“Fixing dreadful sanitation in India requires not just building lavatories but also changing habits.” – The Economist.
Water, sanitation, and hygiene, also referred to as WASH, are all essential ingredients to ensure human development. The data from the World Health Organization (WHO) and UNICEF, among others, indicate that it is the poorest, the young, the elderly, excluded groups, women and girls who suffer the most from poor WASH services.
Therefore, an investment to improve WASH services reduces mortality levels and allows children to be more productive. As such, policies, institutions and infrastructure to improve WASH services are getting priority in the nation’s development agenda.
India should build toilets before temples, Narendra Modi said in a pre-election speech to mark the birthday of Mahatma Gandhi in 2013. To accelerate the efforts to achieve universal sanitation coverage and to put focus on hygiene, Modi launched the Swachh Bharat Abhiyan (Clean India Movement) on October 2, 2014. In addition to cleaning the streets and roads, its main objective is to reduce or eliminate open defecation through construction of individual, cluster and community toilets by 2019, as a fitting tribute to the 150th birth anniversary of Mahatma Gandhi. The mission also makes an initiative of establishing a mechanism of monitoring latrine-use.
No doubt, WASH inputs are essential foundations for human development. Yet, for a large chunk of India’s population, these foundations are not in place. Despite massive outlays for drinking water and sanitation in last couple of decades, millions of Indians still lack access to these basic services.
Every day, numerous women and young girls collect water for their families – a ‘ritual’ that reinforces gender inequalities in employment and education. Only 47% of households have a source of water within the premises – while 53% of households travel more than 500 metres in rural areas and more than 100 metres in urban areas to fetch water as per the findings of the 2011 Census. In addition, a poor water supply has obvious health costs for both urban and rural households, since only one in three households are supplied ‘treated’ water in the country.
This problem is further compounded by the lack of access to sanitation. People from more than half of rural households in India still defecate in the open. This situation is particularly serious for women and girls. According to an estimate, around 300 million women in India still defecate in the open, despite being the worst sufferers of this practice. These statistics only serve to highlight the severity of this public health menace.
Furthermore, according to the 2011 Census, only 51% of households in India have drainage connectivity with a third of these households having closed drainage systems. This means that the remaining 49% do not have a drainage system at all. This leads to a lot of health-related problems for these households. This is a very sorry state of affairs for a country which is one of the largest economies in the world. Even here, there are wide regional variations. The provision of western style toilet facilities differs widely between the various Indian states. According to the 2011 Census, about half of the households in Gujarat have flush latrines, while barely 20% of households in Bihar are lucky to have that facility.
The combination of poverty, poor health and lack of WASH services means that children from unserved homes miss school more frequently than those whose families do benefit from better drinking water and sanitation services. The resulting lack of education and social development further marginalises these children, even further, and reduces their future chances of self-development. Hence, any improvement in access to toilet, water, electricity and LPG facilities is likely to result in a considerable reduction in domestic drudgery, especially for girls and women – thereby freeing up their time for other activities, like schooling and pursuing professional careers.
In addition, investing in WASH facilities is urgently needed to minimise the impact of antimicrobial resistance (AMR). “We are seized of the challenges of antimicrobial resistance,” Mr Anshu Sarkar, the Joint Secretary of the Ministry of Health and Family Welfare, Government of India, had once said. Unclean water, lack of sanitation facilities and poor hygiene standards are responsible for the transmission of diarrhoea, cholera, typhoid, dengue, chikungunya and several parasitic infections. Thousands of people die every year due to such diseases. To manage these diseases, antibiotics are being used on a large scale.
The symptoms of AMR appear when the effectiveness of antimicrobial drugs, including antibiotics, is diminished due to mutations in infectious micro-organisms. This happens when antibiotics are ill-regulated and overused, or when they are used inappropriately or for non-health reasons. The resulting mutations and the superbugs that emerge from this make treating basic infections such as skin sores or diarrhoea almost impossible. Surgery also becomes risky, in such cases. If present trends persist, by mid-21st century, AMR will kill more people than cancer, as was noted by Dr Poonam Khetrapal Singh, WHO Regional Director for South-East Asia.
In 2010, India was the world’s largest consumer of antibiotics for reasons of human health – at 12.9 x 109 units (10.7 units per person). The increase in the use of antibiotics in India has been further enabled by rapid economic growth and rising incomes – which, unfortunately, has not translated into improvements in the spheres of water, sanitation and public health facilities. Moreover, antibiotics still continue to be prescribed or sold to combat diseases like diarrhoea and upper respiratory tract infections, for which they have limited value.
How do we manage the issue of AMR? Many factors contribute to how antimicrobials are used. Therefore, a multi-disciplinary approach is needed to develop, implement and evaluate interventions to promote the optimal use of antimicrobials and thereby improve infection-control programmes.
So where do water, sanitation and hygiene come in? Clean water and sanitation facilities are low-cost solutions to India’s gravest health threats. Besides, these also significantly aid human and skill development agendas. India lags behind several countries when it comes to implementing basic public health measures. The immunisation rate (as measured by diphtheria-tetanus-pertussis vaccine coverage) in India is 72%, which is much lower than the rates in Brazil (95%), China (99%), and Indonesia (85%). Moreover, the percentage of population with access to improved sanitation facilities in India (36%) is far lower than the percentage in Brazil (81.3%), China (65.3%), and Indonesia (58.8%). Under the Swacch Bharat Abhiyan, the government has committed itself to providing toilets and improving sewage systems, but these measures will take time to implement.
Therefore, the Indian government must hasten its efforts to provide clean water and sanitation for all. Communities lacking clean water and effective sanitation in rural and urban areas need to be identified, and steps should be taken to ameliorate their situation.
Remedial measures could include treating the water supplied before its use or systematising the operations and maintenance of local water supply systems. This could also entail investing in water supply systems to serve populations without access to the facility. At the same time, access to safely-managed toilets should be increased by investing in them and building them. Bringing about behavioural changes, aimed at ending open defecation and promoting hand-washing practices, should also be a significant part of the agenda.
It is suggested that the National Rural Employment Guarantee Scheme (NREGA), which is implemented by panchayati raj institutions, should also be used to improve basic amenities like water, sanitation and hygiene in rural areas. Moreover, the funds allocated for the development of smart cities should also be used to develop WASH facilities in urban areas.
Clean water and sanitation facilities form the backbone of an effective human-development agenda, as has been argued by the Johns Hopkins University Water Institute. However, the challenges of providing these services in a large and heterogeneous country like India are vast.
Provisions for clean drinking water and sanitation are certainly not cheap in India. The cost of implementing and maintaining these through the entirety of India will be enormous. Of course, not implementing these will also have huge implications, in terms of health and socio-economic development costs. But, the big question is: will the policy-makers acquiesce?
A version of the article first appeared here.
The author is a development analyst at the Forum for Population Action.