NEW DELHI // Radha Devi takes a number and waits her turn to use the community toilet in a one-room shack every morning.
In her shantytown neighbourhood of New Delhi, there is no sewer system or running water. One latrine is shared by more than 200 people. Most days, the line for the bathroom is so long that Ms Devi, 25, squats outdoors, behind a barn, while her sister-in-law, Lakshmi, 19, keeps watch.
"It is embarrassing but everyone does it," said Ms Devi. "It is better to go outside than in there," she said, referring to the shack's odour of filthiness.
Ms Devi is not alone. Fifty-eight per cent of India's 1.2 billion citizens defecate in the open, according to a global study by the Indian government, the World Health Organization and Unicef.
By way of comparison, the study rated China the second worst country in terms of toilet access with only 5 per cent of the population lacking access to toilet facilities. Pakistan and Ethiopia are third at 4.5 per cent.
Aidan Cronin, a water and sanitation officer with Unicef in India, said the size of the problem can be blamed on the lack of government attention and religious stigma.
"Sanitation is a young subject," Mr Cronin said. The government only began promoting the use of toilets 20 years ago. Those efforts, by the government's own admission, proved largely ineffective.
The problem is not simply that there is a lack of toilets; it is that most people in rural India do not see a need for them.
It has been 12 years since the Indian government launched the Total Sanitation Campaign to increase the number of household toilets. The number of households requiring toilets in India dropped to 27 per cent in 2012 from 78 per cent in 2001, but still fell short of the government's goal for full compliance.
As a result, Jairam Ramesh, India's rural development minister, wants the annual national budget allocation for sanitation to be increased to Rs67 billion (Dh5.02bn) before it is finalised this month.
"Sanitation is the much more difficult issue," said Mr Ramesh in New Delhi on Friday at the launch of the United Nations' Economic and Social Commission for Asia and the Pacific report on Millennium Development Goals.
"Now we are talking of behavioural changes. Women demand mobile phones. They are not demanding toilets," said Mr Ramesh.
Mr Cronin said that, traditionally, the cleaning of toilets was done by the lowest caste, known as the Untouchables. The idea of a family maintaining a toilet, or even having a toilet indoors, carries negative connotations. Many Indians would rather go outdoors than risk being associated with toilet cleaning.
Paul Sathianathan knows first-hand the challenges of trying to overcome thousands of years of culture.
The co-founder of Guardian, a micro-finance firm based in Tamil Nadu, his company provides loans for clean water and sanitation projects.
Since 2008, the organisation have given loans to 25,000 people. About 60 per cent of the loans are for toilets.
"No one accepts us at first when we go in and start talking about toilets," said Mr Sathianathan, 57. "They say,'No, no, there is no need for that.' They won't even speak about these issues because they are traditionally not discussed in public. They think it is a dirty business."
"Traditionally, they will go for open defecation even with 'pukka' houses," said Mr Sathianathan. "They are not aware of diseases. They are careless about hygiene because they don't know any better. We have to explain the problems. They will have a general idea but they don't practise regularly."
The practice of defecating near water sources can contribute to the spread of infectious disease, such as diarrhea and pneumonia. About 1,000 children under the age of five die every day in India from diarrhea-related causes.
It was improvements made to toilet access that has made the largest contribution to the recent elimination of the polio virus in India.
The biggest hurdle, however, is getting communities to talk about the need for toilets.
"The mindset is fixed about going in the open," said Mr Sathianathan. "These are traditional practices and it takes a while to introduce them to use clean water and flush the toilets."
One story that has stuck with Mr Sathianathan in particular came from a father who said he had to rise at 4am each day to escort his daughter to an open toilet.
"When they squat by the roadsides, they have to stand up and sit down repeatedly if anyone is on the road. They are shy about going in public. There is no privacy."