eHEALTH: Transforming public healthcare through technology

Innovations in Public Health and Sanitation using convergence technologies- e-sanitation facility -A case study of Delight eToilet Bincy Baby (1), Ria John (2)
(1) (2)

Eram Scientific Solutions

Introduction
Public health and sanitation are so closely intertwined that it is not possible to look at public health indices in isolation, by ignoring the stark statistics of deprivation of public sanitation facilities. This consequence is more evident in metros and other upcoming cities in India which are now swelling with large migrant population as well as a floating population of global travellers, in addition to the city dwellers. The Millennium Development Goal (MDG) 7, Target 10, is To halve, by 2015, the proportion of people without access to safe drinking water and sanitation. At the halfway point, achievement of the sanitation element is too slow in 74 countries.

Though India has been making significant strides in the public health front, the alarming negligence towards setting up adequate public infrastructure for sanitation is taking dangerous turns. According to an ICRA industry report on Healthcare, India spends 5.1 percent of its GDP on health. A World Bank study has quantified the economic loss of lack of toilets and sanitation facilities in the country at $54 billion, as a consequence of treatment cost for diseases, early deaths, lost productivity, and loss in tourist revenue among other factors. The study Economic Impact of Inadequate Sanitation in India, conducted by the Banks South Asia Water and Sanitation Unit, says lack of toilets and decent sanitation costs India nearly $54 billion (Rs 24,000 crore), or 6.4% of its GDP a year, mainly through premature deaths, especially of children, treatment for hygiene-related illnesses, and lost productivity.

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Moreover, tourism emerging as a major economic contributor, providing hygienic and clean sanitation facilities in major tourist spots and other locations is a pre-requisite. World

Tourism Organization has predicted that by 2020, 1.6 billion people will be undertaking foreign travel each year. Tourism is a key foreign exchange earner for 83 percent of developing countries and the leading export earner for one-third of the worlds poorest countries

In spite of advanced technology being applied in all sectors, public sanitation still remains a neglected area. Thought there had been efforts made by various NGOs, Government and other donors, the universal problem of maintaining cleanliness and ensuring sustainability of these facilities largely remain unanswered. To effectively address these inherent issues, a full life cycle approach towards providing solution by integrating technology solutions, is the need of the hour.

This paper studies the impact of a fully integrated public sanitation system using convergence technologies against set of parameters which are considered as imperatives. The paper puts forth the case study of Delight e-toilet, as a sustainable model for public social infrastructure and an effective medium for mass communication for Government. needs of the society, by deploying appropriate technology1. Eram Scientific

Solutions which has developed the product is a social enterprise which addresses the pressing

The data analysed will be attributed to three installation sites of Delight e-toilet in Kerala; Kozhikode(Calicut), Museum and Kanakakkunnu Palace in Thiruvananthapuram.

This paper evaluates the effectiveness of the integration of appropriate technology to the three components of the e-sanitation solution viz. the enclosure of the toilet unit, the closet unit and the waste management system, which have a direct bearing on the performance levels of the parameters chosen for the study. The project has taken an overall direction as per the objectives stated in National Sanitation Policy2.

The following parameters are analysed to explore the effectiveness of the solutions when compared to a conventional facility.
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a. Ensuring Cleanliness Maintaining cleanliness is identified as the most important challenge and this becomes gruesome when considering the unpredicted civic behaviour of an individual while using such social infrastructures. Delight has integrated self-flushing system after every use and a floor wash system at pre-set intervals to maintain the hygiene levels of the units. Yet water conservation is given utmost importance. The etoilets are programmed to flush 1.5 liters of water if the user takes up to 3 minutes, and 4 liters of water for extended usage. Hence total water usage per user will not exceed 4 liters, which will smartly conserve water. Details of self-flushing and floor wash are given in Table 1.1 below.

Table 1.1 Flushing Pattern- Delight

b. Impact on Public Health The public health indices which correlate to the practices of open defecation, urination are directly connected to wide spread prevalence of infectious diseases like cholera, dysentery is one of the factors. Contamination of water tables and other water sources also are addressed. Though quantitative evidences are too early to be analysed in these installation sites, the public acceptance of the units has seen a drastic improvement.

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The usage history for the last 3 months (August, September, and October) is shown in Table 1.2 below. Table 1.2 USAGE HISTORIES FOR 3 MONTHS

The maximum number of footfall in each location across the 3 months is shown in Table 1.3.

Table 1.3 MAXIMUM FOOT FALL ON DELIGHT UNITS AT VARIOUS LOCATIONS

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The minimum number of footfall in each location across the 3 months is shown in Table 1.4

Table 1.4 MINIMUM FOOT FALL ON DELIGHT UNITS AT VARIOUS LOCATIONS

The usage pattern on a weekly basis for a 3-month period is shown in Charts 1-5 below.

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Chart 1 User pattern of Delight installed at Museum (Male)

Chart 2 User pattern of Delight installed at Museum (Female)

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Chart 3 Usage pattern of Delight at Kanakakkunnu

Chart 4

Usage pattern of Delight at Oyitti road, Kozhikode

Chart 5 Usage pattern of Delight at Sarovaram, Kozhikode

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From the charts 1 to 5, the usage pattern can be inferred; there has been an increased preference towards using Delight units. During festive seasons there is a hike in number of users.

c. Design and modularity of the e-sanitation facility: A compact design using bio-friendly materials for enclosure and an easy to install and dismantle procedure without making any significant impact on the environment or the landscape is stressed in the production phase of the eToilet. Details of materials used are given in Table 1.5.

Table 1.5 Details of materials used

d. Waste management process/ Sewage Treatment Inspite of providing state-of -the-art enclosure, linking it to a conventional sewage system will defeat the whole focus & purpose of e-toilet: hence, a Sewage Treatment system with appropriate technology needs to be closely integrated. It has been an acknowledged fact

that the provision of clean toilets per se would not be a panacea for addressing the debilitating plight of our land, air and water bodies, but rather the grim issue of waste treatment and disposal. Often, there are multiple solutions available for effective solid waste management, but the technologies available for sewage are far from being cost effective and efficient. Delight had encountered real challenges while selecting and integrating sewage disposal systems. Connecting e-toilet to an existing sewer network does not provide any value to the existing system and introduction of e-toilets do not make a significant impact on them.

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The suitability of bio-membrane reactors, connecting to existing sewer lines and construction of traditional sewage pits have been tried in these sites. Each system has its merits and disadvantages and hence a policy and parameterisation for selecting the STP (Sewage Treatment Plant) has been arrived at. However, all these alternatives had to take cognizance of the fact that disposal of sewage waste is a critical issue. In typical water logged areas in Kerala, and high water table areas, underground STPs pose a challenge especially during monsoons. This prompted us to think about modular STPs. Now we plan to introduce sensor based system for identifying the status of sewage treatment, so as to introduce technology in sewage disposal also. Details on Sewage treatment facilities at the 3 sites are given in the Table 1.6 below. Table 1.6 Details on Sewage treatment facilities at different sites

e. Sustainability Non-availability of a sustainable model for meeting the maintenance of such facilities had been a daunting question in various other models tried and tested elsewhere. Ensuring sustainability over and above the user charges, through advertisement displays is an innovation ensures a decent livelihood for people who run the units. Any public infrastructure

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will cease to function, unless it is tied with a sustainable business model. In toilets, this is a critical issue to ensure that the units are sustained for a long period.

Delight incorporates state-of-the-art technology integration and usage of quality materials to ensure the longevity and sustainability of the units. Delight elevates the standard of living of the people engaged in the job of cleaning Delight units. The units enable touch free cleaning and maintenance. The e-sanitation facility is sustainable in terms of revenue and environment compatibility. The units are sustainable through revenue in the form of coin collection and advertisements. Investment in the e-sanitation facility can be recovered through the coin collection and advertisement revenue within a short period of time. The entrepreneurial model can generate employment opportunities. Details of Revenue from Coin Collection and Advertisement is given is Table 1.7 below. Table 1.7 REVENUE PATTERN

Advertisement revenue: The unique sustainable model can recoup the expenditure incurred, by means of coin collection and advertisement revenue. Delight installed at Museum premises earns an average of Rs 30000/year from advertisement.

f. User feedback
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Currently, there is no public infrastructure in India which provides a versatile customer support facility. The reliability and effectiveness of the e-sanitation facility through public feedback and communication is evident from the user feedback and the media reports3. User feedback is available in Attachment No.1.

g. Use of convergent technology Simple to use, Electronics to the core, powered by ICT: Use of multiple technologies enhances the effectives of the monitoring and control of activities. Integration of convergent technology is aimed to cater to an ever-connected, ever-mobile world.

The e-sanitation amenities extended through Delight ensures significant and sustainable changes in the sanitation sector through judicious and effective use of most-modern technology and research facilities. In terms of invention, Delight stands incomparable as the e-toilet can be made operational sans manpower. The integration of unmanned technology in the etoilet facilities is also empowered with operation tracking and reporting facilities via web and mobile technologies. The system can be made operational or shutdown even from a remote location. Remote control shutdown using an SMS would have great implications when large numbers of units are installed in a single location. Details of the technologies deployed in Delight are shown in Table 1.8.

Sensor-based system ensures water conservation and power saving in the units. The units also have a unique theft protection and alarm system that would safeguard the units from vandalism. Technology reveals the working status, down-time, and service details of each unit. Judicious deployment of engineering and multiple technologies with no high-end gadget ensure that users are left with no electronic phobia.

Table 1.8 DETAILS OF TECHNOLOGY CONVERGED

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h. A healthy generation next Healthy children are great promises as well as young pioneers for the nation. Providing enough sanitation facilities at schools for boys and girls can help to make the children free from diseases.

Delight has partnered with , Suchi@School (Sustainable Comprehensive Hygiene Initiative) an initiative by Mr/ Rajeev M.P, by utilising his funds under MPLADS (Member of Parliaments Local Area Development Scheme) to build up school infrastructure for sanitation and provision of safe water in all government schools and government aided schools in Ernakulam district in Kerala. The project envisages completing the task of school sanitation within a period of one year by mobilizing resources, not only under the MPLAD Scheme of the MP, but also those available with different agencies, Government and

private parties. Delight etoilets have been integrated as part of the Suchi@School Initiative for providing state-of-the-art sanitation facilities for the student community in various schools. The current requirement of sanitation infrastructure as per statistics is given below in Chart 6.
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Chart 6 Schools in Government and aided sectors requiring additional infrastructures for school sanitation

The school e-toilets are equipped with facilities like automatic flush, power washing mechanism, emergency exit facility, push button flush, hand pipe, cloth hanger, air freshener, water tank for irrigation etc. The SMS alert facility and customer care service wing are also enabled in school e-toilets. The rack in the toilet is specially set up for dumping sanitary napkins and the electrical insulator mechanism burns the napkins and removes the ashes. A troupe of bubbly animated characters which comprise the Green army to spread awareness regarding cleanliness will also pasted on the side of the toilets. The Green Army consists of Haari crow, Puigi cat, Pupu mushroom, Marmmu earthworm and Thoothan frog. These soldiers will reach out to various schools along with two more characters Shuchi and Joy, to teach the students about the necessity of keeping the place tidy. (Figure 1)

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Figure 1 Delight School Model with Green Army

Thus Delight school model is set up to provide a clean sanitation environment at school levels and to bring up a healthy generation free from the fears of infectious diseases and who are aware of the consequences of unhygienic surroundings. Attachment No. 2- Student Feedback in Regional Language (Malayalam).

i. Universality of Solution Delight is applicable across various geographies, climates and terrains so as to reconfirm its suitability across diverse end user groups.

Different models of Delight are developed and more are being developed to suit the geographical, demographical and economic diversities of various regions. Different combinations of materials are used in each model to suit the climatic and geographical conditions of each location. Units are also designed to suit the underground water levels of these regions; a separate model is being envisaged for the water-logged areas. Local sourcing of manufacturing materials and production facility also enhances the universality of the solution.

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j. Innovations in G2C communications These public social infrastructures with their state-of-the-art backlit advertisement panel will emerge as a powerful medium of mass communication and will be an innovative means for delivering important messages of Government to citizens, which can leverage on the NeGP connectivity infrastructure, being initiated by Government across the nation. This is envisaged as the next generation public infrastructures which will be a sustainable model for Government as well as the entrepreneurs who would run the facilities.

Moreover, it is imperative that the social public infrastructures make use of the innovations in technology to display highvisible, high-impact display systems and high-tech display boards using LED screens so as to ensure the value proposition of the messages conveyed. Government can also consider putting up a facility to centrally or remotely manage the advertisements, messages thus displayed on these facilities. With the nation-wide connectivity infrastructure in place, a well-connected network of intelligent toilets will bring in a paradigm shift in public sanitation in the Nation. Moreover, these e-sanitation facilities will be intended to be talking toilets integrated with toilet mapping, making it accessible and easier to locate and manage.

Vision India: A Sanitation Crusade The future envisions Delight to transform the whole wellness aspect of India with Delight Automated Public Toilet, Vending Machines, Multi-purpose Kiosks, Massage Chairs, Sleep Rooms, all made available under a single roof with a cosy ambience. This many-in-one. More features relating to wellness such as spas with steam bath, herbal garden parks etc could be integrated into the model.

India will soon be home to a well-connected network of intelligent toilets which will bring in a paradigm shift in public sanitation in some of the worlds most exotic tourist locations and in urban locations in the Country. A comprehensive, connected, hygienic, ultra-modern urban sanitation infrastructure which is self-sustainable, income and employment-generating is in

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the making. Moreover, these e-sanitation structures would be talking toilets integrated with toilet mapping, making it accessible and easier to locate and manage them.

Conclusion
The revolutionary impact of e-sanitation facilities which can be provided by the Delight etoilet models, to be set up in different parts of India, is revealed in the above study. Based on the evaluated parameters and their results, eToilets are found to be futuristic, forward looking and highly sustainable compared to the conventional toilets. The state of sanitation facilities in public places and schools can be radically improved by installing Delight eToilets. Delight is an end-to-end solution for effectively addressing the sanitation gaps in our Country and it could be scaled up to cover the whole wellness aspect of the public. Hence it is high time that Delight is taken up as a key component of urban infrastructure.

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References
1. Social Enterprise and Human Development: The Role of Government. Project Thesis by Ms. Pallavi Gupta, Research Student, London School of Economics

2. National Urban Sanitation Policy, Ministry of Urban Development, The Government of India

3. Media Report, The Economic Times, 8 March 2011 http://articles.economictimes.indiatimes.com/2011-03-08/news/28668465_1_public-toiletslocal-bodies-bio

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Attachments
1. User Feedback http://www.scribd.com/doc/72235580 2. Student Feedback http://www.scribd.com/doc/72236528 3. Media Report http://www.scribd.com/doc/72237411 4. Opinion Leaders Statements http://www.scribd.com/doc/72237613 5. Delight Site Photographs http://www.scribd.com/doc/72237973 6. Delight Web links

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