significantly some adverse effects on the people and on the environment.
2.8.1 Health effect
The practice of open defecation adds more burden to the already strained health system. Poor sanitation is known to be associated with a number of disease transmission, these include cholera, diarrhea, dysentery, hepatitis A, typhoid and polio (WHO & UNICEF, 2017). Open defecation is responsible for about 58% of all diarrheal deaths. Up to about 842, 000 persons in Low middle Income Countries (LMICs) are reported to die due to inadequate water, sanitation, and hygiene annually.
Deadly diarrhea is basically as a result of open defecation and it is estimated around 2000 children under the age of five are victims of this and in every 40 seconds they die (WHO 2014), this is something that is avoidable and is mostly in densely populated countries like India (Vyas et al.2014). Children at this age don‟t differentiate between the good and bad things and everything in meant for them to be put in the mouth. In the rural areas where open defecation is rampant by both human beings and animals. Children end up eating them and bacteria, viruses and parasites find comfortable residence starts infecting their intestines resulting to diarrhea (Ngure et al., 2014). Open defecation poses a serious public health threat to children and is one of the biggest obstacles to meeting the Millennium Development Goals (MDGs). The faecal oral route is the cause of diarrheal disease as well as infection. It also increases pathways for polio transmission and many other diseases such as cholera, giardiasis, and Hepatitis A (Taraf, 2016).
Open defecation regarded as unsafe disposal of feces among other methods increases the risk of disease transmission. This behavior enables the spread of pathogens and its practice is related to most cases of diarrhea. All this is as a result of open defecation, improper latrine or toilet facilities, unsafe water and unhygienic practices (Robert et al., 2009).
The practice is the main reason for diarrheal deaths in children under five years, resulting in approximately 1,600 children dying every day (UNICEF-WHO, 2008). About 43% of children in India suffer from malnutrition, affecting school-age children and hindering their learning abilities (JMP, 2012). A recent study by Dean Spears from the Centre for Development Economics, along with Oliver Cumming of the London School of Hygiene and Tropical Medicine in Delhi, found that a 10% increase in open defecation was associated with a 0.7 per cent increase in both stunting and severe stunting (Thomson, 2015). According to UNICEF (2012), 1.7 billion diarrhea cases are reported annually with about 800,000 losses of lives of children under the age of 5 years globally. It is being projected that 1.1 billion persons 15% worldwide still practice Open defecation.
In Sub-Saharan Africa, from 1990 to 2010 the act of open defecation had decreased by 11%, however, the total population of persons doing open defecation has been reported to have a 33 million increase in the same period as a result of population increase. In this period, the practice of open defecation exercise was still more reported in rural areas (35%) compared to urban areas (8%) in 2010 (WHO/UNICEF, 2012).
World Health Organization reported that sanitation involves a number of practices and among all open-air defecation has been rated the most threatening. India leads in open defecation globally with 60% of the people practicing open defecation. There is high rate of diseases and deaths because of improper waste disposal especially human waste, unclean drinking water and untidy hygiene. Of the diseases, diarrhea is the chief reason for demise in the young ones. The poor hygiene is also associated with schistosomiasis, helminth contaminations, enteric fever and trachoma. The poor sanitation use apart from diseases also causes other significances not related to health especially to the girls and women such as safety and confidentiality and absenteeism in school (WHO, 2014; WHO/UNICEF, 2013).
The United Nation hopes to meet the Sustainable Development Goals (SDG 6 target 2) of ensuring that by 2030 open defecation is ended with an indication everyone gets access to suitable and justifiable sanitation and cleanliness taking in to consideration the girls and women who are the most exposed to these conditions (David & Macharia, 2015).
In Ethiopia, most Public Health problems are as a result of poor sanitation and children are the ones greatly affected (Ayalew et al, 2008). Communicable infections have been reported to be 60% to 80% of health complications in Ethiopia and these problems are due to unclean water, insufficient sanitation and poor hygiene (FDREMOH, 2011; Thewodros, 2016).
Sanitation activities are time and again not motivated by health in other countries: for instance, in countryside Benin, Jenkins and Curtis (2005) found out that well-being benefits were not an essential characteristic stirring latrine acceptance. Equally, open defecation is not extensively acknowledged amongst rural north Indians as a danger to health. Again, in a study by Coffey el at (2014), Participants were asked to two villages, one in which everyone is involved in defecating openly and one where nobody openly defecates: 43% of all Participants reported that open defecation is good for children other than going to defecate in latrine for their health. This figure even takes in to account of many Participants who actually are using latrines. Among those who defecate in the open, fully 51% report that widespread open defecation would be at least as good for child health as latrine use by everyone in the village. In another survey, the researchers asked an open-ended question about the possible benefits of latrine use and open defecation. Amongst those who defecate in the open, only 26% mention health perfections from using latrine as an advantage that possibly will effect from putting up a latrine; additionally, those who regularly talk about the convenience of having a latrine for people who already have stomach ailments. In that same study, further open-ended question about why children get diarrhoea. Only 26% responded with an answer that displays an understanding of any possible infectious causes of diarrhoeal disease (Taraf, 2016).
2.8.2 Effect on women
Time spent collecting water is substantial and is mostly a household chore of the women (Okun, 1988). In most societies, it is the woman‟s primary responsibility for the management of household sanitation and health. Inadequate water and sanitation causes increases in time, health, and care-giving burdens on women (Ngorima et al., 2008). For millions of women across the world inadequate access is a source of shame, physical discomfort and insecurity. There is also loss of dignity associated with a lack of privacy in sanitation accesses (UNDP, 2006).
Open defecation puts women‟s dignity and safety at risk. Many women feel constrained to relieve themselves in the dark for reasons of privacy, thus exposing them to rape and sexual assault (Tarraf, 2016). Furthermore, Taraf (2016) added that 30% of marginalized women are violently assaulted every year as the lack of basic sanitation forces them to travel long distances to meet their needs. 24% of girls drop out of school, as many facilities do not have toilets – this problem is exacerbated when they reach menarche (Tom, 2015). A recent research has established a statistically significant association between open defecation and pregnancy outcomes. According to Pinaki Panigrahi, a professor of epidemiology at the University of Nebraska Medical Centre, open defecation could have an effect on women‟s genito-urinary tract due to the proximity of the vagina and the anus, which resulted in a correlation between high numbers of stillborn, preterm births and spontaneous abortions (Mukunth, 2015).
2.8.3 Poverty
Inadequate water supplies are both a cause and an effect of poverty and their effects exacerbate the poverty trap (Sullivan et al, 2003). Poverty compounds the issue of water scarcity in many regions of the world causing a vicious cycle (Amokrane et al., 2007). Today, many of the 10 million childhood deaths each year are caused by diseases of poverty, diarrhea and pneumonia (Burström et al., 2005).
Improper sanitation and open defecation indirectly contribute to poverty as they lead to contaminated water sources, soil and land. Once ruined by disease, children are unable to complete their formal education, and are later hindered in their capacities to work, provide for themselves and educate their children. Illness within the community‟s senior population represents a significant drain on family budgets and healthcare resources. These factors only perpetuate the poverty cycle. (Kundan & Pandey, 2013; Tarraf, 2016).
3.8.4 The Economy
Beyond the human waste and suffering, the global deficit in water and sanitation is undermining prosperity and retarding economic growth (UNDP, 2006). Poor sanitation has many actual or potential negative effects on populations in a country (Kov et al., 2008). Productivity losses linked to that deficit are blunting the efforts of millions of the world „s poorest people to work their way out of poverty and holding back whole countries.
Poor sanitation practices have negative effects on the economy and national development as they cripple workers‟ productivity, their longevity, and their ability to invest and save. The economic
impact of inadequate sanitation is about $38.4 million in most developing nations, or 6.4 % of India‟s gross domestic product (Shivakumar &Girija, 2013).
Open defecation has greatly affected the economic status of the people especially those with poor sanitation. In Kenya Poor sanitation is reported to cost up to US$ 324 million with open defecation accounting for up to US$ 88 million annually. These expenses are mainly due to the resultant deaths or ill-health from diarrhea and other diseases associated with sanitation which accounts for about US$244 million. In Kenya it is the poor population that mostly engage in open defecation that is about 270 times practicing open defecation than the rich. However open defecation also has some social expenses like losing dignity and safety and this mostly affects girls (school going) and women (disabled) as well as gender violence to the women especially at night when going to look for where to defecate (Water and Sanitation Program, 2014).