“If water is life, sanitation is dignity”, said the former South African Minister for Water Affairs and Forestry, Ronnie Kasrils. But an estimated 4.5 billion people - more than half the world - live without access to safe sanitation.

This could have massive implications for achieving many of the UN’s Sustainable Development Goals. Every year, 1.7 billion cases of diarrhoea are recorded, and 500,000 children die from diarrhoea. The economic impact is severe, with an estimated $5.5 billion in losses across 18 African countries annually.

In India, the government has made a concerted effort to provide access to toilets. Its national sanitation programme Swachh Bharat Mission was launched in 2014, and has built more than 80 million toilets. The World Bank estimates that inadequate sanitation causes India economic losses of $53.8 billion - equivalent to 6.4% of its GDP. These losses arise from health-related impacts including premature deaths, the cost of treating disease and productive time lost due to illness. Other causes include the impact of women not going to work due to related illnesses and of girls missing school.

But one question that rarely gets asked is: what happens ‘after the flush’? India has a serious shortage of functioning sewage treatment plants. There are an estimated 800 treatment plants across the country, and most of them operate at around 30% capacity. The government is doing work in this area, sanctioning public-private partnerships for the construction of new sewage treatment plants along the highly populated areas on the banks of the river Ganga. But can the existing infrastructure be used better?

One case study is Population Services International’s (PSI) work in Bihar’s capital city of Patna, funded by the Bill and Melinda Gates Foundation and Grand Challenges Canada. PSI’s work in Patna has seen an increase of 2.7 million litres of sludge - 25% more sludge - entering municipal sewage treatment plants that would otherwise have been dumped in the open environment, in a field or body of water.

The majority of households in Patna are connected to a septic tank and must rely on sludge removal services. However, due to lack of capacity to meet demand at the local government level, this task is largely carried out by private tanker operators, who are not recognized by the government and often perform the function illegally and irresponsibly. This results in unsafe working conditions and poor service quality, with an estimated 89% of the extracted sludge being disposed of in open public spaces and rivers. The contamination of the shared environment has a detrimental effect on people’s health, and often has fatal consequences for children under five. Almost 90% of child deaths from diarrhoeal diseases are directly linked to contaminated water, lack of sanitation or inadequate hygiene.

In response to the market breakdown, the Patna pilot project helped establish an association of private tank operators to advocate at local government level and open up access to the city’s sewage treatment facilities. The local government worked with the association to establish the licensing of private operators so that they could ensure safe, high-quality services. In addition, a consumer hotline was set up so that customers could access these services from the newly licensed providers.

Dedicated efforts to build toilets must be matched with support for dealing with what happens after the flush. To this end, the World Economic Forum’s Forum of Young Global Leaders (YGL), in collaboration with Maverick Collective and PSI, will focus its attention over the next two years and beyond on how the YGL community can positively transform the urban Indian sanitation ecosystem. Led by a coalition of YGLs, #AfterTheFlush is dedicated to mobilizing the expertise, networks and commitment of the YGL community to scale up investment infrastructure and waste management across a select number of Indian cities.