Sanitation and child stunting, the linkages
While infant mortality rate has reduced significantly in India from 37 per 1000 live births in 2015 to 30 per 1,000 live births in 2019, it still accounts for one-fifth of the 5.4 million under-five deaths globally. Reducing infant and child mortality continues to be a crucial challenge for India.
A number of studies in India have directed attention to child stunting (low height for age) and its linkages with open defecation informs this paper titled 'Toilet construction under the Swachh Bharat Mission and infant mortality in India' published in Nature, Scientific Reports.
Historically, lack of access to toilets has served as a major driver of open defecation, particularly in rural India. It has thus been proposed that expansion of access to sanitation facilities may reduce open defecation which, in turn, may improve infant and child health in the country. However, very few studies are available that have looked at the effectiveness of large-scale investments, such as in sanitation, on infant and child mortality in the country.
The paper discusses the findings of a study that looks at the association between the Swachh Bharat Mission (SBM) and infant (IMR) and under five mortality rates (U5MR) in India. The study analyses data from thirty-five Indian states and 640 districts spanning 10 years (2011–2020), with IMR and U5MR per thousand live births as the outcomes. The study maps changes in IMR and U5MR and toilet access at the district level over time.
What was different about SBM
The Government of India constructed over 100 million household toilets and declared more than 600,000 villages as free of open defecation under the SBM - a “Jan Andolan” (people’s movement) that adopted an intensive, multi-pronged approach to sanitation. It spanned a period of 2015-2020 and had an annual budget of approximately 1.25 billion USD and included the following key components:
Subsidised toilets to eliminate open defecation. By 2020, approximately 109 million individual household latrines (IHHLs) were built under the program.
SBM’s “people’s movement” approach included Information, Education and Communication (IEC) campaigns to raise awareness about sanitation and hygiene. These campaigns reached rural Indians with an average of 50 messages per month over 5 years.
Focus was on capacity building and training for government officials, frontline workers, volunteers, and communities to enhance sanitation practices.
SBM also included waste segregation, collection, transportation, and disposal systems, along with treatment plants and recycling centers for effective waste management.
SBM introduced mobile and web applications for citizen engagement and monitoring.
SBM’s approach of combining toilet construction with IEC and community engagement were very different from prior sanitation efforts made in India. However, while there were government reports of increase in household toilet availability and reduction in open defecation post implementation of SBM, concerns regarding actual utilisation of toilets, long term behavior change and overreporting of Open Defecation Free (ODF) status of Indian regions remain.
The study found that:
There was a decline in infant mortality in India from 2003 to 2020. Majority of districts had an infant mortality rate (IMR) exceeding 60 per 1000 live births with a mean of 48.9 in 2003. However, most districts had achieved an IMR below 30, with a district mean of 23.5 by 2020.
Toilet coverage remained relatively low across districts with less than an average of 40 percent. In 2020, the majority of districts had a toilet coverage of more than 60 percent.
The study found an inverse correlation between district-level toilet coverage and IMR both in the short term and long term. For every 10-percentage point increase in district-level toilet access following SBM, there was a reduction in district-level IMR by 0.9 points and U5MR by 1.1 points, on average.
District-level toilet coverage of 30 percent (and above) corresponded with reductions in infant and child mortality. Districts with greater than 30 percent toilets constructed under SBM corresponded with 5.3 lower IMR (p < 0.05), and 6.8 lower U5MR (p < 0.05).
The study found that this relationship was true/strong even when the effect of sociodemographic, income, healthcare-related factors or confounders at the district-level was taken into consideration and controlled to estimate the association between toilets constructed and child mortality
Thus post-SBM period in India exhibited accelerated reductions in infant and child mortality compared to the pre-SBM years and the provision of toilets at-scale may have contributed to averting approximately 60,000–70,000 infant deaths annually.
The study findings indicate that implementation of transformative sanitation programs can deliver population health benefits in low- and middle-income countries, argues the paper.