Health and Sanitation: Pillars of a Healthy India

Health and Sanitation: Pillars of a Healthy India

The celebration of World Health Day this year underscores an uncomfortable truth: while India's achievements in health and sanitation policy are laudable, they remain insufficiently systemic. The push for initiatives like Swachh Bharat Mission (SBM) and Jal Jeevan Mission (JJM) masks enduring inequities in access, reliance on behavioral shifts, and incomplete investment in urban sanitation infrastructure. Real progress demands structural reforms that align the two pillars—health and sanitation—as inseparable facets of governance, not isolated missions.

The Institutional Landscape

At the national level, flagship programs such as SBM Gramin Phase-II and SBM 2.0 (Urban) dominate India's sanitation narrative. SBM aims to achieve ODF Plus villages with solid and liquid waste management, targeting behavioral change alongside infrastructure development. Simultaneously, Jal Jeevan Mission aims at universal household tap-water coverage by 2025, especially in water-scarce regions. Initiatives, such as AMRUT 2.0, bring urban sanitation under strategic city mapping efforts, while the National Health Mission underscores equitable healthcare access with proven gains in maternal and child health, including an IMR reduction from 58 in 2005 to 28 in 2020.

While noteworthy progress has been made—93% of women reportedly feel safer after receiving household toilets, according to UNICEF—the gaps are persistent and indicative of deeper structural issues. NFHS-5 exposes alarming discrepancies: only 70% of rural households have access to improved sanitation, and India's child stunting rate stands at 35.5%. Urban sanitation, especially in slum areas, faces systemic neglect, with nearly 61% of cities yet to operationalize faecal sludge treatment systems.

Arguments and Evidence: A Frayed Model of Progress

India's global health ambitions boast impressive milestones. Declaring ODF status eleven years ahead of SDG 6.2 targets symbolizes political commitment to sanitation infrastructure. Yet, the narrative falters upon closer inspection. A stark disconnect reigns between rural sanitation success and the urban sanitation crisis, where slippage looms large—nearly 8% of rural toilets remain non-functional due to water shortages.

Out-of-Pocket Expenditure (OOPE), despite schemes like PM-JAY, continues to strain family incomes, accounting for over 50% of health costs. Nobel Laureate Dr. Michael Kremer’s research signals the potential impact of basic hygiene interventions—safe drinking water could avert approximately 30% of infant deaths annually. However, JJM’s coverage remains stunted in states like Odisha and Jharkhand, further impacted by climate vulnerabilities. These failures compound malnutrition and maternal health disparities, burdening India's demographic dividend.

Behavioral change, often touted as a linchpin of SBM’s success, demonstrates mixed outcomes. Gates Foundation data from 2017 noted 58% higher child wasting rates among non-ODF families—a clear mandate for better community-driven outreach rather than top-down directives. The institutional neglect of menstrual hygiene and gendered sanitation in schools continues to marginalize women, despite data correlating improved toilet access with reduced female dropout rates.

Criticism of Institutional Approach

India’s centralized approach to sanitation ignores state-specific realities that demand nuanced interventions. The uneven allocation of resources—predominantly skewed towards large-scale infrastructural projects—neglects micro-level sanitation needs. For instance, NFHS-5 reveals regional inequities where economically backward states trail disproportionately, exacerbating inter-state migration pressures.

The judicial realm seems passive, especially concerning violations of the Prohibition of Employment as Manual Scavengers Act (2013). Reports persist of manual scavenging in urban clusters, suggesting desensitized governance and enforcement deficits. Additionally, weak monitoring mechanisms around faecal sludge treatment units and municipal waste-recycling centers amplify India's urban vulnerabilities.

The Counter-Narrative: Are Existing Policies Sufficient?

Supporters of current government initiatives may argue that the combined thrust of SBM, JJM, and NHM lays a robust groundwork to tackle India's sanitation-health nexus. The progress in life expectancy, now at 70.1 years (2024), and institutional deliveries rising from 39% in 2005 to 89% as per NFHS-5, reflect targeted gains. Proponents further highlight the alignment of these programs with Sustainable Development Goals and their proven economic spillover—₹50,000 saved annually by ODF families in healthcare costs.

However, this incremental progress undercuts critical systemic reforms, such as curtailing OOPE in underserved regions or bolstering urban hygiene initiatives beyond check-the-box metrics. This raises pertinent questions about the depth of government's intersectional policymaking, where sanitation and health should converge on common fiscal and operational platforms.

International Comparison: Lessons from Japan

Japan, with its emphasis on integrated health-sanitation planning, offers instructive lessons. The country combines high sanitation standards—nearly universal wastewater treatment rates—with water-conscious city designs in earthquake-prone areas. Unlike India’s piecemeal approach, Japan executes preventive care through district-level governance complemented by robust waste-recycling ecosystems. What India calls "community-led sanitation", Japan operationalizes through technological innovation—smart toilets coupled with real-time waste tracking.

Assessment: Bridging the Structural Divide

India’s health and sanitation landscape stands at an inflection point. The commendable gains made under SBM and JJM require consolidation into a truly integrated framework. This entails harmonized coverage metrics for rural and urban sanitation, greater devolution of sanitation-governance, and multi-stakeholder approaches leveraging SHGs, NGOs, and CSR wings. Unless OOPE and malnutrition concerns are prioritized, the existing policy matrix risks being reduced to incrementalist solutions.

To realize the promise of universal health and sanitation, India needs burden-sharing partnerships that transcend centralized mandates, a fact best emphasized through climate-resilient infrastructure and co-produced policy measures. An empowered institutional health-sanitation convergence could propel India closer to fulfilling its SDG ambitions.

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